Harrison J. Westwick

Complications related to the use of spinal cord stimulation for managing persistent postoperative neuropathic pain after lumbar spinal surgery

OBJECT Structural spinal surgery yields improvement in pain and disability for selected patients with spinal stenosis, spondylolisthesis, or a herniated intervertebral disc. A significant fraction of patients exhibit persistent postoperative neuropathic pain (PPNP) despite technically appropriate intervention, and such patients can benefit from spinal cord stimulation (SCS) to alleviate suffering. The complication profile of this therapy has not been systematically assessed and, thus, was the goal of this review. METHODS A comprehensive literature search was performed to identify prospective cohorts of patients who had PPNP following structurally corrective lumbar spinal surgery and who underwent SCS device implantation. Data about study design, technique of SCS lead introduction, and complications encountered were collected and analyzed. Comparisons of complication incidence were performed between percutaneously and surgically implanted systems, with the level of significance set at 0.05. RESULTS Review of 11 studies involving 542 patients formed the basis of this work: 2 randomized controlled trials and 9 prospective cohorts. Percutaneous implants were used in 4 studies and surgical implants were used in 4 studies; in the remainder, the types were undefined. Lead migration occurred in 12% of cases, pain at the site of the implantable pulse generator occurred in 9% of cases, and wound-related complications occurred in 5% of cases; the latter 2 occurred more frequently among surgically implanted devices. CONCLUSIONS Spinal cord stimulation can provide for improved pain and suffering and for decreased narcotic medication use among patients with PPNP after lumbar spinal surgery. This study reviewed the prospective studies forming the evidence base for this therapy, to summarize the complications encountered and, thus, best inform patients and clinicians considering its use. There is a significant rate of minor complications, many of which require further surgical intervention to manage, including lead migration or implant infection, although such complications do not directly threaten patient life or function.

Complication avoidance in the resection of spinal meningiomas.

BACKGROUND Surgical resection is considered the treatment of choice for spinal meningiomas and can be safe and effective; however, neurologic and surgical complications occur. This article reviews the factors that may predict susceptibility to this postoperative decline and addresses therapeutic choices, adjunctive therapies, and technologic applications that may help avoid complications. METHODS A literature search was conducted for articles related to spinal meningiomas addressing surgical treatment, adjuvant treatment, and technologic applications related to management and minimizing of complications. RESULTS There were 16 surgical series identified, comprising 1090 patients with median mortality of 1% (range, 0%-4%), nonneurologic surgical morbidity of 4% (range, 0%-24%), and permanent neurologic deterioration of 6% (range, 0%-21%). Common complications were cerebrospinal fluid leaks and fistulas, venous thromboembolic disease, myocardial infarction, and neurologic deterioration with either transient or permanent neurologic deficits. Predictive risk factors of neurologic decline included pathoanatomic features of lesion calcification, anterior dural attachment, infiltrative tumor, and tumoral adherence to the spinal cord and patient-specific factors of preoperative neurologic and advanced age. CONCLUSIONS Alongside surgery, selection of more direct approaches and use of adjuvant radiotherapy in patients with higher grade lesions and recurrent disease may lead to improved outcomes. New technologies, including microsurgical technique, intraoperative electrophysiologic monitoring, intraoperative ultrasound, and ultrasonic aspiration, may improve the safety and limit the complications of resection.

Effects of sex on the incidence and prognosis of spinal meningiomas: a Surveillance, Epidemiology, and End Results study

OBJECT Most spinal meningiomas are intradural lesions in the thoracic spine that present with both local pain and myelopathy. By using the large prospective Surveillance, Epidemiology, and End Results (SEER) database, the authors studied the incidence of spinal meningiomas and examined demographic and treatment factors predictive of death. METHODS Using SEER*Stat software, the authors queried the SEER database for cases of spinal meningioma between 2000 and 2010. From the results, tumor incidence and demographic statistics were computed; incidence was analyzed as a function of tumor location, pathology, age, sex, and malignancy code. Survival was analyzed by using a Cox proportional hazards ratio in SPSS for age, sex, marital status, primary site, size quartile, treatment modality, and malignancy code. In this analysis, significance was set at a p value of 0.05. RESULTS The 1709 spinal meningiomas reported in the SEER database represented 30.7% of all primary intradural spinal tumors and 7.9% of all meningiomas. These meningiomas occurred at an age-adjusted incidence of 0.193 (95% CI 0.183-0.202) per 100,000 population and were closely related to sex (337 [19.7%] male patients and 1372 [80.3%] female patients). The Cox hazard function for mortality in males was higher (2.4 [95% CI1.7-3.5]) and statistically significant, despite the lower lesion incidence in males. All-cause survival was lowest in patients older than 80 years. Primary site and treatment modality were not significant predictors of mortality. CONCLUSIONS Spinal meningiomas represent a significant fraction of all primary intradural spinal tumors and of all meningiomas. The results of this study establish the association of lesion incidence and survival with sex, with a less frequent incidence in but greater mortality among males.

