Pacific Spine and Pain Society (PSPS) Evidence Review of Surgical Treatments for Lumbar Degenerative Spinal Disease: A Narrative Review.

INTRODUCTION: Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments. METHODS: The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria. RESULTS: The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis. CONCLUSIONS: There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes.

American Society of Pain and Neuroscience Best Practice (ASPN) Guideline for the Treatment of Sacroiliac Disorders.

Clinical management of sacroiliac disease has proven challenging from both diagnostic and therapeutic perspectives. Although it is widely regarded as a common source of low back pain, little consensus exists on the appropriate clinical management of sacroiliac joint pain and dysfunction. Understanding the biomechanics, innervation, and function of this complex load bearing joint is critical to formulating appropriate treatment algorithms for SI joint disorders. ASPN has developed this comprehensive practice guideline to serve as a foundational reference on the appropriate management of SI joint disorders utilizing the best available evidence and serve as a foundational guide for the treatment of adult patients in the United States and globally.

Blood pressure cuff-induced radial nerve palsy following minimally invasive lateral microdiscectomy: illustrative case.

BACKGROUND: The authors describe a rare case of transient postoperative wrist and finger drop following a prone position minimally invasive surgery (MIS) lateral microdiscectomy. OBSERVATIONS: Hand and wrist drop is an unusual complication following spine surgery, especially in prone positioning. The authors' multidisciplinary team assessed a patient with this complication following MIS lateral microdiscectomy. The broad differential diagnosis included radial nerve palsy, C7 radiculopathy, stroke, and spinal cord injury. Given the patient's supinator weakness, intact pronation and wrist flexion, and transient recovery within 4 weeks, the most likely diagnosis was radial nerve neuropraxia secondary to ischemic compression. After careful consideration of the operative environment and anatomical constraints, the patient's blood pressure cuff was found to be the most probable source of compression. LESSONS: Blood pressure cuff-induced peripheral nerve injury may be a source of postoperative radial nerve neuropraxia in patients undergoing spine surgery. Careful considerations must be given to the blood pressure cuff location, which should not be placed at the distal end of the humerus due to higher susceptibility of peripheral nerve compression. Spine surgeons should be aware of and appropriately localize postoperative deficits along the neuroaxis, including central versus proximal or distal peripheral injuries, in order to guide appropriate postoperative management.

Nerve transfers for restoration of upper extremity motor function in a child with upper extremity motor deficits due to transverse myelitis: case report.

Transverse myelitis (TM) may result in permanent neurologic dysfunction. Nerve transfers have been developed to restore function after peripheral nerve injury. Here, we present a case report of a child with permanent right upper extremity weakness due to TM that underwent nerve transfers. The following procedures were performed: double fascicle transfer from median nerve and ulnar nerve to the brachialis and biceps branches of the musculocutaneous nerve, spinal accessory to suprascapular nerve, and medial cord to axillary nerve end-to-side neurorraphy. At 22 months, the patient demonstrated excellent recovery of elbow flexion with minimal improvement in shoulder abduction. We propose that the treatment of permanent deficits from TM represents a novel indication for nerve transfers in a subset of patients.

The impact of interbody approach and lumbar level on segmental, adjacent, and sagittal alignment in degenerative lumbar pathology: a radiographic analysis six months following surgery.

