Intraoperative image-guided spinal navigation: technical pitfalls and their avoidance.

Spinal instrumentation has made significant advances in the last two decades, with transpedicular constructs now widely used in spinal fixation. Pedicle screw constructs are routinely used in thoracolumbar-instrumented fusions, and in recent years, the cervical spine as well. Three-column fixations with pedicle screws provide the most rigid form of posterior stabilization. Surgical landmarks and fluoroscopy have been used routinely for pedicle screw insertion, but a number of studies reveal inaccuracies in placement using these conventional techniques (ranging from 10% to 50%). The ability to combine 3D imaging with intraoperative navigation systems has improved the accuracy and safety of pedicle screw placement, especially in more complex spinal deformities. However, in the authors' experience with image guidance in more than 1500 cases, several potential pitfalls have been identified while using intraoperative spinal navigation that could lead to suboptimal results. This article summarizes the authors' experience with these various pitfalls using spinal navigation, and gives practical tips on their avoidance and management.

Spinal cord stimulator--trial lead migration study.

OBJECTIVES: Investigate whether percutaneous spinal cord stimulator (SCS) leads migrate significantly during a 3-day trial, and determine whether the skin anchoring method influences lead migration. MATERIAL AND METHODS: Twenty patients were prospectively enrolled. Ten leads were anchored with suture and tape and 10 were anchored with tape only. A standardized X-ray protocol of lead position was obtained immediately following lead placement and upon completion of the trial. RESULTS: Using a standardized method, SCS leads were measured and movement was calculated. The average movement for leads anchored with tape only was 8.72 mm (SD=5.77), inferiorly; while movement for leads anchored with suture and tape was 24.49 mm (SD=11.3), inferiorly. A t-test revealed a significant difference between the groups (t=3.9, P=0.001). CONCLUSIONS: Percutaneous SCS trial electrodes migrate significantly, inferiorly, during a 3-day trial. Anchoring the trial electrodes to the skin with a suture and tape results in significantly greater inferior migration when compared with anchoring the lead with tape only.

Initial Results of Precision Treatment of Postoperative Cerebrospinal Fluid Leak with Ultrasound-Guided Epidural Blood Patch.

BACKGROUND: Incidental durotomy, a known complication of spinal surgery, can lead to persistent cerebrospinal fluid leak and pseudomeningocele if unrecognized or incompletely repaired. We describe the use of ultrasound to visualize the site of durotomy, observe the aspiration of the pseudomeningocele, and guide the precise application of an ultrasound-guided epidural blood patch (US-EBP), under direct visualization in real time. METHODS: A retrospective review was performed to determine demographic, procedural, and outcome characteristics for patients who underwent US-EBP for symptomatic postoperative pseudomeningocele. RESULTS: Overall, 48 patients who underwent 49 unique episodes of care were included. The average age and body mass index were 60.5 (±12.6) years and 27.8 (±4.50) kg/m2, respectively. The most frequent index operation was laminectomy (24.5%), and 36.7% of surgeries were revision operations. Durotomy was intended or recognized in 73.4% of cases, and the median time from surgery to symptom development was 7 (interquartile range 4-16) days. A total of 61 US-EBPs were performed, with 51.0% of patients experiencing resolution of their symptoms after the first US-EBP. An additional 20.4% were successful with multiple US-EBP attempts. Complications occurred in 14.3% of cases, and the median clinical follow-up was 4.3 (interquartile range 2.4-14.5) months. CONCLUSIONS: This manuscript represents the largest series in the literature describing US-EBP for the treatment of postoperative pseudomeningocele. The success rate suggests that routine utilization of US-guided EBP may allow for targeted treatment of pseudomeningoceles, without the prolonged hospitalization associated with lumbar drains or the risks of general anesthesia and impaired wound healing associated with surgical revision.

Painful medial branch neuroma treated with minimally invasive medial branch neurectomy.

