George R. Cybulski

Lower Extremity Functional Neuromuscular Stimulation in Cases of Spinal Cord Injury

&NA; Functional neuromuscular stimulation (FNS) provides a mechanism for the activation of muscles paralyzed by injury to the spinal cord. Although this technique was first used to treat patients with spinal cord injury over 20 years ago, only recent advances in electronics and biomechanics have made it a promising aid for the rehabilitation of these patients. Thus far, restoration of palmar prehension and lateral prehension in quadriplegics and of standing and biped gait in paraplegics has been achieved under carefully controlled laboratory conditions. This article reviews the current status of FNS and its potential as a practical tool to aid spinal cord‐injured patients. Neurosurgeons who care for these patients might be expected to be involved in the future use of FNS if implantable systems are developed and tested. (Neurosurgery 15:132‐146, 1984)

Methods of surgical stabilization for metastatic disease of the spine

&NA; A variety of surgical techniques is available for treatment of metastatic disease of the spine. Prior emphasis on the use of these procedures has been on their benefit as a palliative measure to relieve signs and symptoms of spinal cord and nerve root compression not aided by radiation therapy and corticosteroid administration. More recently, development of surgical techniques that combine neural decompression with restoration of spinal stability has brought about consideration of additional indications for surgery in the treatment of metastatic disease of the spine. The present scope of such surgical procedures is reviewed along with identification of the most reliable selection factors for surgical candidates in order to improve functional outcome from surgical treatment of metastatic disease of the spine. Over 70 surgical series with more than 2,000 patients treated were reviewed. (Neurosurgery 25:240‐252, 1989)

Use of Halifax interlaminar clamps for posterior C1-C2 arthrodesis

Eight patients with atlantoaxial instability secondary to trauma or rheumatoid arthritis were treated with posterior C1-C2 arthrodesis using the Halifax interlaminar clamp and autogenous bone graft or methylmethacrylate. Thus far, with an average follow-up of 6 months, satisfactory stability has been achieved with no instrument failure.

Predictors of unplanned readmission in patients undergoing lumbar decompression: multi-institutional analysis of 7016 patients.

OBJECT Unplanned hospital readmission represents a large financial burden on the Centers for Medicare and Medicaid Services, commercial insurance payers, hospitals, and individual patients, and is a principal target for cost reduction. A large-scale, multi-institutional study that evaluates risk factors for readmission has not been previously performed in patients undergoing lumbar decompression procedures. The goal of this multicenter retrospective study was to find preoperative, intraoperative, and postoperative predictive factors that result in unplanned readmission (UR) after lumbar decompression surgery. METHODS The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all patients who received lumbar decompression procedures in 2011. Risk-adjusted multivariate logistic regression analysis was performed to estimate independent predictors of UR. RESULTS The overall rate of UR among patients undergoing lumbar decompression was 4.4%. After multivariate logistic regression analysis, anemia (odds ratio [OR] 1.48), dependent functional status (OR 3.03), total operative duration (OR 1.003), and American Society of Anesthesiologists Physical Status Class 4 (OR 3.61) remained as independent predictors of UR. Postoperative complications that were significantly associated with UR included overall complications (OR 5.18), pulmonary embolism (OR 3.72), and unplanned reoperation (OR 56.91). CONCLUSIONS There were several risk factors for UR after lumbar spine decompression surgery. Identification of high-risk patients and appropriate allocation of resources to reduce postoperative incidence may reduce the readmission rate.

Intraoperative neurophysiological monitoring in spine surgery: indications, efficacy, and role of the preoperative checklist

Spine surgery carries an inherent risk of damage to critical neural structures. Intraoperative neurophysiological monitoring (IONM) is frequently used to improve the safety of spine surgery by providing real-time assessment of neural structures at risk. Evidence-based guidelines for safe and efficacious use of IONM are lacking and its use is largely driven by surgeon preference and medicolegal issues. Due to this lack of standardization, the preoperative sign-in serves as a critical opportunity for 3-way discussion between the neurosurgeon, anesthesiologist, and neuromonitoring team regarding the necessity for and goals of IONM in the ensuing case. This analysis contains a review of commonly used IONM modalities including somatosensory evoked potentials, motor evoked potentials, spontaneous or free-running electromyography, triggered electromyography, and combined multimodal IONM. For each modality the methodology, interpretation, and reported sensitivity and specificity for neurological injury are addressed. This is followed by a discussion of important IONM-related issues to include in the preoperative checklist, including anesthetic protocol, warning criteria for possible neurological injury, and consideration of what steps to take in response to a positive alarm. The authors conclude with a cost-effectiveness analysis of IONM, and offer recommendations for IONM use during various forms of spine surgery, including both complex spine and minimally invasive procedures, as well as lower-risk spinal operations.

