Jacob R. Joseph

Comparison of complication rates of minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion: a systematic review of the literature.

OBJECT Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and lateral lumbar interbody fusion (LLIF) are 2 currently popular techniques for lumbar arthrodesis. The authors compare the total risk of each procedure, along with other important complication outcomes. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies (up to May 2015) that reported complications of either MI-TLIF or LLIF were identified from a search in the PubMed database. The primary outcome was overall risk of complication per patient. Secondary outcomes included risks of sensory deficits, temporary neurological deficit, permanent neurological deficit, intraoperative complications, medical complications, wound complications, hardware failure, subsidence, and reoperation. RESULTS Fifty-four studies were included for analysis of MI-TLIF, and 42 studies were included for analysis of LLIF. Overall, there were 9714 patients (5454 in the MI-TLIF group and 4260 in the LLIF group) with 13,230 levels fused (6040 in the MI-TLIF group and 7190 in the LLIF group). A total of 1045 complications in the MI-TLIF group and 1339 complications in the LLIF group were reported. The total complication rate per patient was 19.2% in the MI-TLIF group and 31.4% in the LLIF group (p < 0.0001). The rate of sensory deficits and temporary neurological deficits, and permanent neurological deficits was 20.16%, 2.22%, and 1.01% for MI-TLIF versus 27.08%, 9.40%, and 2.46% for LLIF, respectively (p < 0.0001, p < 0.0001, p = 0.002, respectively). Rates of intraoperative and wound complications were 3.57% and 1.63% for MI-TLIF compared with 1.93% and 0.80% for LLIF, respectively (p = 0.0003 and p = 0.034, respectively). No significant differences were noted for medical complications or reoperation. CONCLUSIONS While there was a higher overall complication rate with LLIF, MI-TLIF and LLIF both have acceptable complication profiles. LLIF had higher rates of sensory as well as temporary and permanent neurological symptoms, although rates of intraoperative and wound complications were less than MI-TLIF. Larger, prospective comparative studies are needed to confirm these findings as the current literature is of relative poor quality.

Current applications of robotics in spine surgery: a systematic review of the literature

OBJECTIVE Surgical robotics has demonstrated utility across the spectrum of surgery. Robotics in spine surgery, however, remains in its infancy. Here, the authors systematically review the evidence behind robotic applications in spinal instrumentation. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Relevant studies (through October 2016) that reported the use of robotics in spinal instrumentation were identified from a search of the PubMed database. Data regarding the accuracy of screw placement, surgeon learning curve, radiation exposure, and reasons for robotic failure were extracted. RESULTS Twenty-five studies describing 2 unique robots met inclusion criteria. Of these, 22 studies evaluated accuracy of spinal instrumentation. Although grading of pedicle screw accuracy was variable, the most commonly used method was the Gertzbein and Robbins system of classification. In the studies using the Gertzbein and Robbins system, accuracy (Grades A and B) ranged from 85% to 100%. Ten studies evaluated radiation exposure during the procedure. In studies that detailed fluoroscopy usage, overall fluoroscopy times ranged from 1.3 to 34 seconds per screw. Nine studies examined the learning curve for the surgeon, and 12 studies described causes of robotic failure, which included registration failure, soft-tissue hindrance, and lateral skiving of the drill guide. CONCLUSIONS Robotics in spine surgery is an emerging technology that holds promise for future applications. Surgical accuracy in instrumentation implanted using robotics appears to be high. However, the impact of robotics on radiation exposure is not clear and seems to be dependent on technique and robot type.