Successful management of a giant anterior sacral meningocele with an endoscopic cutting stapler: case report

Anterior sacral meningoceles (ASMs) are rare defects in the sacrum with thecal sac herniations and symptoms that commonly include constipation, dysmenorrhea, and urinary disturbances. An ASM causing hydronephrosis and acute renal failure from compression of the lower portion of the urinary tract is a rare clinical entity. Only one other case has been reported. The authors present the case of a 37-year-old man admitted for obstructive renal failure and hydronephrosis due to a giant ASM that measured 25 × 12 × 18 cm and compressed the ureters and bladder. The ASM was successfully treated via an anterior transabdominal approach in which the authors used a novel technique for watertight closure of the meningocele pedicle with an endoscopic cutting stapler. The authors review the literature and discuss the surgical options for the treatment of ASMs, specifically the management of ASMs in the context of obstructive renal failure and hydronephrosis.

Incidence and Prognosis of Spinal Hemangioblastoma: A Surveillance Epidemiology and End Results Study.

Objective: Intradural spinal hemangioblastoma are infrequent, vascular, pathologically benign tumors occurring either sporadically or in association with von Hippel-Lindau disease along the neural axis. Described in fewer than 1,000 cases, literature is variable with respect to epidemiological factors associated with spinal hemangioblastoma and their treatment. The objective of this study was to evaluate the epidemiology of intradural spinal hemangioblastoma with the Surveillance, Epidemiology and End Results (SEER) database while also presenting an illustrative case. Methods: The SEER database was queried for cases of spinal hemangioblastoma between 2000 and 2010 with the use of SEER*Stat software. Incidence was evaluated as a function of age, sex and race. Survival was evaluated with the Cox proportionate hazards ratio using IBM SPSS software evaluating age, sex, location, treatment modality, pathology and number of primaries (p = 0.05). Descriptive statistics of the same factors were also calculated. The case of a 43-year-old patient with a surgical upper cervical intramedullary hemangioblastoma is also presented. Results: In the data set between 2000 and 2010, there were 133 cases with an age-adjusted incidence of 0.014 (0.012-0.017) per 100,000 to the standard USA population. Hemangioblastoma was the tenth most common intradural spinal tumor type representing 2.1% (133 of 6,156) of all spinal tumors. There was no difference in incidence between men and women with an female:male rate ratio of 1.05 (0.73-1.50) with p = 0.86. The average age of patients was 48.0 (45.2-50.9) years, and a lower incidence was noted in patients <15 years compared to all other age groups (p < 0.05). There was no difference in incidence amongst the different races. Treatment included surgical resection in 106 (79.7%) cases, radiation with surgery in 7 (5.3%) cases, and radiation alone was used in only 1 (0.8%) case, and no treatment was performed in 17 (12.8%) cases. Mortality was noted in 12 (9%) cases, and median survival of 27.5 months (range 1-66 months) over the 10-year period. Mortality was attributable to the malignancy in 3 (2%) cases. There was no statistically significant different in Cox hazard ratios for mortality for sex, race, treatment modality, pathology or number of primaries. Conclusions: Spinal hemangioblastoma represent a small fraction of primary intradural spinal tumors, and this study did not identify any difference in incidence between genders. Surgical treatment alone was the most common treatment modality. Overall prognosis is good, with 9% observed mortality over the 10-year period, with 2% mortality attributable to the malignancy.

Acute spontaneous cervical disc herniation causing rapidly progressive myelopathy in a patient with comorbid ossified posterior longitudinal ligament: Case report and literature review.

Background: Ossification of the posterior longitudinal ligament (OPLL) and cervical disc herniation are commonly encountered neurosurgical conditions. Here we present an unusual case of nontraumatic rapidly progressive myelopathy due to cervical disc herniation with comorbid OPLL and conduct a literature review focusing on the frequency and management of disc herniations with OPLL. Case Description: A 52-year-old healthy female presented with a 72-h history of rapid progression of dense quadriparesis with sensory deficits, with a precedent 4-week history of nontraumatic midline neck pain. Clinical examination revealed profound motor deficits below the C5 myotome. Spinal neuroimaging revealed OPLL (computed tomography [CT]) and a cervical disc herniation spanning from C4/5 to C5/6 with significant retrovertebral disease (magnetic resonance imaging [MRI]). Operative management involved an anterior cervical corpectomy and instrumented fusion, with removal of both the sequestered disc material and the locally compressive OPLL. The patient recovered full motor function and independent ambulation with no residual signs or symptoms of myelopathy at the time of discharge. Conclusion: This unique case of a spontaneous cervical disc herniation in the context of OPLL causing rapidly progressive myelopathy illustrates the complementarity of CT and MRI in diagnosing the underlying cause of a rapidly progressive neurologic deficit in the absence of antecedent trauma. Though the optimal surgical management of such pathology remains uncertain; in this case, the anterior approach was motivated by the significant retrovertebral ventrally compressive sequestrum, and provided for excellent neurologic outcome. This article also reviews the occurrence/management of such acute cervical discs with OPLL.

