Bjarne Lied

Immediate (0–6 h), early (6–72 h) and late (>72 h) complications after anterior cervical discectomy with fusion for cervical disc degeneration; discharge six hours after operation is feasible

SummaryObjectives. The introduction of minimally invasive techniques and total intravenous anaesthesia has led to reports of the performance of anterior cervical discectomy and fusion as an outpatient. The safety of this approach, requires information about the complications presenting within this period. The aim of this study was to assess the rates and types of immediate (0–6 h), early (6–72 h) and late (>72 h) complications after anterior cervical discectomy with fusion.Methods. We prospectively studied complications after anterior cervical discectomy with fusion in patients with degenerative cervical disc disease. There were 390 consecutive operations: 278 fused with autologous iliac crest bone graft and 112 with a PEEK (Polyetheretherketone) graft.Results. No patient died. Thirty seven patients (9%) experienced one or more complications that could be related to the operation. These presented in the immediate, early and late periods in 17, 1 and 19 patients, respectively. Thus, 18/37 complications were detected before discharge from the neurosurgical department 48–72 h after operation and of these 17 (4.2%) were detected within the first 6 h after surgery. Each of the five potentially life-threatening neck hematomas was detected within 6 h (immediate).Conclusions. After anterior cervical discectomy and fusion, a 6 h postoperative observation period followed by discharge from the neurosurgical unit is likely to be as safe as observation as an inpatient for a longer period.

Long-term outcome after resection of intraspinal ependymomas: report of 86 consecutive cases.

BACKGROUND: Objective: To evaluate progression-free survival, overall survival (OS) and long-term clinical outcome in a consecutive series of 86 patients with intraspinal ependymomas. METHODS: Medical charts were retrospectively reviewed. Surviving patients voluntarily participated in a clinical history and physical examination that focused on neurological function and current tumor status. RESULTS: Follow-up data are nearly 100% complete; mean follow-up time was 82 months. Eighty-five patients (99%) had surgery as a first-line treatment; 14 (17%) of these patients received adjuvant radiotherapy. Of the 85 patients who underwent primary surgery, gross total resection was performed in 60 patients (71%) and subtotal resection in 25 patients (29%). Ten-year progression-free survival rate was 75%; 5-year OS, 97%; and 10-year OS, 91%. Reduced preoperative neurological function and older age at diagnosis were significantly associated with increased risk of death. At follow-up, spontaneous regression of residual tumor after primary surgery may have occurred in 7 of 19 patients (37%). More than 75% of patients had neurological function compatible with an independent life at follow-up. Good preoperative neurological function was significantly associated with favorable outcome. It was not possible to evaluate the effect of radiotherapy on progression-free survival and OS. CONCLUSION: Gross total resection remains the optimal treatment for patients with spinal ependymoma. Patients should be monitored with a clinical examination and magnetic resonance imaging at regular intervals up to 10 years after surgery.

The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway

AimThe aim of this study was to estimate the incidence of traumatic cervical spine fractures (CS-fx) in a general population.BackgroundThe incidence of CS-fx in the general population is largely unknown.MethodsAll CS-fx (C0/C1 to C7/Th1) patients diagnosed with cervical-CT in Southeast Norway (2.7 million inhabitants) during the time period from April 27, 2010-April 26, 2011 were prospectively registered in this observational cohort study.ResultsOver a one-year period, 319 patients with CS-fx at one or more levels were registered, constituting an estimated incidence of 11.8/100,000/year. The median age of the patients was 56 years (range 4–101 years), and 68% were males. The relative incidence of CS-fx increased significantly with age. The trauma mechanisms were falls in 60%, motorized vehicle accidents in 21%, bicycling in 8%, diving in 4% and others in 7% of patients. Neurological status was normal in 79%, 5% had a radiculopathy, 8% had an incomplete spinal cord injury (SCI), 2% had a complete SCI, and neurological function could not be determined in 6%. The mortality rates after 1 and 3 months were 7 and 9%, respectively. Among 319 patients, 26.6% were treated with open surgery, 68.7% were treated with external immobilization with a stiff collar and 4.7% were considered stable and not in need of any specific treatment. The estimated incidence of surgically treated CS-fx in our population was 3.1/100,000/year.ConclusionsThis study estimates the incidence of traumatic CS-fx in a general Norwegian population to be 11.8/100,000/year. A male predominance was observed and the incidence increased with increasing age. Falls were the most common trauma mechanism, and SCI was observed in 10%. The 1- and 3-month mortality rates were 7 and 9%, respectively. The incidence of open surgery for the fixation of CS-fx in this population was 3.1/100,000/year.Level of evidenceThis is a prospective observational cohort study and level II-2 according to US Preventive Services Task Force.