Ultrasonography for neonatal brachial plexus palsy

Ultrasonography has previously been reported for use in the evaluation of compressive or traumatic peripheral nerve pathology and for its utility in preoperative mapping. However, these studies were not performed in infants, and they were not focused on the brachial plexus. The authors report a case in which ultrasonography was used to improve operative management of neonatal brachial plexus palsy (NBPP). An infant boy was born at term, complicated by right-sided shoulder dystocia. Initial clinical evaluation revealed proximal arm weakness consistent with an upper trunk injury. Unlike MRI or CT myelography that focus on proximal nerve roots, ultrasonography of the brachial plexus in the supraclavicular fossa was able to demonstrate a small neuroma involving the upper trunk (C-5 and C-6) and no asymmetry in movement of the diaphragm or in the appearance of the rhomboid muscle when compared with the unaffected side. However, the supra- and infraspinatus muscles were significantly asymmetrical and atrophied on the affected side. Importantly, ultrasound examination of the shoulder revealed posterior glenohumeral laxity. Instead of pursuing the primary nerve reconstruction first, timely treatment of the shoulder subluxation prevented formation of joint dysplasia and formation of a false glenoid, which is a common sequela of this condition. Because the muscles innervated by proximal branches of the cervical nerve roots/trunks were radiographically normal, subsequent nerve transfers were performed and good functional results were achieved. The authors believe this to be the first report describing the utility of ultrasonography in the surgical treatment planning in a case of NBPP. Noninvasive imaging, in addition to thorough history and physical examination, reduces the intraoperative time required to determine the extent and severity of nerve injury by allowing improved preoperative planning of the surgical strategy. Inclusion of ultrasonography as a preoperative modality may yield improved outcomes for children with NBPP.

Utility of ultrasound in noninvasive preoperative workup of neonatal brachial plexus palsy.

BackgroundUltrasound has been utilized in the evaluation of compressive and traumatic peripheral nerve pathology.ObjectiveTo determine whether US can provide comprehensive evaluation of the post-ganglionic brachial plexus in the setting of neonatal brachial plexus palsy and whether this information can be used to guide preoperative nerve reconstruction strategies.Materials and methodsIn this retrospective cohort study, preoperative brachial plexus ultrasonography was performed in 52 children with neonatal brachial plexus palsy who were being considered for surgery. The 33 children who had surgery compose the patient cohort. The presence and location of post-ganglionic neuromas were evaluated by US and compared to the surgical findings. US evaluation of shoulder muscle atrophy was conducted as an indirect way to assess the integrity of nerves. Finally, we correlated glenohumeral joint laxity to surgical and clinical management.ResultsUltrasound correctly identified 21 of 25 cases of upper trunk and middle trunk neuroma involvement (84% sensitivity for each). It was 68% sensitive and 40% specific in detection of lower trunk involvement. US identified shoulder muscle atrophy in 11 of 21 children evaluated; 8 of these 11 went on to nerve transfer procedures based upon the imaging findings. US identified 3 cases of shoulder joint laxity of the 13 children evaluated. All 3 cases were referred for orthopedic evaluation, with 1 child undergoing shoulder surgery and another requiring casting.ConclusionUltrasound can provide useful preoperative evaluation of the post-ganglionic brachial plexus in children with neonatal brachial plexus palsy.

The impact of blood pressure management after spinal cord injury: A systematic review of the literature

OBJECTIVE Spinal cord injury (SCI) results in significant morbidity and mortality. Improving neurological recovery by reducing secondary injury is a major principle in the management of SCI. To minimize secondary injury, blood pressure (BP) augmentation has been advocated. The objective of this study was to review the evidence behind BP management after SCI. METHODS This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Using the PubMed database, the authors identified studies that investigated BP management after acute SCI. Information on BP goals, duration of BP management, vasopressor selection, and neurological outcomes were analyzed. RESULTS Eleven studies that met inclusion criteria were identified. Nine studies were retrospective, and 2 were single-cohort prospective investigations. Of the 9 retrospective studies, 7 reported a goal mean arterial pressure (MAP) of higher than 85 mm Hg. For the 2 prospective studies, the MAP goals were higher than 85 mm Hg and higher than 90 mm Hg. The duration of BP management varied from more than 24 hours to 7 days in 6 of the retrospective studies that reported the duration of treatment. In both prospective studies, the duration of treatment was 7 days. In the 2 prospective studies, neurological outcomes were stable to improved with BP management. The retrospective studies, however, were contradictory with regard to the correlation of BP management and outcomes. Dopamine, norepinephrine, and phenylephrine were the agents that were frequently used to augment BP. However, more complications have been associated with dopamine use than with the other vasopressors. CONCLUSIONS There are no high-quality data regarding optimal BP goals and duration in the management of acute SCI. Based on the highest level of evidence available from the 2 prospective studies, MAP goals of 85-90 mm Hg for a duration of 5-7 days should be considered. Norepinephrine for cervical and upper thoracic injuries and phenylephrine or norepinephrine for mid- to lower thoracic injuries should be considered.

