The role of Vertebral Augmentation Procedures in the management of vertebral compression fractures secondary to multiple myeloma.

Multiple myeloma (MM) is a systemic disorder characterised by proliferation of B-lymphocytes and plasma cells in the bone marrow. The primary aims of the management of spinal lesions in MM are pain control and fracture stabilisation. Vertebral augmentation procedures (VAP) can be subdivided into percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP). BKP involves the placement of orthopaedic balloons into the fractured vertebral body, creating a void into which polymethylmethacrylate bone cement is injected. This review outlines the management of spinal lesions in patients with MM, with a focus on the comparative risks and efficacy of vertebroplasty (VP) and balloon kyphoplasty (BKP). Soft tissue masses in MM are highly radiosensitive. Bisphosphonates and newer oncological therapies have decreased the indications for palliative radiotherapy, while spinal bracing can be utilised in selected cases to provide stability. BKP and VP provide equivalent long term pain control after MM vertebral compression fractures (VCF). BKP is superior to non-operative management and VP for restoration of vertebral body height and prevention of segmental kyphosis. Current evidence suggests a greater degree of correction of kyphotic deformity and restoration of mid vertebral height (MVH) with BKP when compared with VP. The literature supports the use of BKP even in the presence of posterior vertebral body wall (PVBW) fractures, a group previously considered a contraindication to VAP. Superior functional outcomes have been reported in patients undergoing early versus delayed BKP (<6-8 weeks). Current evidence supports a lower risk of cement extrusion with BKP than with VP, but serious complications following VAP are rare. MM spinal pathology should be managed in a multidisciplinary setting. Surgical decompression and instrumentation are rarely indicated, due to the radio-sensitivity of soft tissue lesions in MM. BKP is a safe and effective procedure for VCF secondary to MM.

Patterns in neurosurgical adverse events: endovascular neurosurgery.

As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in endovascular neurosurgery concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. Based on a review of the literature, thromboembolic events appeared to be the most common adverse events in endovascular neurosurgery, with a reported incidence ranging from 2% to 61% depending on aneurysm rupture status and mode of detection of the event. Intraprocedural and periprocedural prevention and rescue regimens are advocated to minimize this risk; however, evidence on the optimal use of anticoagulant and antithrombotic agents is limited. Furthermore, it is unknown what proportion of eligible patients receive any prophylactic treatment. Groin-site hematoma is the most common access-related complication. Data from the cardiac literature indicate an overall incidence of 9% to 32%, but data specific to neuroendovascular therapy are scant. Manual compression, compression adjuncts, and closure devices are used with varying rates of success, but no standardized protocols have been tested on a broad scale. Contrast-induced nephropathy is one of the more common causes of hospital-acquired renal insufficiency, with an incidence of 30% in high-risk patients after contrast administration. Evidence from medical fields supports the use of various preventive strategies. Intraprocedural vessel rupture is infrequent, with the reported incidence ranging from 1% to 9%, but it is potentially devastating. Improvements in device technology combined with proper endovascular technique play an important role in reducing this risk. Occasionally, anatomical or technical difficulties preclude treatment of the lesion of interest. Reports of such occurrences are scant, but existing series suggest an incidence of 4% to 6%. Management strategies for radiation-induced effects are also discussed. The incidence rates are unknown, but protective techniques have been demonstrated. Many of these complications have strategies that appear effective in reducing their risk of occurrence, but development and evaluation of systematic guidelines and protocols have been widely lacking. Furthermore, there has been little monitoring of levels of adherence to potentially effective practices. Protocols and monitoring programs to support integrated implementation may be broadly effective.

Patterns in neurosurgical adverse events: intracranial neoplasm surgery.

OBJECT: Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to measuring and improving outcomes. As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in cranial tumor resection concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. METHODS: The authors performed a PubMed search using search terms "intracranial neoplasm," "cerebral tumor," "cerebral meningioma," "glioma," and "complications" or "adverse events." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to maximize the range of rates of occurrence for the reported adverse events. RESULTS: Review of the tumor neurosurgery literature showed that documented overall complication rates ranged from 9% to 40%, with overall mortality rates of 1.5%-16%. There was a wide range of types of adverse events overall. Deep venous thromboembolism (DVT) was the most common adverse event, with a reported incidence of 3%-26%. The presence of new or worsened neurological deficit was the second most common adverse event found in this review, with reported rates ranging from 0% for the series of meningioma cases with the lowest reported rate to 20% as the highest reported rate for treatment of eloquent glioma. Benign tumor recurrence was found to be a commonly reported adverse event following surgery for intracranial neoplasms. Rates varied depending on tumor type, tumor location, patient demographics, surgical technique, the surgeon's level of experience, degree of specialization, and changes in technology, but these effects remain unmeasured. The incidence on our review ranged from 2% for convexity meningiomas to 36% for basal meningiomas. Other relatively common complications were dural closure-related complications (1%-24%), postoperative peritumoral edema (2%-10%), early postoperative seizure (1%-12%), medical complications (6%-7%), wound infection (0%-4%), surgery-related hematoma (1%-2%), and wrong-site surgery. Strategies to minimize risk of these events were evaluated. Prophylactic techniques for DVT have been widely demonstrated and confirmed, but adherence remains unstudied. The use of image guidance, intraoperative functional mapping, and real-time intraoperative MRI guidance can allow surgeons to maximize resection while preserving neurological function. Whether the extent of resection significantly correlates with improved overall outcomes remains controversial. DISCUSSION: A significant proportion of adverse events in intracranial neoplasm surgery may be avoidable by use of practices to encourage use of standardized protocols for DVT, seizure, and infection prophylaxis; intraoperative navigation among other steps; improved teamwork and communication; and concentrated volume and specialization. Systematic efforts to bundle such strategies may significantly improve patient outcomes.

Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery.

OBJECT: As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in CSF shunt surgery concerning the frequency of adverse events in practice, their patterns, and the state of knowledge regarding methods for their reduction. This review may also inform future and ongoing efforts for the advancement of neurosurgical quality. METHODS: The authors performed a PubMed search using search terms "cerebral shunt," "cerebrospinal fluid shunt," "CSF shunt," "ventriculoperitoneal shunt," "cerebral shunt AND complications," "cerebrospinal fluid shunt AND complications," "CSF shunt AND complications," and "ventriculoperitoneal shunt AND complications." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the adverse events reported. RESULTS: In this review of the neurosurgery literature, the reported rate of mechanical malfunction ranged from 8% to 64%. The use of programmable valves has increased but remains of unproven benefit even in randomized trials. Infection was the second most common complication, with the rate ranging from 3% to 12% of shunt operations. A meta-analysis that included 17 randomized controlled trials of perioperative antibiotic prophylaxis demonstrated a decrease in shunt infection by half (OR 0.51, 95% CI 0.36-0.73). Similarly, use of detailed protocols including perioperative antibiotics, skin preparation, and limitation of OR personnel and operative time, among other steps, were shown in uncontrolled studies to decrease shunt infection by more than half. Other adverse events included intraabdominal complications, with a reported incidence of 1% to 24%, intracerebral hemorrhage, reported to occur in 4% of cases, and perioperative epilepsy, with a reported association with shunt procedures ranging from 20% to 32%. Potential management strategies are reported but are largely without formal evaluation. CONCLUSIONS: Surgery for CSF shunt placement or revision is associated with a high complication risk due primarily to mechanical issues and infection. Concerted efforts aimed at large-scale monitoring of neurosurgical complications and consistent quality improvement within these highlighted realms may significantly improve patient outcomes.

Patterns in neurosurgical adverse events: open cerebrovascular neurosurgery.

OBJECT: As part of a project to devise evidence-based safety interventions for specialty surgery, we sought to review current evidence concerning the frequency of adverse events in open cerebrovascular neurosurgery and the state of knowledge regarding methods for their reduction. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. METHODS: The authors performed a PubMed search using search terms "cerebral aneurysm", "cerebral arteriovenous malformation", "intracerebral hemorrhage", "intracranial hemorrhage", "subarachnoid hemorrhage", and "complications" or "adverse events." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the reported adverse events. RESULTS: The review revealed hemorrhage-related hyperglycemia (incidence rates ranging from 27% to 71%) and cerebral salt-wasting syndromes (34%-57%) to be the most common perioperative adverse events related to subarachnoid hemorrhage (SAH). Next in terms of frequency was new cerebral infarction associated with SAH, with a rate estimated at 40%. Many techniques are advocated for use during surgery to minimize risk of this development, including intraoperative neurophysiological monitoring, but are not universally used due to surgeon preference and variable availability of appropriate staffing and equipment. The comparative effectiveness of using or omitting monitoring technologies has not been evaluated. The incidence of perioperative seizure related to vascular neurosurgery is unknown, but reported seizure rates from observational studies range from 4% to 42%. There are no standard guidelines for the use of seizure prophylaxis in these patients, and there remains a need for prospective studies to support such guidelines. Intraoperative rupture occurs at a rate of 7% to 35% and depends on aneurysm location and morphology, history of rupture, surgical technique, and surgeon experience. Preventive strategies include temporary vascular clipping. Technical adverse events directly involving application of the aneurysm clip include incomplete aneurysm obliteration and parent vessel occlusion. The rates of these events range from 5% to 18% for incomplete obliteration and 3% to 12% for major vessel occlusion. Intraoperative angiography is widely used to confirm clip placement; adjuncts include indocyanine green video angiography and microvascular Doppler ultrasonography. Use of these technologies varies by institution. DISCUSSION: A significant proportion of these complications may be avoidable through development and testing of standardized protocols to incorporate monitoring technologies and specific technical practices, teamwork and communication, and concentrated volume and specialization. Collaborative monitoring and evaluation of such protocols are likely necessary for the advancement of open cerebrovascular neurosurgical quality.