Outpatient anterior cervical discectomy and fusion for cervical disk disease: a prospective consecutive series of 96 patients

To evaluate surgical complications and clinical outcome in a consecutive series of 96 patients undergoing anterior cervical discectomy and fusion (ACDF) for cervical disk degeneration (CDD) in an outpatient setting.

Outpatient Cervical and Lumbar Spine Surgery is Feasible and Safe: A Consecutive Single Center Series of 1449 Patients.

BACKGROUND There is an increasing demand for surgery of degenerative spinal disease. Limited healthcare resources draw attention to the need for cost-effective treatments. Outpatient surgery, when safe and feasible, is more cost effective than inpatient surgery. OBJECTIVE To study types and rates of complications after outpatient lumbar and cervical spine decompressions. METHODS Complications were recorded prospectively in 1449 (1073 lumbar, 376 cervical) outpatients undergoing microsurgical decompression for degenerative spinal disease at the private Oslofjord Clinic from 2008 to 2013. RESULTS Surgical mortality was 0%. A total of 51 (3.5%) minor and major complications were recorded in 51 patients. Three (0.2%) patients had to be admitted to a hospital the day of surgery. Twenty-two (1.5%) patients were admitted to a hospital within 3 months due to surgery-related events. The encountered complications were postoperative hematoma (0.6%), neurological deterioration (0.3%), deep wound infection (0.9%), dural lesions with cerebrospinal fluid leakage (1.0%), persistent dysphagia (0.1%), persistent hoarseness (0.1%), and severe pain/headache (0.4%). All of the life-threatening hematomas were detected within 6 and 3 hours after cervical and lumbar surgery, respectively. CONCLUSION This series of 1449 consecutive outpatient microsurgical spine decompressions adds to the growing literature in favor of outpatient spinal surgery in properly selected patients. In our study, 99.8% of the patients were successfully discharged either to their homes or to a hotel on the day of surgery. The overall complication rate was 3.5%, surgical mortality was 0%, and only 1.5% had to be admitted to a hospital within 3 months after surgery.

Surgical mortality and complications leading to reoperation in 318 consecutive posterior decompressions for cervical spondylotic myelopathy.

Halvorsen CM, Lied B, Harr ME, Rønning P, Sundseth J, Kolstad F, Helseth E. Surgical mortality and complications leading to reoperation in 318 consecutive posterior decompressions for cervical spondylotic myelopathy.
Acta Neurol Scand: 2011: 123: 358–365.
© 2010 John Wiley & Sons A/S.

Surgical Management of Acute Odontoid Fractures: : surgery-related complications and long-term outcomes in a consecutive series of 97 patients

BACKGROUND: The purpose of this study was to determine the incidence of surgery for odontoid fractures and to study surgical mortality, surgical morbidity, and long-term outcome in a large, contemporary, consecutive, single-institution, surgical series of odontoid fractures. METHODS: This is a retrospective study of all odontoid fractures treated by open surgery at our hospital during 2002 to 2009. The fractures were classified according to Grauer. Follow-up data, clinical examinations, and cervical computed tomographies were collected in 2010. RESULTS: This study included 97 consecutive patients with a median age of 73.0 years. The incidence of open fixation of odontoid fractures in this population was 0.45 per 100,000, and the incidence increased with age. The fractures were classified as type IIA in 3 patients, type IIB in 63 patients, type IIC in 8 patients, and type III in 23 patients. Anterior fixation and posterior fixation were performed in 41 and 56 patients, respectively. Immediate postoperative neurologic status was unchanged or improved in 97% of the patients. None of the patients developed postoperative hematoma, wound infection, deep venous thrombosis, or pulmonary embolism. Eleven patients underwent resurgery during the follow-up period; five had suboptimal reposition after the first surgery, one had suboptimal position of an anterior odontoid screw, two had rupture of fixation materials, and three developed pseudarthrosis. Overall survival (OS) rates after 1, 12, and 24 months were 96%, 84%, and 75%, respectively. Fifty-seven patients were available for follow-up evaluation with a mean time of 37 months. Radiologic follow-up showed definite bony fusion in 82% of the patients and uncertain bony fusion in 18% of the patients. Flexion-extension radiographs were obtained in 6 of the 10 patients with uncertain bony fusion; 5 of these were defined as stable (fibrous union) and 1 was unstable. Multivariate logistic regression demonstrated increased odds of nonbony fusion in more displaced fractures (OR, 1.44; 95% CI, 1.04–2.16; p = 0.04) and when using the anterior fusion technique (OR, 0.17; 95% CI, 0.03–0.75; p = 0.02). There was no significant association between neck pain and fusion method (Mann-Whitney U test, p = 0.86). Patients treated with a posterior fusion approach had significantly more neck stiffness than patients who underwent fusion with an anterior odontoid screw (Fishers exact test, p = 0.04). CONCLUSIONS: The annual incidence of open fixation of odontoid fractures was 0.45 per 100,000 inhabitants, and the incidence increased with age. The median age at time of surgery was 73.0 years, and the surgical mortality was 4%. Increased odds of nonbony fusion were observed in more displaced fractures and after anterior screw fixations. There were no significant differences between patients treated with anterior screw fixation versus posterior wiring with respect to neck pain, but patients fused with a posterior approach reported significantly more neck stiffness.