STUDY DESIGN: Case report. OBJECTIVE: To report an unusual complication following lumbar facet radiofrequency denervation and describe a successful, minimally invasive treatment of a presumed medial branch neuroma. SUMMARY OF BACKGROUND DATA: Radiofrequency medial branch neurotomy is a common procedure for the treatment of mechanical back pain. Deafferentation injury and neuroma formation is well known and reported following chemical, surgical, and cryoablation neurolysis; however, it is thought to be rare with radiofrequency ablation. When this problem is encountered, treatment options appear to be limited. Further radiofrequency ablations may be ineffective and indeed may cause further injury. METHODS: A 17-year-old male who sustained a traumatic fracture of the right L3-4 facet joint presented with increasing back pain after multiple radiofrequency ablations of the medial branches of the L2 and L3 dorsal rami. The description of the back pain, initially nociceptive in nature, had become progressively neuropathic with clear focal areas of allodynia and hyperesthesia. Further medial branch radiofrequency denervation was found to be ineffective. RESULTS: Diagnostic block of the right medial branch of the L2 dorsal ramus provided the patient with total relief of pain. This was followed by a minimally invasive open surgical ablation of the L2 medial branch neuroma using three-dimensional, fluoroscopy-based image guidance. At 7 months of follow-up, the patient reported complete resolution of pain, discontinuation of all pain medications, and return to all previous physical activities. CONCLUSION: Deafferentation injury is a rare but recognized complication of chemical, surgical, and thermal neuroablation. This case report presents a rare instance of presumed neuroma formation following multiple radiofrequency ablations for the treatment of facet-generated mechanical back pain. Open and minimally invasive medial branch neurectomy resulted in complete resolution of pain and return to baseline function.

Iatrogenic intradural spinal arachnoid cyst as a complication of lumbar spine surgery.

Iatrogenic spinal arachnoid cysts are rare, but have been described as a complication of spinal injection and lumbar puncture procedures. The authors describe 2 cases of iatrogenic spinal arachnoid cyst formation that occurred after incidental durotomy during lumbar spine surgery. In both cases, postoperative MR imaging revealed compression of the cauda equina by an intradural arachnoid cyst. Intradural exploration and fenestration of the arachnoid cyst was accomplished in each case. This entity should be considered in the differential diagnosis of a patient experiencing symptoms of neurological compression after a lumbar surgery complicated by incidental durotomy.

Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort.

OBJECT: The goal of this study was to analyze the placement accuracy and complications of thoracolumbar pedicle screws (PSs) inserted using 3D image guidance in a large patient cohort. METHODS: The authors reviewed the charts of 220 consecutive patients undergoing posterior spinal fusion using 3D image guidance for instrumentation placement. A total of 1084 thoracolumbar PSs were placed using either the BrainLAB Vector Vision (BrainLAB, Inc.) or Medtronic StealthStation Treon (Medtronic, Inc.) image guidance systems. Postoperative CT scanning was performed in 184 patients, allowing for 951 screws to be graded by an independent radiologist for bone breach. All complications resulting from instrumentation placement were noted. Using the intraoperative planning function of the image-guided system, the largest diameter screw possible in each particular case was placed. The screw diameter of instrumentation placed into the L3-S1 levels was noted. RESULTS: No vascular or visceral complications occurred as a result of screw placement. Two nerve root injuries occurred in 1084 screws placed, resulting in a 0.2% per screw incidence and a 0.9% patient incidence of nerve root injury. Neither nerve root injury was associated with a motor deficit. The breach rate was 7.5%. Grade 1 and minor anterolateral "tip out" breaches accounted for 90% of the total breaches. Patients undergoing revision surgery accounted for 46% of the patients in this study. Accordingly, 154 screws placed through previous fusion mass could be evaluated using postoperative CT scanning. The breach rate in this specific cohort was 7.8%. A total of 765 PSs were placed into the L3-S1 levels in this study; 546 (71%) of these screws were > or = 7.5 mm in diameter. No statistical difference in breach rate was noted in PSs placed through revision spinal levels versus nonrevision spinal levels (p = 0.499). Additionally, no increase in breach rate was noted with placement of 7.5-mm-diameter screws. CONCLUSIONS: Three-dimensional image guidance is a useful adjunct to placement of spinal instrumentation. The complication rate in this study was low, and accurate placement of instrumentation was achieved despite the high percentage of revision surgery cases in our patient population. Additionally, because active fluoroscopy was not used for instrumentation placement, there was minimal to no radiation exposure to the surgeon or operating room staff.

Timing of vertebral registration in three-dimensional, fluoroscopy-based, image-guided spinal surgery.

