J. Patrick Johnson

Uniportal and biportal endoscopic thoracic sympathectomy

SYMPATHECTOMY FOR TREATMENT of hyperhidrosis and pain syndromes of the upper extremities has recently evolved from invasive open procedures to endoscopic procedures. These minimally invasive techniques also have evolved, from complex staged procedures with multiple ports to more simplified biportal and uniportal procedures that require minimal tissue disruption and more limited yet effective sympathectomy procedures. We describe our techniques, experience, and results using endoscopic sympathectomy procedures with further reduced invasiveness, morbidity, and complications.

Scoliosis surgery in the elderly: Complications, readmissions, reoperations and mortality

The operative management of scoliosis in the elderly remains controversial. The authors of this study sought to evaluate outcomes in elderly patients with scoliosis undergoing deformity correction. Patient data was obtained from a 5% sample of the Medicare Provided Analysis and Review database (MEDPAR). Patients over 65years of age with scoliosis undergoing corrective surgery were identified between the years 2005 to 2011. A total of 453 patients were analyzed: 262 (57%) between ages 66 to 74years, and 191 (42%) over the age of 75years. Female predominance (78%) was observed in this sample. Pre-diagnosis follow-up averaged 118months. Post-surgery follow-up averaged 33months. Patients between 66 and 74years old were mostly discharged home, while patients over the age of 75years were discharged to skilled nursing facilities (SNFs) (38.55% versus 34.04%, p value=0.0011). Readmission rates were lower in patients between 66 and 74years old when compared to patients over the age of 75years (9.92% versus 17.28%, p value=0.0217). Complication rates 30-days after discharge were less in patients between 66 and 74years, compared to those over 75years (21% versus 26.6%, respectively), but this was not statistically significant. These findings suggest varying outcomes following scoliosis surgery in the elderly, but interpretation of these results is weakened by the inherent limitations of database utilization. Future prospective studies are needed to understand risk factors and other confounding variables, such as discharge disposition, that may influence outcomes.

National trends following decompression, discectomy, and fusion in octogenarians and nonagenarians

BackgroundThe National Inpatient Sample (NIS) database is used to evaluate a wide variety of surgical procedures across a range of specialties. The authors of this study assess national trends of the three commonest spine procedures performed (decompression, fusion, and discectomy) in patients between the ages of 80 and 100xa0years (octogenarians and nonagenarians).MethodsThe NIS database was queried to identify patients between the ages of 80 and 100 with a primary diagnosis of spinal stenosis, disk herniation without myelopathy, or protrusion due to degeneration of spine/disk disorders and who have undergone spinal decompression, fusion, or discectomy between the years 1998 and 2011. Variables of concern included length-of-stay (LOS), non-routine discharge, average total charges, in-hospital complications, and mortality rate.ResultsDecompression was the most common procedure performed (nu2009=u2009113,267, 50.5%). Fusion (nu2009=u200960,345, 26.9%) was associated with the longest LOS (5.1xa0days), highest in-hospital complication and mortality rates (nu2009=u200913,170, 21.8% and nu2009=u2009449, 0.7%, respectively), most non-routine discharges (nu2009=u200942,662, 70.7%), and highest mean for average total charges (

Treatment patterns of children with spine and spinal cord tumors: national outcomes and review of the literature

69,295) (pu2009<u20090.001). Discectomy (nu2009=u200950,740, 22.6%), had the shortest LOS (3.7xa0days), lowest complication and mortality rates (nu2009=u20096823, 13.4% and nu2009=u2009102, 0.2%, respectively), fewest non-routine discharges (nu2009=u200922,861, 45.1%), and lowest mean for average total charges (

Hemangiopericytoma invading the craniovertebral junction: First reported case and review of the literature.

22,787) (pu2009<u20090.001).ConclusionsDecompression was most common. Fusion had the longest LOS, highest complication and mortality rates, most non-routine discharges, and was most expensive. Discectomy was least commonly performed, had the shortest LOS, lowest complication and mortality rates, fewest non-routine discharges, and was least expensive.

P105. Posterior atlantoaxial stabilization: a new alternative to C1-2 transarticular screws

BackgroundTumors of the spine in children are rare, and further clinical description is necessary.ObjectiveThis study investigated epidemiology, interventions, and outcomes of pediatric patients with spine and spinal cord tumors.MethodsThe National Inpatient Sample and Kids’ Inpatient Database were used for the study. Outcomes were studied, and bivariate significant trends were analyzed in a multivariate setting.ResultsAnalysis of 2870 patients between 2000 and 2009 found a median age of diagnosis of 11xa0years (Tables 1 and 2). Most were white (65.2%) and had private insurance (62.3%), and 46.8% of procedures were emergent operations. Treatment occurred at teaching (93.6%) and non-children’s hospitals (81.1%). Overall mortality rate was 1.7%, non-routine discharges occurred at a rate 19.9%, complications at 21.1%, and average total charges were

Posterior atlantoaxial stabilization

66,087. A majority of patients (87.5%) had no intervention, and of those patients receiving treatment, 78.2% underwent surgery and 23.1% had radiotherapy. Treatment with surgery alone increased significantly over time (pxa0<xa00.0001). Odds ratio (OR) of mortality was significantly higher in 2006 (OR 3.5) and 2009 (OR 2.6) when compared to 2000. Complications (OR 7.9) and disease comorbidities (OR 1.5) were associated with significantly increased odds of mortality.ConclusionsHospital characteristics, length of stay, and charges remained relatively unchanged. In recent years, there has been a decreasing incidence of spine and spinal cord tumors in children. Notably, a higher mortality rate is evident over time in addition to an increase in the proportion of patients undergoing surgery. The high percentage of emergent operations suggests a weak recognition of spine tumors in children and should prompt a call for increased awareness of this cancer. In spite of these findings, lack of tumor type identification was a limitation to this study.