The Long-term Outcome After Resection of Intraspinal Nerve Sheath Tumors: Report of 131 Consecutive Cases.

BACKGROUND The existing literature on recurrence rates and long-term clinical outcome after resection of intraspinal nerve sheath tumors is limited. OBJECTIVE To evaluate progression-free survival, overall survival, and long-term clinical outcome in a consecutive series of 131 patients with symptomatic intraspinal nerve sheath tumors. METHODS Medical charts were retrospectively reviewed. Surviving patients voluntarily participated in a clinical history and physical examination that focused on neurological function and current tumor status. RESULTS Follow-up data are 100% complete; median follow-up time was 6.1 years. All patients (100%) had surgery as the first line of treatment; gross total resection was performed in 112 patients (85.5%) and subtotal resection in 19 patients (14.5%). Five-year progression-free survival was 89%. The following risk factors for recurrence were identified: neurofibroma, malignant peripheral nerve sheath tumor, subtotal resection, neurofibromatoses/schwannomatosis, and advancing age at diagnosis. More than 95% of patients had neurological function compatible with an independent life at follow-up. The rate of tumor recurrence in nonneurofibromatosis patients undergoing total resection of a single schwannoma was 3% (3/93), in comparison with a recurrence rate of 32% (12/38) in the remaining patients. CONCLUSION Gross total resection is the gold standard treatment for patients with intraspinal nerve sheath tumors. In a time of limited health care resources, we recommend that follow-up be focused on the subgroup of patients with a high risk of recurrence. The benefit of long-term, yearly magnetic resonance imaging follow-up with respect to recurrence in nonneurofibromatosis patients undergoing gross total resection of a single schwannoma is, in our opinion, questionable. 1NF2, neurofibromatosis 2NST, nerve sheath tumorOS, overall survivalPFS, progression-free survivalSTR, subtotal resectionWHO, World Health Organization.

Minimally invasive microsurgical resection of primary, intradural spinal tumours using a tubular retraction system

Study design. This is a retrospective review of prospectively collected data. Background. Primary, intradural spinal tumours have traditionally been microsurgically resected following macrosurgical laminectomy or laminoplasty. We hypothesize that approach-related morbidity can be reducedwith less-invasive approaches; we have therefore implemented a minimally invasive approach, with the assistance of a tubular retraction system, for microsurgical resection of primary intradural spinal tumours. Methods. From January 2007 to December 2009, 54 patients underwent surgery for a spinal intradural tumour. Of these, nine patients who underwent minimally invasive posterior unilateral transmuscular surgery using a tubular retraction system were included in this study. Resection grade and surgery-related complications were retrospectively reviewed. Results. All tumours were totally resected (verified by postoperative magnetic resonance imaging). There were no post-operative complications. Eight of the nine patients were mobilized on the day of surgery or on post-operative day 1. One patient was mobilized on post-operative day 2. Conclusions. Selected primary, intradural spinal tumours can be safely and successfully resected using a minimally invasive posterior unilateral transmuscular approach with the assistance of a tubular retraction system.

160 Outpatient Surgery for Herniated Cervical Disc and Fusion Is Feasible and Safe: A Consecutive Single-Center Series of 759 Patients.

INTRODUCTION There is an increasing demand for surgery of degenerative spinal disease. Limited health care resources draw attention to the need for cost-effective treatments. Outpatient surgery, when safe and feasible, is more cost-effective than inpatient surgery. The aim of this study is to study types and rates of complications following surgery for herniated cervical disc and fusion. METHODS Complications were recorded prospectively in 759 outpatients undergoing outpatient cervical surgery at the private Oslofjord Clinic in the time period 2008 to 2015. RESULTS Surgical mortality was 0%. A total of 13 (1.7%) minor and major complications were recorded in 13 individual patients. Two (0.2%) patients had to be admitted to a hospital the day of surgery. The encountered complications were postoperative hematoma (0.3%), neurological deterioration (0.4%), deep wound infection (0.3%), dural lesions with cerebrospinal fluid leakage (0.1%), persistent dysphagia (0.4%), and persistent hoarseness (0.3%). All the life-threatening hematomas were detected within 3 hours after surgery. CONCLUSION This series of 759 consecutive outpatient cervical spine decompressions adds to the growing literature in favor of outpatient spinal surgery in properly selected patients. Of the patients, 99.8% were successfully discharged either to their homes or to a hotel on the day of surgery. The surgical mortality was 0%; the overall complication rate was 1.7%.