Expandable vs Static Cages in Transforaminal Lumbar Interbody Fusion: Radiographic Comparison of Segmental and Lumbar Sagittal Angles

BACKGROUND One criticism of transforaminal lumbar interbody fusion (TLIF) is the inability to increase segmental lordosis (SL). Expandable interbody cages are a relatively new innovation theorized to allow improvement in SL. OBJECTIVE To compare changes in SL and lumbar lordosis (LL) after TLIF with nonexpandable vs expandable cages. METHODS We performed a retrospective cohort study of patients who were ≥18 years old and underwent single-level TLIF between 2011 and 2014. Patients were categorized by cage type (static vs expandable). Primary outcome of interest was change in SL and LL from preoperative values to those at 1 month and 1 year postoperatively. RESULTS A total of 89 patients were studied (48 nonexpandable group, 41 expandable group). Groups had similar baseline characteristics. For SL, median (interquartile range) improvement was 3° for nonexpandable and 2° for expandable (unadjusted, P = .09; adjusted, P = .68) at 1 month postoperatively, and 3° for nonexpandable and 1° for expandable (unadjusted, P = .41; adjusted, P = .28) at 1 year postoperatively. For LL, median improvement was 1° for nonexpandable and 2° for expandable (unadjusted, P = .20; adjusted, P = .21), and 2° for nonexpandable and 5° for expandable (unadjusted, P = .15; adjusted, P = .51) at 1 year postoperatively. After excluding parallel expandable cages, there was still no difference in SL or LL improvement at 1 month or 1 year postoperatively between static and expandable cages (both unadjusted and adjusted, P > .05). CONCLUSION Patients undergoing single-level TLIF experienced similar improvements in SL and LL regardless of whether nonexpandable or expandable cages were placed.

Does clinical improvement of symptomatic degenerative lumbar disease impact obesity

OBJECTIVE Obesity and low-back pain associated with degenerative spondylosis or spondylolisthesis are common comorbid conditions. Many patients report that the pain and disability associated with degenerative lumbar disease are key factors in their inability to lose weight. The aim of this retrospective study was to determine if there is an association between improved functional status and weight loss following a successful transforaminal lumbar interbody fusion (TLIF) procedure. METHODS A retrospective cohort study of patients who underwent single-level TLIF was performed. Inclusion criteria were preoperative body mass index (BMI) greater than 30 kg/m2, achievement of minimum clinically important difference in the Oswestry Disability Index (ODI, defined as improvement of 15 points), and minimum 1-year postoperative followup BMI. Preoperative and postoperative BMI, ODI, and visual analog scale (VAS) scores were compared. A subgroup analysis of patients who achieved substantial clinical benefit (SCB, defined as a net improvement of 18.8 points on the ODI) was also performed. RESULTS A total of 56 patients met the inclusion criteria. The mean age of the study population was 55.6 ± 13.7 years. The mean preoperative BMI was 34.8 ± 4.6 kg/m2, the mean preoperative ODI was 66.2 ± 10.1, and the mean preoperative VAS score was 7.1 ± 1.7. The mean change in ODI was -33.1 ± 13.5 (p < 0.01) and the mean change in the VAS score was -4.1 ± 2.1 (p < 0.01). The mean change in BMI was +0.15 ± 2.1 kg/m2 (range -4.2 to +6.5 kg/m2; p = 0.6). SCB was achieved in 46 patients on the ODI. The mean preoperative BMI for patients with SCB was 34.8 ± 4.8 kg/m2, and the mean postoperative BMI was 34.7 ± 5.0 kg/m2. The mean change in BMI was -0.03 ± 1.9 kg/m2 (p = 0.9). CONCLUSIONS Despite successful surgical intervention via TLIF with achievement of improved function and pain, obese patients did not have significant change in weight postoperatively.

