Anthony M. DiGiorgio

Stereotactic navigation for the prepsoas oblique lateral lumbar interbody fusion: technical note and case series

The prepsoas retroperitoneal approach is a minimally invasive technique used for anterior lumbar interbody fusion. The approach may have a more favorable risk profile than the transpsoas approach, decreasing the risks that come with dissecting through the psoas muscle. However, the oblique angle of the spine in the prepsoas approach can be disorienting and challenging. This technical report provides an overview of the use of navigation in prepsoas oblique lateral lumbar interbody fusion in a series of 49 patients.

Women fare best following surgery for degenerative lumbar spondylolisthesis: A comparison of the most and least satisfied patients utilizing data from the Quality Outcomes Database

OBJECTIVE The American Association of Neurological Surgeons launched the Quality Outcomes Database (QOD), a prospective longitudinal registry that includes demographic, clinical, and patient-reported outcome (PRO) data, to measure the safety and quality of neurosurgical procedures, including spinal surgery. Differing results from recent randomized controlled trials have established a need to clarify the groups that would most benefit from surgery for degenerative lumbar spondylolisthesis. In the present study, the authors compared patients who were the most and the least satisfied following surgery for degenerative lumbar spondylolisthesis. METHODS This was a retrospective analysis of a prospective, national longitudinal registry including patients who had undergone surgery for grade 1 degenerative lumbar spondylolisthesis. The most and least satisfied patients were identified based on an answer of 1 and 4, respectively, on the North American Spine Society (NASS) Satisfaction Questionnaire 12 months postoperatively. Baseline demographics, clinical variables, surgical parameters, and outcomes were collected. Patient-reported outcome measures, including the Numeric Rating Scale (NRS) for back pain, NRS for leg pain, Oswestry Disability Index (ODI), and EQ-5D (the EuroQol health survey), were administered at baseline and 3 and 12 months after treatment. RESULTS Four hundred seventy-seven patients underwent surgery for grade 1 degenerative lumbar spondylolisthesis in the period from July 2014 through December 2015. Two hundred fifty-five patients (53.5%) were the most satisfied and 26 (5.5%) were the least satisfied. Compared with the most satisfied patients, the least satisfied ones more often had coronary artery disease (CAD; 26.9% vs 12.2%, p = 0.04) and had higher body mass indices (32.9 ± 6.5 vs 30.0 ± 6.0 kg/m2, p = 0.02). In the multivariate analysis, female sex (OR 2.9, p = 0.02) was associated with the most satisfaction. Notably, the American Society of Anesthesiologists (ASA) class, smoking, psychiatric comorbidity, and employment status were not significantly associated with satisfaction. Although there were no significant differences at baseline, the most satisfied patients had significantly lower NRS back and leg pain and ODI scores and a greater EQ-5D score at 3 and 12 months postoperatively (p < 0.001 for all). CONCLUSIONS This study revealed that some patient factors differ between those who report the most and those who report the least satisfaction after surgery for degenerative lumbar spondylolisthesis. Patients reporting the least satisfaction tended to have CAD or were obese. Female sex was associated with the most satisfaction when adjusting for potential covariates. These findings highlight several key factors that could aid in setting expectations for outcomes following surgery for degenerative lumbar spondylolisthesis.

Primary pain generator identification by CT–SPECT in a patient with low back pain: a case report

BackgroundChronic low back pain is one of the most common conditions encountered in the middle-age population. Identifying the primary pain generator is notoriously difficult. The computed tomography–single-photon emission computed tomography (CT–SPECT) is emerging as a new diagnostic modality for this purpose.Case presentationThis 68-year-old Caucasian male presented with intractable low back pain refractory to maximal conservative treatment, including medication and extensive physical therapy. The lumbar computed tomography, magnetic resonance imaging, and flexion–extension X-rays showed advanced degenerative changes throughout the lumbar spine, but no single level significantly worse than the others. The CT–SPECT showed markedly increased uptake at the L1–2 disc level and only minimal uptake at the other levels. The patient underwent a minimally invasive lateral L1–2 fusion with near-complete resolution of his low back pain.ConclusionsThe CT–SPECT may provide a unique tool in establishing the primary pain generator in patients with degenerative spine disease.