BACKGROUND CONTEXT: Interbody fusion, including: transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF); effectively treat lumbar degenerative pathology and provide spinopelvic balance. Although the decision on surgical approach and technique are multifactorial and patient specific, the impact of the interbody approach on segmental and adjacent level lordosis could be an important factor to consider during pre-operative planning to achieve pre-specified alignment goals. PURPOSE: The purpose of this study is to compare the 6-month postoperative radiographic outcomes in the lumbar spine following 1 to 2 level transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF) interbody fusions at the L3-4, L4-5, and L5-S1 levels. As our primary outcome, we evaluated the change in segmental lordosis at the level of fusion in ALIF/LLIF approaches compared to TLIF/PLIF. Secondarily, we evaluated the pelvic incidence to lumbar lordosis (PI-LL) mismatch and examined the compensatory lordotic changes at the adjacent levels 6 months following surgery. STUDY DESIGN: Retrospective cohort. PATIENT SAMPLE: This retrospective study included 18 centers of various practice settings across the United States. Patients were included in the study if they underwent a one- or two-level primary lumbar fusion for degenerative pathology. OUTCOMES MEASURES: Measurements of the pre-operative and 6-month post-operative lumbar AP and lateral lumbar plain radiographs included: pelvic incidence (PI), pelvic tilt, lumbar lordosis from L1-S1 (LL), as well as segmental lordosis (SL) of each segment between L1-S1. METHODS: Due to there being 2 evaluated time points, patients were then grouped based on alignment into categories of preserved, restored, not corrected, and worsened. RESULTS: 474 patients underwent 608 levels of fusion. ALIF/LLIF resulted in significantly more segmental lordosis compared to TLIF/PLIF procedures at both L4-5 and L5-S1 (p<.001). Overall, ALIF/LLIF resulted in significantly more global lumbar lordotic alignment change compared to TLIF/PLIF (p=.01). Whether patients' alignment was preserved versus worsened was not significantly predicted by type of procedure. Similarly, whether patients' alignment was restored versus not corrected was not significantly predicted by type of procedure. Finally, anterior approaches resulted in decreased lordosis at adjacent levels, thus resulting in a more neutral position. CONCLUSION: In this large multicenter retrospective study of 1 to 2 level interbody fusion surgeries, we identified that A/LLIF procedures at L4-L5 and L5-S1 resulted in greater segmental lordosis restoration and PI-LL mismatch improvement compared to T/PLIF procedures. A/LLIF may also significantly reduce lordosis (compared to T/PLIF) at the adjacent levels in a fashion that serves to reduce the lumbar lordosis that may have been increased at the fused level.

Strategies to avoid wrong-site surgery during spinal procedures.

Wrong-site surgery (WSS) is a rare occurrence that can have devastating consequences for patient care. There are several factors inherent to spine surgery that increase the risk of WSS compared with other types of surgery. Not only can a surgeon potentially operate on the wrong side of the spine or the wrong level, but there are unique issues related to spinal localization that can be challenging for even the most experienced clinicians. The following review discusses important issues that can help prevent WSS during spinal procedures.

Dorsal rhizotomy for treatment of bilateral intercostal neuralgia following augmentation mammaplasty: case report and review of the literature.

Intercostal neuralgia may develop following breast augmentation. The authors describe a woman who suffered 2 years of severe pain associated with cutaneous hypaesthesia in a T3-T5 distribution. Serial, placebo-controlled T3-T5 dorsal root nerve blocks provided temporary pain relief. The patient experienced immediate and lasting pain relief (34 months) following bilateral T3-T5 dorsal rhizotomies. This case provides anecdotal evidence that dorsal rhizotomy is a beneficial intervention for refractory intercostal neuralgia.

Magnetic resonance neurography-surgical correlation of neurologic thoracic outlet syndrome.

For evaluation of thoracic outlet syndrome (TOS), 3 Tesla magnetic resonance neurography (MRN) is being increasingly used. The authors report the findings on 3 T MRN with surgical correlation in a rare case of neurologic TOS caused by anomalous costal pseudoarthrosis.

The Role of Vancomycin Powder During Spinal Cord Stimulator Implantation: A Case Series and Review of the Literature.

OBJECTIVE: We examined the role of intrawound vancomycin powder as prophylaxis against postoperative surgical site infection (SSI) after spinal cord stimulator (SCS) implantation. METHODS: We performed a retrospective analysis of 153 consecutive patients who had undergone permanent SCS implantation surgery via open laminectomy between 2014 and 2020. We queried the patients' medical records for patient age, sex, relevant medical history, and whether intrawound vancomycin had been administered. We compared the rates of SSI (primary outcome) and seroma (secondary outcome) within 3 months after surgery between the vancomycin and no-vancomycin groups. Finally, we conducted multivariable logistic regression analyses to identify independent predictors of postoperative SSI or seroma. RESULTS: Of the 153 patients, 59% were women, and the average age was 65.4 years. Overall, 3 patients (2%) had developed an SSI: 2 (methicillin-resistant Staphylococcus aureus, Klebsiella) in the vancomycin group and 1 (methicillin-sensitive Staphylococcus aureus) in the no-vancomycin group. This difference in SSI rate between the 2 groups was insignificant (P = 0.73). Three seromas, all in the no-vancomycin group, accounted for a statistically significant difference in seroma formation between the 2 groups (P = 0.04). Multivariate logistic regression failed to identify any perioperative characteristics as independent predictors of postoperative SSI or seroma. CONCLUSIONS: Our experience suggests open laminectomy for SCS implantation surgery can be performed with a low postoperative SSI rate, with or without the use of powdered vancomycin. We found no evidence suggesting that the use of powdered vancomycin is unsafe or related to postoperative seroma formation. We failed to draw any definitive conclusions regarding its efficacy, despite referencing the largest single case series of SCS implantation to date.