STUDY DESIGN: The timing of vertebral registration using isocentric fluoroscopy was recorded in 20 consecutive patients undergoing image-guided spinal surgery. OBJECTIVE: To determine if vertebral registration in three-dimensional, fluoroscopy-based, image-guided spinal surgery can be performed in an efficient manner. SUMMARY OF BACKGROUND DATA: Many spine surgeons are reluctant to incorporate spinal image guidance into their surgical practice due to the perception that it is time consuming and tedious, especially the task of vertebral registration. The authors evaluated the time required for vertebral level registration using the Arcadis Orbic isocentric C-arm (Siemens Medical Solutions, Erlangen, Germany) in conjunction with the BrainLAB (BrainLAB, Westchester, IL) image-guided system for spinal surgery cases. METHODS: The time required to register vertebral segments using the isocentric C-arm was assessed in 20 consecutive patients undergoing spinal fusions by the senior author (E.W.N.). Overall, 80 vertebral segments spanning from C1 to S1 were registered with 23 spins of the isocentric C-arm. Timing was started when the surgeon began to place the image-guided reference arc on the spine and commenced when the spine could be navigated using the image-guided system. RESULTS: The average time required for this process was 8 minutes and 34 seconds per patient. No complications occurred in this study as a result of instrumentation placement or the use image guidance. Excellent navigation accuracy was obtained in all cases and no malfunction of the isocentric C-arm or image-guided system occurred. Postoperative radiographic studies were performed on all patients and revealed adequate placement of instrumentation. CONCLUSIONS: The use of the isocentric C-arm for vertebral registration in image-guided spinal surgery can be performed in an efficient manner. In this study, multiple vertebral levels of registration could be accomplished in less than 9 minutes with minimal to no radiation exposure to the surgeon and operating room personnel.

Cervical kyphotic deformity correction using 360-degree reconstruction.

OBJECTIVE: The authors report on their experience with cervical sagittal deformity correction using 360-degree reconstruction. SUMMARY OF BACKGROUND DATA: A paucity of literature exists concerning 360-degree approaches for the correction of cervical kyphotic sagittal deformity in which the amount of deformity correction achieved, as well as the maintenance of deformity correction, is detailed. METHODS: The charts of all patients undergoing 360-degree cervical reconstruction for kyphotic sagittal plane deformity between 2000 and 2006 at Mayo Clinic Jacksonville and Mayo Clinic Scottsdale were retrospectively reviewed. Only patients with a minimum of 1-year follow-up were included in this study; 41 patients fit this criterion. The clinical data were further analyzed in this cohort to determine preoperative and postoperative sagittal angle, loss of correction, fusion rate, complications, and clinical status at last follow-up. RESULTS: Average follow-up was 19 months (range: 12 to 48 mo). The mean preoperative sagittal angle was 18 degrees of kyphosis (range: 3 to 58 degrees). The mean correction of sagittal angle was 22 degrees (range: 4 to 56 degrees), resulting in a postoperative mean sagittal angle of 4-degree lordosis. There was no loss of correction across the instrumented segments in any patient. Neurologic complications included 1 case of quadriparesis and 1 case of transient C8 radiculopathy. CONCLUSIONS: The correction of cervical kyphotic sagittal plane deformity can be accomplished safely and effectively using a 360-degree approach. The incidence of major complications in this study was low. All patients could be corrected to a neutral or lordotic alignment. No loss of deformity correction was seen in any patient, and a 97.5% fusion rate was obtained.

Partial Costotransversectomy and Corpectomy for Thoracic Spinal Metastatic Disease: Operative Technique and Nuances: 2-Dimensional Operative Video.

We describe the operative approach and management for thoracic metastatic disease in a 78-yr-old man with worsening mechanical lower back and left-sided thoracic radicular pain. Imaging of the thoracic spine revealed an osteolytic T11 mass with destruction of the left T11 pedicle and transverse process. Biopsy confirmed spinal metastasis from the liver. Preoperative angiogram was completed for localization of the artery of Adamkewicz and microparticle embolization of the left T11 intercostal artery. Surgical resection was supplemented with electrophysiological monitoring and neuronavigation. The corpectomy was approached by resecting the medial aspect of the rib, transverse process, and pedicle, which were all invaded with tumor. The left T11 nerve root was isolated and sacrificed to allow for placement of the expandable corpectomy cage and also resulted in sustained relief of the patient's radicular pain. The patient recovered from surgery well, with postoperative improvement of his pain. This case highlights the complex technical nuances of this procedure, and the importance of a thorough preoperative evaluation, including angiography, as proper identification of the artery of Adamkewitz can prevent severe neurological deficit from a spinal cord stroke. The patient consented to the procedure.