The Safety and Efficacy of CT-Guided, Fluoroscopy-Free Vertebroplasty in Adult Spinal Deformity Surgery

OBJECTIVEnThe goal of this study is to analyze the safety and efficacy of a novel technique of computed tomography-guided, fluoroscopy-free vertebroplasty as an adjunct to help prevent proximal junction kyphosis (PJK) in long-segment posterior spinal fusions.nnnMETHODSnWe performed a retrospective analysis of 118 consecutive patients with adult spinal deformity who underwent long-segment fusion with vertebroplasty augmentation from 2013-2016 at a single institution. For each patient, we collected demographics, surgical information, length of stay, discharge disposition, and complications, including reoperation, PJK, and PJK requiring reoperation. We reviewed all postoperative radiographs to assess for cement leakage from vertebroplasty. These patients were compared to a historical control of 253 patients who underwent adult spinal deformity surgery without vertebroplasty augmentation.nnnRESULTSnThe PJK rate of 14% and the PJK requiring reoperation rate of 3% in the cohort of 118 patients who underwent vertebroplasty-augmented fusion was significantly lower than that of the 253 historical controls at our institution who did not undergo vertebroplasty (40% PJK rate, 17% PJK-rate requiring reoperation; both P < 0.001). After controlling for patient and other surgical factors in multivariate analyses, vertebroplasty was significantly associated with lower rates of PJK and PJK requiring reoperation (P < 0.001 and Pxa0= 0.003).nnnCONCLUSIONSnOur novel vertebroplasty technique is safe, and it eliminates the need for additional fluoroscopy in cases already using the O-arm to verify screw placement. In addition, it is an effective technique for reducing PJK in adult spinal deformity surgery compared with historical institutional controls.

Sacro-Iliac Joint Fusion

The minimally invasive sacro-iliac joint fusion is a relatively new technique that has been shown to achieve good results. The SI joint is a recently recognized potential pain generator and the diagnosis requires a specific algorithm. The surgeon should always think of this potential source of pain in patients with back pain radiating to one of the legs and no concordant spinal pathology. While there are multiple available systems to perform this arthrodesis, they all aim to achieve at least three points of fixation through the joint.

Percutaneous Pedicle Screw/Rod Fixation

Percutaneous instrumented posterior fixation with pedicle screws and rods is frequently used. The insertion of the percutaneous pedicle screws is identical among the various platforms, whereas insertion of the rod can be done in three different ways, depending on the system utilized. The target entry point is at the junction of the lateral facet and the transverse process (or ala, for S1). We prefer to use beveled Jamshidi needles, since they provide better directional insertion.

Introduction to Minimally Invasive Spine Surgery

Minimally invasive spine surgery started at the turn of the century and many predicted it would soon become the standard of care. Nonetheless, almost twenty years later, these techniques are used in less than 20% of the procedures performed in the United States. While certainly multifactorial, some of the reasons for this slow adoption include the difficult learning curve, as well as the initially increased operative time (and thus decreased surgical volume and revenue) for the seasoned “open” surgeon who tries to convert to the new minimally invasive techniques. The goal of this book is to share almost 20 years of experience in teaching (and sometimes learning) the minimally invasive spinal surgery techniques to those who understand the benefits and want to embrace a better option for their patients.

Lateral Prepsoas (Oblique) Approach Nuances

The prepsoas oblique approach to the lumbar spine provides many similar benefits of the transpsoas lateral approach. Because the psoas is not traversed, however, many of the postoperative complications associated with psoas violation are reduced. Working at an oblique angle to the spine can be challenging and the approach may be unfamiliar for the surgeon. Thais article provides a technical description and nuances of the approach.

Safety and effectiveness of early chemical deep venous thrombosis prophylaxis after spinal cord injury: pilot prospective data

OBJECTIVE Spinal cord injuries (SCIs) occur in approximately 17,000 people in the US each year. The average length of hospital stay is 11 days, and deep venous thrombosis (DVT) rates as high as 65% are reported in these patients. There is no consensus on the appropriate timing of chemical DVT prophylaxis for this critically injured patient cohort. The object of this study was to determine if low-molecular-weight heparin (LMWH) was safe and effective if given within 24 hours of SCI. METHODS The Transforming Research and Clinical Knowledge in SCIs study is a prospective observational study conducted by the UCSF Brain and Spinal Injury Center. Protocol at this center includes administration of LMWH within 24 hours of SCI. Data were retrospectively reviewed to determine DVT rate, pulmonary embolism (PE) rate, and hemorrhagic complications. RESULTS Forty-nine patients were enrolled in the study. There were 3 DVTs (6.1%), 2 PEs (4.1%), and no hemorrhagic complications. Regression modeling did not find an association between DVT and/or PE and age, American Spinal Injury Association grade, sex, race, or having undergone a neurosurgical procedure. CONCLUSIONS A standardized protocol in which LMWH is given to patients with SCI within 24 hours of injury is effective in keeping venous thromboembolism at the lower end of the reported range, and is safe, with a zero rate of adverse bleeding events.

The Case for Deformity Correction in the Management of Radiculopathy with Concurrent Spinal Deformity

The management of adult deformity varies significantly. Options range from nonoperative care to limited decompression to decompression with limited or extensive fusion. The appropriate surgical management is the approach that optimizes the likelihood of improvement in health-related quality of life, while limiting risks of complications and costs. Decompression alone is unreliable in the setting of significant deformity contributing to radiculopathy. Decompression with limited fusion is most appropriate for patients with age-appropriate global alignment of the spine, and decompression with more extensive fusion is most appropriate for patients with progressive deformity or with global sagittal or coronal malalignment.