Treatment for thoracic outlet syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) is one of the most controversial clinical entities in medicine. Despite many reports of operative and non-operative interventions, rigorous scientific investigation of this syndrome leading to evidence based management is lacking. OBJECTIVES: To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of thoracic outlet syndrome. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (July 2009), The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2009), MEDLINE (January 1966 to June 2009), EMBASE (January 1980 to June 2009), CINAHL (January 1981 to June 2009 ), AMED (January 1985 to June 2009 ) and reference lists of articles. SELECTION CRITERIA: We selected randomized or quasi-randomized studies in any language of participants with the diagnosis of any type of thoracic outlet syndrome (neurogenic, vascular, and 'disputed'). The primary outcome measure was change in pain rating on a validated visual analog or similar scale at least six months after the intervention. The secondary outcomes were change in muscle strength and adverse effects of the interventions. DATA COLLECTION AND ANALYSIS: Four authors independently selected the trials to be included and extracted data. The one included study was rated for risk of bias according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS: This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosis of TOS by the investigators in the reviewed studies. There were no studies comparing natural progression with any active intervention. In one trial with a high risk of bias involving 55 participants transaxillary first rib resection decreased pain more than supraclavicular neuroplasty of the brachial plexus. There were no adverse effects in either group. AUTHORS' CONCLUSIONS: This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty but no randomized evidence that either is better than no treatment. There is no randomized evidence to support the use of other currently used treatments. There is a need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.

Multidisciplinary management of primary tumors of the vertebral column.

OPINION STATEMENT: Primary spinal neoplasms are rare tumors that can lead to significant morbidity secondary to local bone destruction and invasion into adjacent neurological and vascular structures. These tumors represent a clinical challenge to even the most experienced physicians and require a multidisciplinary approach to ensure optimal patient outcomes. This review will discuss the most common primary bone tumors and focus on recent surgical, medical, and radiation treatment advances.

A Novel 3D Printed Titanium Implant for Anterior Cervical Discectomy and Fusion.

Cervical spondylosis is a common age-related disorder that results in pain, radiculopathy, and myelopathy. A retrospective chart and radiograph review of a 50-year-old male who underwent surgical treatment for correction of cervical radiculopathy was performed. Immediately after surgery the patient reported complete relief of his preoperative arm pain. In two weeks, he had recovered full strength and sensation. Six months postoperatively, the patient reported relief of all pain and complete recovery of strength and sensation. Anterior cervical discectomy and fusion (ACDF) with an open architecture titanium implant was successfully utilized to improve cervical radiculopathy. This technique increases the likelihood of fusion and improved patient outcome. The objective of the report is to highlight the treatment of cervical radiculopathy through anterior cervical discectomy and fusion with a 3D printed titanium alloy with an arched design and large porous openings. This is one of the first reports using this interbody device in a multilevel procedure.

Computed tomography reconstruction artifact suggesting cervical spine subluxation.

Use of computed tomography (CT) imaging for evaluation of the cervical spine following blunt trauma is both an efficient and reliable method for detecting injury. As a result, many trauma centers and emergency departments rely exclusively on CT scans to acutely clear the cervical spine of injury. Although quite sensitive for detecting bone injury, CT may be associated with a low sensitivity for detecting herniated discs, injured soft tissue or ligaments, and dynamic instability. In addition, CT-generated artifact may obscure pathological findings. In this case report, we describe the course of a patient whose CT scan harbored CT-generated artifact that suggested traumatic subluxation of the cervical spine. Clinicians should be aware of such artifact and how to recognize it when basing clinical management on such studies.