Placement of C2 laminar screws using three-dimensional fluoroscopy-based image guidance.

The use of C2 laminar screws in posterior cervical fusion is a relatively new technique that provides rigid fixation of the axis with minimal risk to the vertebral artery. The techniques of C2 laminar screw placement described in the literature rely solely on anatomical landmarks to guide screw insertion. The authors report on their experience with placement of C2 laminar screws using three-dimensional (3D) fluoroscopy-based image-guidance in eight patients undergoing posterior cervical fusion. Overall, fifteen C2 laminar screws were placed. There were no complications in any of the patients. Average follow-up was 10 months (range 3-14 months). Postoperative computed tomographic (CT) scanning was available for seven patients allowing evaluation of placement of thirteen C2 laminar screws, all of which were in good position with no spinal canal violation. The intraoperative planning function of the image-guided system allowed for 4-mm diameter screws to be placed in all cases. Using modified Odom's criteria, excellent or good relief of preoperative symptoms was noted in all patients at final follow-up.

Stabilization of the atlantoaxial complex via C-1 lateral mass and C-2 pedicle screw fixation in a multicenter clinical experience in 102 patients: modification of the Harms and Goel techniques.

OBJECT: Stabilization of the atlantoaxial complex has proven to be very challenging. Because of the high mobility of the C1-2 motion segment, fusion rates at this level have been substantially lower than those at the subaxial spine. The set of potential surgical interventions is limited by the anatomy of this region. In 2001 Jürgen Harms described a novel technique for individual fixation of the C-1 lateral mass and the C-2 pedicle by using polyaxial screws and rods. This method has been shown to confer excellent stability in biomechanical studies. Cadaveric and radiographic analyses have indicated that it is safe with respect to osseous and vascular anatomy. Clinical outcome studies and fusion rates have been limited to small case series thus far. The authors reviewed the multicenter experience with 102 patients undergoing C1-2 fusion via the polyaxial screw/rod technique. They also describe a modification to the Harms technique. METHODS: One hundred two patients (60 female and 42 male) with an average age of 62 years were included in this analysis. The average follow-up was 16.4 months. Indications for surgery were instability at the C1-2 level, and a chronic Type II odontoid fracture was the most frequent underlying cause. All patients had evidence of instability on flexion and extension studies. All underwent posterior C-1 lateral mass to C-2 pedicle or pars screw fixation, according to the method of Harms. Thirty-nine patients also underwent distraction and placement of an allograft spacer into the C1-2 joint, the authors' modification of the Harms technique. None of the patients had supplemental sublaminar wiring. RESULTS: All but 2 patients with at least a 12-month follow-up had radiographic evidence of fusion or lack of motion on flexion and extension films. All patients with an allograft spacer demonstrated bridging bone across the joint space on plain x-ray films and computed tomography. The C-2 root was sacrificed bilaterally in all patients. A postoperative wound infection developed in 4 patients and was treated conservatively with antibiotics and local wound care. One patient required surgical debridement of the wound. No patient suffered a neurological injury. Unfavorable anatomy precluded the use of C-2 pedicle screws in 23 patients, and thus, they underwent placement of pars screws instead. CONCLUSIONS: Fusion of C1-2 according to the Harms technique is a safe and effective treatment modality. It is suitable for a wide variety of fracture patterns, congenital abnormalities, or other causes of atlantoaxial instability. Modification of the Harms technique with distraction and placement of an allograft spacer in the joint space may restore C1-2 height and enhance radiographic detection of fusion by demonstrating a graft-bone interface on plain x-ray films, which is easier to visualize than the C1-2 joint.

Redirecting pedicle screws: a revision spinal fusion strategy using three-dimensional image guidance.