The current role of diagnostic imaging in the preoperative workup for refractory neonatal brachial plexus palsy

IntroductionDespite recent improvements in perinatal care, the incidence of neonatal brachial plexus palsy (NBPP) remains relatively common. CT myelography is currently considered to be the optimal imaging modality for evaluating nerve root integrity. Recent improvements in MRI techniques have made it an attractive alternative to evaluate nerve root avulsions (preganglionic injuries).AimWe demonstrate the utility of MRI for the evaluation of normal and avulsed spinal nerve roots. We also show the utility of ultrasound in providing useful preoperative evaluation of the postganglionic brachial plexus in patients with NBPP.

Aggressive Myeloid Sarcoma Causing Recurrent Spinal Cord Compression

OBJECTIVE Myeloid sarcoma is a rare extramedullary solid tumor comprised of immature myeloid precursor cells, most commonly associated with acute myelogenous leukemia (AML). We present the case of a patient with a history of Shwachman-Diamond syndrome and AML who presented with myeloid sarcoma causing acute spinal cord compression. CASE DESCRIPTION The patient was a 20-year-old man who presented with acute onset weakness and numbness in his lower extremities. Magnetic resonance imaging revealed a thoracic dorsal epidural mass. Despite the history of AML, we elected to forego image-guided biopsy and up-front radiation due to the rapidly progressive nature of his myelopathy. Immediate surgical decompression was performed, but the patient had recurrence of tumor leading to further compression 13 days postoperatively. Subsequently, emergent radiation was performed, leading to resolution of cord compression and local disease control. CONCLUSIONS To our knowledge, there are no randomized controlled trials examining the appropriate timing for postoperative radiation. Because most typical neuro-oncologic cases have no need for immediate postoperative radiation, our practice has been to wait 14 days to initiate postoperative radiation to ensure wound healing. One unique feature of our case was the rapid recurrence of symptoms due to tumor progression. Given this observation, we believe that radiation therapy should be considered as soon as possible after confirmatory pathology diagnosis for patients presenting with neurological compromise due to myeloid sarcoma of the spine.

Radiosurgery for Treatment of Renal Cell Metastases to Spine: A Systematic Review of the Literature

BACKGROUND The incidence of renal cell carcinoma (RCC) continues to increase, and the spine is the most common site for bony metastasis. Radiation therapy is one treatment for spinal RCC metastasis. Stereotactic body radiotherapy (SBRT) is a newer treatment that reportedly has benefits over conventional external beam radiotherapy. This study systematically reviewed the current literature on SBRT for metastatic RCC to spine. METHODS A search of PubMed, Embase, and Scopus databases was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Clinical articles evaluating SBRT for RCC metastases were identified. After inclusion and exclusion criteria were applied, the search resulted in 9 articles. Data including pain outcomes, local control, survival outcomes, vertebral compression fracture (VCF), and toxicity were extracted and evaluated. RESULTS The studies analyzed showed an improvement in pain in 41%-95% of patients. Local control rates after SBRT ranged 71.2%-85.7% at 1 year, a significant improvement when compared with conventional external beam radiotherapy. The rate of VCF after treatment with SBRT ranged 16%-27.5%, with single-fraction therapy being a risk factor for increased incidence. Overall toxicity rates ranged 23%-38.5%, with only 3 cases of grade 3 toxicity (nausea) and no cases of radiation myelitis. CONCLUSIONS Use of SBRT for spinal metastasis from RCC resulted in significant local control and pain outcomes. There is a risk of VCF with SBRT; however, treatment seems to be well tolerated with few serious side effects. There is continued need for long-term prospective studies investigating the optimal role of SBRT in the treatment algorithm of RCC spinal metastases.