Standing performance of persons with paraplegia

This study measures standing stability of four individuals with paraplegia using knee-ankle-foot orthoses (KAFOs) with a center-of-force monitoring platform as compared with similar data from 10 neurologically healthy subjects. Both groups were compared under conditions of quiet standing with eyes open and closed and with hands on and off parallel bars. Individuals with paraplegia were also tested under similar conditions with the ankles of their KAFOs mechanically unlocked and with bilateral functional neuromuscular stimulation of the quadriceps muscles. Sway path, mean amplitude, and mean frequency were measured for each subject. We found that postural stability in paraplegic individuals using KAFOs compared favorably with the control group under conditions of eyes open and closed with hands on parallel bars; however, visual information was much more important for paraplegic individuals during quiet stance. Unlocking the ankles of the KAFOs resulted in an increase in swap path and mean frequency. Functional muscular stimulation of the quadriceps muscles resulted in standing stability slightly less than with KAFOs. Although KAFOs may not be the ideal assistive device for various reasons, postural stability appears reasonable, and other proposed orthoses must be comparable in order to be considered as an alternative.

Spinal extradural angiolipoma: A report of two cases and review of the literature

Extradural angiolipomas are rare tumors that can produce spinal cord compression. Two patients with thoracic spinal angiolipoma are presented that were treated with surgical resection and radiation. The histological and clinical features of the 18 previously reported cases of these tumors are discussed.

Outcome of laminectomy for civilian gunshot injuries of the terminal spinal cord and cauda equina: review of 88 cases.

Case records of 88 patients with low-velocity gunshot injuries of the terminal spinal cord and cauda equina treated by laminectomy at Cook County Hospital between 1969 and 1987 were reviewed. Sixty-one patients were operated upon within 72 hours of injury, 29 of whom (47.5%) experienced neurological improvement or pain relief. Twenty-seven patients were operated upon at a later time for associated injuries, 13 of whom (48.1%) experienced neurological improvement or pain relief. When laminectomy was delayed for more than 2 weeks, either arachnoid adhesions (15%) or occult abscesses (17%) were observed. From this review as well as from the literature, it appears that the timing of laminectomy for gunshot injuries of the thoracolumbar and lumbosacral spine is not essential to neurological recovery. It appears, however, that adequate debridement of these injuries, performed as soon as the patient is stable from any associated injuries, may help to mitigate the late sequelae of arachnoiditis, infection, and pain syndromes in the lower extremities.

Predictors of thirty-day readmission after anterior cervical fusion.

Study Design. Retrospective cohort study. Objective. To determine the incidence of and factors predicting 30-day readmission after anterior cervical discectomy and fusion (ACDF). Summary of Background Data. ACDF is being performed on an increasing basis on a wider population of patients, which is accompanied by rising costs. Readmissions have the potential to further deplete health care resources. Although past studies have shown that readmissions after surgery are driven by operative complications, specific predictors of readmission after ACDF are not well researched. Methods. All patients who underwent ACDF or anterior corpectomy and fusion procedures in 2011 were selected from the American College of Surgeons National Quality Improvement database. Readmissions were analyzed on the basis of demographics, comorbidities, operative characteristics, and complications were compared in univariate analyses. Multivariate logistic regression models were created to isolate the independent effects of preoperative and postoperative factors on readmission. Results. The nationwide readmission rate after ACDF surgery in this study is 2.5%. Pulmonary complications (8.5%), wound complications (8.5%), and urinary tract infections (8.5%) are the most common complications seen in readmitted patients. Readmitted patients were significantly older (58 vs. 53, P = 0.003), with higher rates of diabetes and hypertension (28.8% vs. 13.9%, P = 0.001; 64.4% vs. 42.6%, P = 0.001, respectively). Although certain preoperative factors such as age 65 years or more and preoperative stay more than 24 hours increase the odds of operative complications (odds ratio, 3.5; 95% confidence interval, 2.0–6.0 and odds ratio, 6.2; 95% confidence interval, 3.4–11.1, respectively), hypertension may independently increase the likelihood of readmission outside of any effect on complications (odds ratio, 1.8; 95% confidence interval, 1.0–3.4). Conclusion. The data in this study suggests that surgeons are already controlling readmission rates by limiting peri- and postoperative complications, but patients with a history of hypertension could have an increased likelihood of being readmitted despite avoiding a complication. Level of Evidence: 3

Falcine chondrosarcoma: case report and literature review.

We present a case of falcine chondrosarcoma in a 58-year-old man. Only a few other examples of chondrosarcomas in this location and a total of approximately 50 intracranial cases have been reported. Because its rarity prevents any group of neurosurgeons from collecting a large experience in managing this tumor, we reviewed descriptions of previous cases to determine the natural history of intracranial chondrosarcomas. The distinguishing features of this rare tumor are compared with previous examples of intracranial tumors derived from cartilage and more common tumors in the parasagittal region, such as meningioma.