BACKGROUND: Pedicle screws are a preferred method for spinal fixation because of their three-column support and rigid posterior stabilization. The purpose of this study was to evaluate the outcome of patients requiring pedicle screw redirection, and to describe a technique using cone-beam computed tomography (cbCT). METHODS: A retrospective review of 30 patients undergoing revision spinal fusion with redirection of pedicle screws was performed. Fifty pedicle screws were redirected in these patients using cbCT-based 3D image guidance. They were graded pre- and post-operatively using an established grading system. RESULTS: No complications occurred in this study as a result of redirection. No pedicle breach was noted in all of the redirected pedicle screws. CONCLUSION: Redirection of misplaced pedicle screws using cbCT-based 3D image guidance seems to be safe and accurate in our experience. Further studies are needed to establish its safety, accuracy, fusion rate, and clinical outcome compared with other methods. Copyright © 2016 John Wiley & Sons, Ltd.

Radiographic comparison of cross-sectional lumbar pedicle fill when placing screws with navigation versus free-hand technique.

BACKGROUND: Pedicle screws are often used for spinal fixation. Increasing the percentage of pedicle that is filled with the screw presumably yields greater fixation. It has not been shown whether spinal navigation helps surgeons more completely fill their instrumented pedicles. METHODS: Fifty consecutive patients from each arm (navigated and free-hand) were retrospectively reviewed. The cross-sectional area of each instrumented lumbar pedicle and screw were measured using an automatic area calculation tool. The coronal images and measurements were blinded to the surgeons. RESULTS: The instrumented pedicles in the navigated patients were significantly more filled by screws than the pedicles in the non-navigated patients (P < 0.001). CONCLUSION: Obtaining a higher cross-sectional percentage fill of the pedicle with a screw is expected to provide greater spinal fixation in instrumented fusion surgery. This study shows that utilizing spinal navigation helps to more completely fill the pedicles that are being instrumented. Copyright © 2015 John Wiley & Sons, Ltd.

Biomechanics of transvertebral screw fixation in the thoracic spine: an in vitro study.

OBJECTIVE Transvertebral screws provide stability in thoracic spinal fixation surgeries, with their use mainly limited to patients who require a pedicle screw salvage technique. However, the biomechanical impact of transvertebral screws alone, when they are inserted across 2 vertebral bodies, has not been studied. In this study, the authors assessed the stability offered by a transvertebral screw construct for posterior instrumentation and compared its biomechanical performance to that of standard bilateral pedicle screw and rod (PSR) fixation. METHODS Fourteen fresh human cadaveric thoracic spine segments from T-6 to T-11 were divided into 2 groups with similar ages and bone quality. Group 1 received transvertebral screws across 2 levels without rods and subsequently with interconnecting bilateral rods at 3 levels (T8-10). Group 2 received bilateral PSR fixation and were sequentially tested with interconnecting rods at T7-8 and T9-10, at T8-9, and at T8-10. Flexibility tests were performed on intact and instrumented specimens in both groups. Presurgical and postsurgical O-arm 3D images were obtained to verify screw placement. RESULTS The mean range of motion (ROM) per motion segment with transvertebral screws spanning 2 levels compared with the intact condition was 66% of the mean intact ROM during flexion-extension (p = 0.013), 69% during lateral bending (p = 0.015), and 47% during axial rotation (p < 0.001). The mean ROM per motion segment with PSR spanning 2 levels compared with the intact condition was 38% of the mean intact ROM during flexion-extension (p < 0.001), 57% during lateral bending (p = 0.007), and 27% during axial rotation (p < 0.001). Adding bilateral rods to the 3 levels with transvertebral screws decreased the mean ROM per motion segment to 28% of intact ROM during flexion-extension (p < 0.001), 37% during lateral bending (p < 0.001), and 30% during axial rotation (p < 0.001). The mean ROM per motion segment for PSR spanning 3 levels was 21% of intact ROM during flexion-extension (p < 0.001), 33% during lateral bending (p < 0.001), and 22% during axial rotation (p < 0.001). CONCLUSIONS Biomechanically, fixation with a novel technique in the thoracic spine involving transvertebral screws showed restoration of stability to well within the stability provided by PSR fixation.

Balloon kyphoplasty for treatment of sacral insufficiency fractures. Report of three cases.