Mechanical hyperalgesia after an L5 spinal nerve lesion in the rat is not dependent on input from injured nerve fibers.

An injury to a peripheral nerve in animals often leads to signs of neuropathic pain including hyperalgesia to heat, cold and mechanical stimuli. The role of injured and intact nerve fibers in mechanical hyperalgesia was evaluated in rats subjected to an L5 spinal nerve ligation-and-cut ('modified SNL lesion'). To assess the contribution of injured afferents, an L5 dorsal rhizotomy was performed immediately before, or 7 days after the modified SNL lesion. To study the role of adjacent intact spinal nerves, an L4 dorsal rhizotomy was performed 7 days after the modified SNL lesion. The up-down method of Dixon (Dixon WJ, Annu Rev Pharmacol Toxicol 1980;20:441-462) was used to measure the paw withdrawal threshold to mechanical stimuli at three sites on the rat hindpaw corresponding to the L3, L4, and L5 dermatomes. We found that the modified SNL lesion produced a significant, lasting (20 days) decrease of the mechanical withdrawal threshold. The severity and duration of mechanical hyperalgesia varied across testing sites. The L5 and L4 dermatome test sites developed the most severe and lasting mechanical hyperalgesia. In contrast, the L3 testing site developed significantly less severe and shorter lasting mechanical hyperalgesia. L5 dorsal rhizotomy, by itself, produced a transient decrease in mechanical withdrawal thresholds. L5 dorsal rhizotomy performed before, or 7 days after, the modified SNL lesion did not prevent or resolve the observed decrease in mechanical withdrawal thresholds. L4 dorsal rhizotomy performed 7 days after the modified SNL lesion resulted in an immediate reversal of mechanical withdrawal thresholds back to baseline values. These results suggest that, after L5 spinal nerve ligation-and-cut, mechanical hyperalgesia develops and persists independent of input from injured afferents. We propose that the Wallerian degeneration that develops after a nerve injury leads to interactions between the degenerating fibers of the injured spinal nerve and the intact fibers of adjacent spinal nerves. This leads to changes in the intact fibers that play a critical role for both initiation and maintenance of mechanical hyperalgesia.

Mechanical hyperalgesia after an L5 ventral rhizotomy or an L5 ganglionectomy in the rat.

An L5 spinal nerve ligation (SNL) in the rat leads to behavioral signs of mechanical hyperalgesia. Our recent finding that an L5 dorsal root rhizotomy did not alter the mechanical hyperalgesia following an L5 SNL suggests that signals originating from the proximal stump of the injured nerve are not essential. We postulate that Wallerian degeneration of L5 nerve fibers leads to altered properties of adjacent intact nociceptive afferents. To investigate the role of degeneration in sensory versus motor fibers, five injury models were examined concurrently in a blinded fashion. An L5 ganglionectomy produced a selective lesion of sensory fibers. An L5 ventral root rhizotomy produced a selective lesion of motor fibers. The three control lesions included: (1) SNL with L5 dorsal root rhizotomy; (2) L5 dorsal root rhizotomy; and (3) exposure of the L5 roots without transection (sham). Paw withdrawal thresholds to mechanical stimuli were measured at three sites in the rat hindpaw corresponding to the L3, L4, and L5 dermatomes. Both the ganglionectomy and the ventral rhizotomy produced a significant, lasting (>or=20 d) decrease of mechanical withdrawal thresholds that was comparable to that produced by the SNL lesion. The L5 dorsal rhizotomy, by itself, produced a short lasting (

Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons.