Esophageal injury associated with anterior cervical spine surgery.

Occurrence of hemangiopericytoma (HPC) in the central nervous system is rare. Spinal HPCs with intramedullary involvement are even more unusual. We present a case of a craniovertebral intradural HPC with both extra- and intra-medullary extensions. Though the patient presented with vague cervical symptoms, imaging was indicative of an intradural lesion from the occiput to C4 and a second smaller, subclinical lesion, at the T2-3 level. He underwent gross total surgical resection of the craniovertebral lesion and did well post-operatively. The thoracic lesion was treated with radiosurgery and the patient is neurologically at baseline 5 years later. Gross total resection of HPCs is the recommended treatment when possible. Histopathology is crucial for diagnosis due to both its rarity and similar characteristics to other tumors on physical and radiographic evaluations. Recognizing that these uncommon tumors can occur with both extra-medullary and intra-medullarly locations are important for diagnosis and treatment recommendations. Future studies using national surgical databases that contain histology will be needed to understand the long-term clinical outcomes.

Access strategies for revision or explantation of the Charité lumbar artificial disc replacement

Abstract Purpose of study: Develop new techniques to improve safety and success of C1–C2 fusion procedures. Methods used: A standard posterior C1–C2 exposure is performed. Cross-table lateral fluoroscopy is used to guide and confirm screw trajectories. The C2 pedicle screw entry point is identified and drilled with angles 15 degrees medially and 25 degrees cephalad for pedicle cannulation. Drill depth is stopped short of the C2 transverse foramen. The C1 lateral mass screw insertion point is located beneath the posterior arch of C1 in the midposition of the lateral mass just above the C2 root. The drill is then angled 10 degrees medial to lateral and cephalad toward the anterior tubercle of C1 on lateral fluoroscopy. The C1–C2 joint is then decorticated and packed with local bone fragments. Posterior rods are contoured and connected to polyaxial screw heads, and a cross-connector is applied. of findings: This technique has been used in five cases of atlantoaxial instability at our institution during the past year. There have been no C2 nerve root or vertebral artery injuries. No construct failures have been observed during the current follow-up. Relationship between findings and existing knowledge: C1 lateral mass and C2 pedicle screw fixation offers an alternative means of atlantoaxial fusion. The technique is less demanding than C1–C2 transarticular screw placement and reduces the risk of vertebral artery injury. The linked construct is stable in flexion, extension and rotation. Laminectomy or fracture of the posterior elements does not preclude this fixation technique. We think this procedure will replace the C1–C2 transarticular screw procedure. Overall significance of findings: This new technology has the potential to supplant previous C1–C2 procedures with improved safety and success. Disclosures: Device or drug: pedicle screws. Status: approved. Conflict of interest: No conflicts.

Evaluation of registration techniques for spinal image guidance

Abstract Purpose of study: Develop new techniques to improve safety and success of C1–C2 fusion procedures. Methods used: A standard posterior C1–C2 exposure is performed. Cross-table lateral fluoroscopy is used to guide and confirm screw trajectories. The C2 pedicle screw entry point is identified and drilled with angles 15 degrees medially and 25 degrees cephalad for pedicle cannulation. Drill depth is stopped short of the C2 transverse foramen. The C1 lateral mass screw insertion point is located beneath the posterior arch of C1 in the midposition of the lateral mass just above the C2 root. The drill is then angled 10 degrees medial to lateral and cephalad toward the anterior tubercle of C1 on lateral fluoroscopy. The C1–C2 joint is then decorticated and packed with local bone fragments. Posterior rods are contoured and connected to polyaxial screw heads, and a cross-connector is applied. of findings: This technique has been used in five cases of atlantoaxial instability at our institution during the past year. There have been no C2 nerve root or vertebral artery injuries. No construct failures have been observed during the current follow-up. Relationship between findings and existing knowledge: C1 lateral mass and C2 pedicle screw fixation offers an alternative means of atlantoaxial fusion. The technique is less demanding than C1–C2 transarticular screw placement and reduces the risk of vertebral artery injury. The linked construct is stable in flexion, extension and rotation. Laminectomy or fracture of the posterior elements does not preclude this fixation technique. We think this procedure will replace the C1–C2 transarticular screw procedure. Overall significance of findings: This new technology has the potential to supplant previous C1–C2 procedures with improved safety and success. Disclosures: Device or drug: pedicle screws. Status: approved. Conflict of interest: No conflicts.