Sacral insufficiency fracture is a painful injury, for which no effective treatment currently exists. The objective of this study was to report on the clinical outcomes and technical aspects of balloon kyphoplasty, which was used in three patients with this injury. Three elderly women with intractable pain from sacral insufficiency fractures were treated with polymethyl methacrylate (PMMA) injections into the sacrum by using a modified balloon kyphoplasty procedure. The visual analog scale pain score improved by four points in each case. Functional status was improved and analgesic medication requirements were decreased in all three patients. There were no complications associated with the procedure. Because of the unique anatomy of the sacrum, it was difficult to monitor instrument placement and PMMA injection by using conventional fluoroscopy. BrainLAB image guidance was used in one case, and was helpful in guiding instrument placement and assuring accurate PMMA deposition at the fracture site. Balloon kyphoplasty may be a treatment alternative in selected patients with sacral insufficiency fractures. BrainLAB image guidance may offer some advantages over conventional fluoroscopy with regard to the monitoring of instrument placement and PMMA injection.

A case series on the technical use of three-dimensional image guidance in subaxial anterior cervical surgery.

BACKGROUND: Three dimensional (3D) image guidance has been used to improve the safety of complex spine surgeries, but its use has been limited in anterior cervical spine approaches. METHODS: Twenty-two patients underwent complex anterior cervical spine surgeries in which 3D image guidance provided intraoperative assistance with the dissection, decompression and implant placement. One of two paired systems, the BrainLAB (BrainLAB, Westchester, Illinois) system, or Stealth (Medtronic Inc., Littleton, Massachusetts) system was used for 3D image guidance in this study. RESULTS: Image guidance was able to reliably locate pertinent anatomical structures in complex anterior cervical spine surgery involving re-exploration, dissection around vertebral arteries or deformity correction. No complications occurred, and no patients required a revision anterior surgery. CONCLUSION: This technical note describes the setup and technique for the use of cone beam computed tomography (cbCT)-based, 3D image guidance in subaxial anterior cervical surgery. The authors have found this technique to be a useful adjunct in revision anterior cervical procedures, as well as anterior cervical procedures involving corpectomy or tumor removal.

A retrospective study of iliac crest bone grafting techniques with allograft reconstruction: do patients even know which iliac crest was harvested? Clinical article.

OBJECT: Considerable biological research has been performed to aid bone healing in conjunction with lumbar fusion surgery. Iliac crest autograft is often considered the gold standard because it has the vital properties of being osteoconductive, osteoinductive, and osteogenic. However, graft site pain has been widely reported as the most common donor site morbidity. Autograft site pain has led many companies to develop an abundance of bone graft extenders, which have limited proof of efficacy. During the surgical consent process, many patients ask surgeons to avoid harvesting autograft because of the reported pain complications. The authors sought to study postoperative graft site pain by simply asking patients whether they knew which iliac crest was grafted when a single skin incision was made for the fusion operation. METHODS: Twenty-five patients underwent iliac crest autografting with allograft reconstruction during instrumented lumbar fusion surgery. In all patients the autograft was harvested through the same skin incision but with a separate fascial incision. At various points postoperatively, the patients were asked if they could tell which iliac crest had been harvested, and if so, how much pain did it cause (10-point Numeric Rating Scale). RESULTS: Most patients (64%) could not correctly determine which iliac crest had been harvested. Of the 9 patients who correctly identified the side of the autograft, 7 were only able to guess. The 2 patients who confidently identified the side of grafting had no pain at rest and mild pain with activity. One patient who incorrectly guessed the side of autografting did have significant sacroiliac joint degenerative pain bilaterally. CONCLUSIONS: Results of this study indicate the inability of patients to clearly define their graft site after iliac crest autograft harvest with allograft reconstruction of the bony defect unless they have a separate skin incision. This simple, easily reproducible pilot study can be expanded into a larger, multiinstitutional investigation to provide more definitive answers regarding the ideal, safe, and cost-effective bone graft material to be used in spinal fusions.

Radiographic fusion rate after implantation of facet bone dowels.