The effect of operative timing on functional outcome after isolated spinal trauma.

BACKGROUND: To evaluate the effect of operative timing on functional outcome in patients suffering spinal trauma, we conducted a retrospective analysis of the National Trauma Data Bank. By treating time to operation as a categorical variable and limiting our analysis to isolated spinal trauma, we hypothesized that time to operation would not be a predictor of functional outcome. METHODS: The National Trauma Data Bank was queried for all patients with isolated spinal trauma who underwent spinal fixation or decompression. Functional outcomes at the time of hospital discharge were measured using Functional Independent Motor Locomotion Score. Generalized ordered logistic model was used to determine the effect of time until operation on functional outcomes. Gender, age, injury severity, the level of trauma center, and the presence of spinal cord injury were included as covariates. RESULTS: Of the final sample of 1,848 patients (mean age 44.3 years), 78% were White and 71% male. Fifty-seven percent of patients had Injury Severity Score between 8 and 15, with the remainder having Injury Severity Score ≤8. Forty-five percent were treated at a Level I trauma center. Using generalized ordered logistic regression, time to operation was not a significant predictor of functional outcomes, whereas treatment at Level I trauma centers seemed to confer marginally better outcomes. CONCLUSIONS: In patients with isolated spinal trauma, time until spinal operation does not seem to be an important predictor of functional outcome at the time of hospital discharge. Operative timing, at the discretion of the surgeon, needs to consider the risks and benefits associated with delayed versus emergent operation.

Chronic Low Back Pain Occurring in Association With Hypermobility Spectrum Disorder and Ehlers-Danlos Syndrome.

BACKGROUND: This review paper outlines recent advances in diagnostic criteria for hypermobility spectrum disorder (HSD) and its association with Ehlers-Danlos syndrome (EDS), as well as current literature on the association between joint hypermobility syndrome and lumbar back pain. We outline the optimal multidisciplinary management of lumbar back pain in the context of joint hypermobility syndrome, as well as the indications and possible side effects of surgical management of patients with these conditions.Several studies have suggested a link between chronic low back pain and hypermobility. HSD has been described as an excessive range of motion in a joint, when accounting for patient demographics. The nomenclature surrounding symptomatic joint hypermobility has varied historically, and various groups, including most notably the international EDS consortium, have introduced new classification schemes to acknowledge the systemic effects of joint hypermobility, which were previously poorly understood. METHODS: Narrative literature review. RESULTS: Not applicable. CONCLUSIONS: Lower back pain experienced in patients on the HSD-EDS spectrum is multifactorial in origin and should not be considered solely in anatomical terms. Caution has been advised in the surgical management of patients on the HSD-hEDS spectrum, particularly where the subtype is unclear. The vascular type of EDS has a particular propensity for severe bleeding complications. Rates of perioperative complications after lumbar spinal surgery in the hypermobile EDS population have been reported to be up to 50%. When hypermobility and chronic lumbar back pain coexist, we advocate management in a multidisciplinary setting involving physiotherapists, pain physicians, surgeons, and psychologists.

Lumbar Percutaneous Pedicle Screw Breach Rates: A Comparison of Robotic Navigation Platform Versus Conventional Techniques.

STUDY DESIGN: Cadaveric study. SUMMARY OF BACKGROUND DATA: Pedicle screw fixation is an established means of stabilizing the thoracic and lumbar spine. However, there are associated complications including pedicle breach which can result in neurological injury, durotomy, vascular injury, and suboptimal fixation. OBJECTIVE: The aim of this study is to determine whether use of a navigated robotic platform results in fewer pedicle breaches and the underlying reasons for any difference in pedicle breach rates. MATERIALS AND METHODS: Ten board-certified neuro- and orthopedic spine surgeons inserted 80 percutaneous lumbar screws in 10 unembalmed human cadavers. Forty screws were inserted using conventional fluoroscopic guidance and 40 were inserted using a navigated robotic platform. None of the participating surgeons had any prior experience with navigated robotic spine surgery. At the end of the study each screw was assessed with a computed tomography scan, plain radiographs and visual inspection to determine the presence or absence of pedicle breaches. RESULTS: Forty percent (40%) of screws inserted using conventional fluoroscopic guidance breached compared with 2.5% of screws inserted with robot assistance (P=0.00005). Lateral breaches accounted for 88.2% (15/17) of all breaches. Detailed analysis revealed that the starting point of screws that breached laterally were significantly more lateral than that of the contralateral accurate screw (P=0.016). Pedicle screw diameter, length, and angulation in the transverse plane did not differ significantly between accurate screws and those that breached (P>0.05). CONCLUSIONS: The use of a navigated robotic platform in the present study resulted in significantly fewer pedicle breaches. This was achieved through correct starting point selection with subsequent safe pedicle screw insertion.