Colloidal stability of superparamagnetic iron oxide nanoparticles in the central nervous system: a review

Superparamagnetic iron oxide nanoparticles (SPIONs) consist of nanosized metallic-based particles with unique magnetic properties. Their potential in both diagnostic and therapeutic applications in the CNS is at the source of an expanding body of the literature in recent years. Colloidal stability of nanoparticles represents their ability to resist aggregation and is a central aspect for the use of SPION in biological environment such as the CNS. This review gives a comprehensive update of the recent developments and knowledge on the determinants of colloidal stability of SPIONs in the CNS. Factors leading to aggregate formation and the repercussions of colloidal instability of SPION are reviewed in detail pertaining to their use in the CNS.

Mini-open oblique lumbar interbody fusion (OLIF) approach for multi-level discectomy and fusion involving L5–S1: Preliminary experience

STUDY DESIGN Technical description and single institution retrospective case series. OBJECTIVE Evaluate technical feasibility and evaluate complications of mini-open retroperitoneal oblique lumbar interbody fusion (OLIF) at the L5-S1 level. SUMMARY OF BACKGROUND The mini-open retroperitoneal oblique lumbar interbody fusion (OLIF) approach was first described in 2012 as a surgical approach to achieve spinal fusion while limiting invasiveness of the exposure to the anterior lumbar spine. Surgeons who use this approach, along with those who described it in cadaveric studies describe it as a feasible approach in targeting the L2 down to the L5 level and recommend alternative approaches to the L5-S1 level due to the vascular challenges and possible complications. METHODS Technical description and single institution case series of patients treated with the OLIF between 2013 and 2015 at the L5-S1 level. The previously described surgical approach was modified by identifying and ligating the iliolumbar vein before retracting the iliac artery and vein anteriorly instead of passing between the vessels. RESULTS Six patients (3 males, 3 females, mean age 62 years) were operated between 2013 and 2015. There were no vascular injuries or peripheral nerve trauma associated with the surgical procedure. Complications associated with the procedure included: cage displacement immediately postoperative requiring re-operation in one patient, transient psoas weakness in one patient, extended hospital stay for pain control in one patient, and transfusion was required in one patient. CONCLUSIONS Mini-open retroperitoneal oblique lumbar interbody fusion is feasible at the L5-S1 level with limited vascular complications through a technical modification for safe mobilization of the iliac vessels by first ligating the iliolumbar vein.

Subaxial Cervical Spine Alignment After C1 to C2 Fusion

Atlantoaxial fusion is a common strategy for managing segmental C1 to C2 spinal instability, with an incidence of postoperative subaxial instability (kyphosis and subaxial subluxation) of up to 40%. Our objective was to conduct a literature review of atlantoaxial fusion postoperative subaxial instability, addressing incidence, specific risk factors, and management. An online PubMed/MEDLINE and EMBASE search for subaxial deformity associated with atlantoaxial fusion was conducted. Sixteen research studies addressing atlantoaxial postoperative subaxial instability were identified. Subaxial kyphosis and subaxial subluxation were the primary cervical postoperative deformities identified, with incidences of each reported as high as in 40% of patients. A relationship between atlantoaxial fusion angle and C2 to C7 angulation was identified. Risk factors for such deformity include C1 to C2 fusion hyperlordosis, spontaneous subaxial vertebral fusion, rheumatoid arthritis, and selected fusion techniques. Management strategies including subaxial cervical fusion are discussed.

Imaging of spontaneous intraventricular rupture of a septum pellucidum colloid cyst: case report.

Intraventricular rupture of a colloid cyst is a rare phenomenon and has been proposed as a mechanism for sudden death in patients with colloid cysts. Imaging of a colloid cyst during rupture has been described in only one other instance. The authors report a highly unusual case of a 53-year-old man who presented with acute onset headaches and imaging findings of hydrocephalus caused by a colloid cyst originating from the septum pellucidum and superior surface of the roof of the third ventricle. Interestingly, the colloid cyst revealed imaging signs of intraventricular rupture characterized by a tail-like drainage of cystic contents into the occipital horn of the lateral ventricle. The patient was surgically treated with a craniotomy and transcallosal approach to the colloid cyst, where it was noted that the cyst wall was spontaneously open. This rare case highlights unique imaging findings of a rare event in an infrequent pathology confirmed with intraoperative microscopy. The authors further document the process of cyst rupture and speculate on its pathomechanisms.