OBJECT: Brachial plexus injuries (BPIs) are often devastating events that lead to upper-extremity paralysis, rendering the limb a painful extraneous appendage. Fortunately, there are several nerve repair techniques that provide restoration of some function. Although there is general agreement in the medical community concerning which patients may benefit from surgical intervention, the actual repair technique for a given lesion is less clear. The authors sought to identify and better define areas of agreement and disagreement among experienced peripheral nerve surgeons as to the management of BPIs. METHODS: The authors developed a detailed survey in two parts: one part addressing general issues related to BPI and the other presenting four clinical cases. The survey was mailed to 126 experienced peripheral nerve physicians and 49 (39%) participated in the study. The respondents represent 22 different countries and multiple surgical subspecialties. They performed a mean of 33 brachial plexus reconstructions annually. Areas of significant disagreement included the timing and indications for surgical intervention in birth-related palsy, treatment of neuroma-in-continuity, the best transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for motor neurotization, and the use of distal or proximal coaptation during nerve transfer. CONCLUSIONS: Experienced peripheral nerve surgeons disagree in important ways as to the management of BPI. The decisions made by the various treating physicians underscore the many areas of disagreement regarding the treatment of BPI, including the diagnostic approach to defining the injury, timing of and indications for surgical intervention in birth-related palsy, the treatment of neuroma-in-continuity, the choice of nerve transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for neurotization, and the use of distal or proximal coaptation during nerve transfer.

Paraspinal nerve sheath tumors.

Spinal tumors compose a vast heterogeneous group of neoplasms that are classified by origin into vertebral column, spinal canal, or paraspinal region tumors. Tumors with both intraspinal (intracanalicular) and paraspinal (extracanalicular) components that communicate via an intravertebral foramen are defined as "dumbbell tumors." This article focuses on the characteristics of a few types of paraspinal tumors, with special emphasis on the management of nerve sheath dumbbell tumors.

Intracerebral abscess with dissecting pneumocephalus caused by a gas-producing gram-positive rod following craniotomy for glioblastoma multiforme resection.

Propionibacterium acnes (P. acnes), an indolent and slow-growing anaerobic gram-positive bacterium, has largely been known as a commensal organism of the normal skin flora. However, P. acnes is increasingly being recognized as the causative infectious organism complicating craniotomies and shunt insertions. To our knowledge, we present the first reported patient with an intracerebral abscess with dissecting pneumocephalus caused by P. acnes. A 58-year-old woman who was immunocompetent presented 3 weeks after a craniotomy for resection of a glioblastoma multiforme with worsening mental status, lethargy and left hemiparesis. Head CT scans and MRI demonstrated significant vasogenic edema and dissecting pneumocephalus in the resection cavity. A craniotomy was performed and purulent material was found in the subdural space and resection cavity. Cultures were positive for P. acnes. She completed a full course of intravenous antibiotics appropriate for the organism. The infection was eradicated and the patient survived albeit with persistent deficits. This case illustrates the importance of considering an underlying intracerebral abscess in patients with worsening neurological function and pneumocephalus on imaging several weeks after surgery. Our review of the literature underscores the great importance in early recognition and treatment with both surgical debridement and antibiotic therapy in achieving optimal patient recovery.

"Can't walk nor raise arms to head": Harvey Cushing's surgical treatment of poliomyelitis.

STUDY DESIGN: This study was a retrospective chart review for patients undergoing operative treatment by Dr. Harvey Cushing at the Johns Hopkins Hospital between 1896 and 1912. OBJECTIVE: To illustrate the early use of peripheral nerve anastomoses for the treatment of postpoliomyelitis paralysis. SUMMARY OF BACKGROUND DATA: At the turn of the 20th century, poliomyelitis was recognized as a disease of neurons; neurological surgeons sought to find a surgical cure for the paralysis occurring after the disease onset. Peripheral nerve anastomoses were an attractive option employed during this time. METHODS: Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, the surgical records of the Johns Hopkins Hospital from 1896 to 1912 were reviewed. A single case of peripheral nerve anastomosis for the treatment of postpoliomyelitis paralysis was selected for further analysis. RESULTS: Cushing performed a multiple peripheral nerve anastomoses in a 3-year-old girl. Although the patient experienced no postoperative complications, there was no improvement in her function at the time of discharge from the hospital, and no long-term follow-up was available. CONCLUSION: While unsuccessful, Cushing's use of peripheral nerve anastomoses to restore motor function in the pediatric patient described here demonstrates his commitment to pushing the boundaries of neurological surgery at the turn of the 20th century.