The role of artificial intelligence in orthopaedic surgery.

Despite significant advances in orthopaedic surgery, variability still exists between providers and practice locations, and process inefficiencies are found throughout the health care continuum. Evolving technologies, namely artificial intelligence, challenge the status quo by improving patient care in four areas: diagnosis, management, research and systems analysis. Artificial intelligence shows promise in promoting practice efficiency, personalizing patient care, improving institutional research capacity, and expanding high quality orthopaedic care to lower resource settings. Physicians should be involved in the development of artificial intelligence algorithms to ensure that patients derive maximum benefit from new advances while considering the ethical challenges of implementation.

Assessment and management of adult spinal deformities.

Adult spinal deformity is a complex condition, increasing in prevalence, and occurring in a patient population in which it poses unique challenges. This review provides an overview of adult spinal deformity with a particular focus on its clinical evaluation, radiological assessment and classification, reviewing the current literature and amalgamating this with the authors' clinical experience.

Blunt vertebral vascular injury in trauma patients: ATLS® recommendations and review of current evidence.

Blunt cerebrovascular injury (BCVI) encompasses two distinct clinical entities: traumatic carotid artery injury (TCAI) and traumatic vertebral artery injury (TVAI). The latter is the focus of our review. These are potentially devastating injuries which pose a diagnostic challenge in the acute trauma setting. There is still debate regarding the optimal screening criteria, diagnostic imaging modality and treatment methods. In 2012 the American College of Surgeons proposed criteria for investigating patients with suspected TVAI and subsequent treatment methods, caveated with the statement that evidence is limited and still evolving. Here we review the historical evidence and recent literature relating to these recommendations.

Review article: Surgical approaches for correction of post-tubercular kyphosis.

This study reviewed the literature regarding the pros and cons of various surgical approaches (anterior, anterolateral, combined, and posterior) for correction of post-tubercular kyphosis. The anterior and anterolateral approaches are effective in improving neurological deficit but not in correcting kyphosis. The combined anterior and posterior approach and the posterior approach combined with 3-column osteotomy achieve good neurological improvement and kyphosis correction. The latter is superior when expertise and facilities are available.

Nasu-hakola syndrome: an unusual cause of pathological fractures.

Nasu-Hakola syndrome is a hereditary cause of pathological fractures. Uniquely, patients also develop neuropsychiatric symptoms and signs. The disease is ultimately fatal. We propose a management strategy for pathological fractures in sufferers based on the stage of the disease.

The routine use of tranexamic acid in hip and knee replacements.

PURPOSE: Our aim was to determine whether the administration of intravenous tranexamic acid is a safe and effective means of reducing blood loss associated with hip and knee replacement surgery. METHOD: Sequential cohort study analysing hemoglobin titers, transfusion rates, and the occurrence of venous thromboembolism in patients undergoing hip and knee replacements with and without the administration of tranexamic acid at the time of induction. Finally, a cost benefit analysis was performed. RESULTS: Two hundred and seventy-three patients were included in our study. We demonstrated that 1 gram of tranexamic acid administered intravenously at the time of induction significantly reduces operative blood loss and transfusion rates (p < 0.05). Moreover, the use of tranexamic acid reduces the costs associated with surgery. CONCLUSIONS: The administration of 1 gram of intravenous tranexamic acid is a safe and effective means of reducing operative blood loss and blood transfusion rates in patients undergoing hip and knee replacements.

Cervical C2 osteoma, unusual presentation and transoral approach for complete excision.

BACKGROUND CONTEXT: Osteoid osteomas are benign tumors of the bone with 10% occurring in the spine. The authors discuss a case of a 70-year-old lady with an unusual presentation of a cervical C2 osteoma. The presentation was with mild dysphagia and pressure symptoms behind the left ear similar to earache experienced on an aircraft at high altitude with no hearing loss. PURPOSE: The authors postulate that with the appropriate preoperative imaging, operation, and postoperative care, patients with C2 body osteomas can make a good recovery. STUDY DESIGN: This is the case of a patient with a C2 osteoma. METHODS: A swelling in the left tonsillar region was noted on examination. A computed tomography and magnetic resonance imaging scans revealed a lesion associated with the left half of the body of C2. En bloc excision was performed via the transoral route. RESULTS: The patient made a successful recovery. CONCLUSIONS: C2 osteomas are rare and the mode of presentation of the patient discussed is unique. Despite this, with careful planning, the transoral approach to upper cervical region is a direct and safe route for high cervical and base of skull pathology.