BACKGROUND CONTEXT: Achieving a posterolateral fusion in conjunction with performing decompressive laminectomies can prevent recurrence of stenosis or worsening of spondylolisthesis. Facet bone dowels have been introduced and marketed as a less invasive alternative to pedicle screws. Surgeons have been placing them during lumbar laminectomy surgery and coding for intervertebral biomechanical device and posterolateral fusion. These bone dowels have also been placed percutaneously in outpatient surgery centers and pain clinics for facet-mediated back pain. PURPOSE: To describe fusion outcomes in patients who underwent facet bone dowel placement. STUDY DESIGN/SETTING: Retrospective analysis of a single center's experience. PATIENT SAMPLE: Ninety-six patients comprise the entire cohort of patients who underwent facet bone dowel implantation at our institution with adequate postoperative imaging to determine fusion status. OUTCOME MEASURES: Fusion rates as determined on postoperative computed tomography (CT) scans and dynamic lumbar X-rays if CT is not available. METHODS: Threaded facet bone dowels in this study were placed according to the manufacturer's recommended methods. The bone dowels were placed after open exploration of the facet complex or percutaneously through a tubular retractor on the contralateral side from a microdiscectomy or synovial cyst resection. The most recent available postoperative imaging was reviewed to determine fusion status. RESULTS: Of 96 patients in our series, 6 (6.3%) had a fusion seen on CT and 4 did not exhibit any movement on dynamic lumbar X-rays for a total fusion rate of 10.4% (10/96). Eighty-six (89.6%) patients were shown on imaging to not have a solid fusion either by visualizing a patent facet joint on CT or measurable movement between the flexion and the extension lumbar X-rays. CONCLUSIONS: This article is mainly intended to question whether the implantation of facet bone dowels can produce a solid fusion radiographically. In our experience, the placement of facet bone dowels does not equal the time, skill, or attention to detail that is necessary for a posterolateral lumbar arthrodesis, and our follow-up radiographic studies clearly demonstrate an inadequate fusion rate.

Migration to the ICD-10 coding system: A primer for spine surgeons (Part 1).

BACKGROUND: On 1 October 2015, a new federally mandated system goes into effect requiring the replacement of the International Classification of Disease-version 9-Clinical Modification (ICD-9-CM) with ICD-10-CM. These codes are required to be used for reimbursement and to substantiate medical necessity. ICD-10 is composite with as many as 141,000 codes, an increase of 712% when compared to ICD-9. METHODS: Execution of the ICD-10 system will require significant changes in the clinical administrative and hospital-based practices. Through the transition, diminished productivity and practice revenue can be anticipated, the impacts of which the spine surgeon can minimizeby appropriate education and planning. RESULTS: The advantages of the new system include increased clarity and more accurate definitions reflecting patient condition, information relevant to ambulatory and managed care encounters, expanded injury codes, laterality, specificity, precise data for safety and compliance reporting, data mining for research, and finally, enabling pay-for-performance programs. The disadvantages include the cost per physician, training administrative staff, revenue loss during the learning curve, confusion, the need to upgrade hardware along with software, and overall expense to the healthcare system. CONCLUSIONS: With the deadline rapidly approaching, gaps in implementation result in delayed billing, delayed or diminished reimbursements, and absence of quality and outcomes data. It is thereby essential for spine surgeons to understand their role in transitioning to this new environment. Part I of this article discusses the background, coding changes, and costs as well as reviews the salient features of ICD-10 in spine surgery.

Implementation and impact of ICD-10 (Part II).

BACKGROUND: The transition from the International Classification of Disease-9(th) clinical modification to the new ICD-10 was all set to occur on 1 October 2015. The American Medical Association has previously been successful in delaying the transition by over 10 years and has been able to further postpone its introduction to 2015. The new system will overcome many of the limitations present in the older version, thus paving the way to more accurate capture of clinical information. METHODS: The benefits of the new ICD-10 system include improved quality of care, potential cost savings, reduction of unpaid claims, and improved tracking of healthcare data. The areas where challenges will be evident include planning and implementation, the cost to transition, a shortage of qualified coders, training and education of the healthcare workforce, and a loss of productivity when this occurs. The impacts include substantial costs to the healthcare system, but the projected long-term savings and benefits will be significant. Improved fraud detection, accurate data entry, ability to analyze cost benefits with procedures, and enhanced quality outcome measures are the most significant beneficial factors with this change. RESULTS: The present Current Procedural Terminology and Healthcare Common Procedure Coding System code sets will be used for reporting ambulatory procedures in the same manner as they have been. ICD-10-PCS will replace ICD-9 procedure codes for inpatient hospital services. The ICD-10-CM will replace the clinical code sets. Our article will focus on the challenges to execution of an ICD change and strategies to minimize risk while transitioning to the new system. CONCLUSION: With the implementation deadline gradually approaching, spine surgery practices that include multidisciplinary health specialists have to anticipate and prepare for the ICD change in order to mitigate risk. Education and communication is the key to this process in spine practices.