Kartik Shenoy

Extensive ossification of the ligamentum flavum treated with triple stage decompression: a case report

BACKGROUND CONTEXT Concurrent ossification of the ligamentum flavum (OLF) in the cervical, thoracic, and lumbar spine is a rare occurrence often associated with rheumatologic abnormalities. Although the pathology may be asymptomatic and discovered incidentally on routine imaging, compression of the cord and surrounding nerve roots can produce myelopathic or radiculopathic symptoms that are best treated with surgical decompression. There is limited evidence to support the use of single versus multistage decompression for tandem ossification at multiple levels, although several factors including duration of symptoms have been associated with a worse prognosis. PURPOSE To describe the presence of extensive symptomatic tandem OLF with concurrent ossification of the posterior longitudinal ligament (PLL) and its treatment using multistage decompression. STUDY DESIGN Case report and literature review. METHODS The authors describe a case of a 35-year-old woman with OLF extending from the cervical to lumbar spine and tandem ossification of the cervical PLL. Her initial presentation was significant for symptoms consistent with thoracic myelopathy in the absence of radiculopathic findings, and initial imaging also demonstrated disc herniation at L4-L5 and L5-S1. RESULTS The patient was first treated with a thoracic laminectomy and fusion from T7 to T11, given her back pain and thoracic myelopathy. Persistence of myelopathic symptoms necessitated further surgical intervention with a posterior cervical decompression and fusion from C3 to T1. Finally, after the appearance of radiculopathic findings, she underwent a microscopic L4-L5 laminectomy with improvements in her symptoms and ambulation. CONCLUSIONS Symptomatic OLF in non-East Asian population is a rare occurrence. Its etiology is likely multifactorial, involving both biomechanical and genetic factors. Although early detection and management are necessary, multistage decompression can be an effective intervention for extensive multilevel ossification.

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management

BACKGROUND Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized. METHODS We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy. RESULTS We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary. CONCLUSION Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

The Influence of Body Mass Index on Achieving Age-Adjusted Alignment Goals in Adult Spinal Deformity Corrective Surgery with Full-Body Analysis at 1 Year

BACKGROUND The impact of obesity on global spinopelvic alignment is poorly understood. This study investigated the effect of body mass index on achieving alignment targets and compensation mechanisms after corrective surgery for adult spinal deformity (ASD). METHODS Retrospective review of a single-center database. Inclusion: patients ≥18 years with full-body stereographic images (baseline and 1 year) and who met ASD criteria (sagittal vertical axis [SVA] >5 cm, pelvic incidence minus lumbar lordosis [PI-LL] >10°, coronal curvature >20° or pelvic tilt >20°). Patients were stratified by age (<40, 40-65, and ≥65 years) and body mass index (<25, 25-30, and >30). Postoperative alignment was compared with age-adjusted ideal values. Prevalence of patients who matched ideals and unmatched (undercorrected/overcorrected) was assessed. Health-related quality of life (HRQL) scores, alignment, and compensatory mechanisms were compared across cohorts using analysis of variance and temporally with paired t tests. RESULTS A total of 116 patients were included (average age, 62 years; 66% female). After corrective surgery, obese and overweight patients had more residual malalignment (worse PI-LL, T1 pelvic angle, pelvic tilt, and SVA) compared with normal patients (P < 0.05). In addition, obese and overweight patients recruited more pelvic shift (obese, 62.36; overweight, 49.80; normal, 31.50) and had a higher global sagittal angle (obese, 6.51; overweight, 6.35; normal, 3.40) (P < 0.05). Obese and overweight patients showed lower overcorrection rates and higher undercorrection rates (P < 0.05). Obese patients showed worse postoperative HRQL scores (Scoliosis Research Society 22 Questionnaire, Oswestry Disability Index, visual analog scale-leg) than did overweight and normal patients (P < 0.05). Obese and overweight patients who matched age-adjusted alignment targets for SVA or PI-LL showed no HRQL improvements (P > 0.05). CONCLUSIONS After surgery, obese patients were undercorrected, showed more residual malalignment, recruited more pelvic shift, and had a greater global sagittal angle and worse HRQL scores. The benefits from age-adjusted alignment targets seem to be less substantial for obese and overweight patients.

Friday, September 28, 2018 10:30 AM–12:00 PM abstracts: complications of cervical spine surgery

BACKGROUND CONTEXT Outpatient ACDFs are being performed at an increasing rate and prior studies have shown similar complication and readmission rates when compared to traditional admission. However, the ideal patient for same day ACDF has yet to be identified. A multidisciplinary group at a tertiary academic center developed a protocol for patient selection and discharge for patients undergoing same day discharge ACDF with the aim of ensuring patient safety and reducing the likelihood of readmission. PURPOSE Our aim was to show that utilizing a standardized protocol to select patients for outpatient ACDF will result in a noninferior readmission rate compared to traditional overnight admission. STUDY DESIGN/SETTING Retrospective review of a prospectively implemented protocol. PATIENT SAMPLE A total of 434 patients undergoing one or two-level ACDF from March 2016 to March 2017 at a tertiary academic institution. OUTCOME MEASURES A total of 30 and 90 day readmission rates. METHODS A retrospective chart-review was performed to identify patients undergoing one or two level primary ACDF who were eligible for same day discharge (SDD) according to the institutional protocol. Patients undergoing cervical disc replacement, three or more level surgery, corpectomy, posterior or revision surgery were excluded. All patients underwent ACDF via the anterior approach with implants based on surgeon preference. Patients with identical surgery and discharge dates were grouped as SDD and admitted patients were grouped as same day admission (SDA). Using our electronic health records analytics, readmissions in the 90-day postoperative period were identified. RESULTS A total of 434 patients underwent one or two level ACDF from March 2016 to March 2017 of which 126 patients were SDD and 308 were SDA. Due to the protocol, baseline characteristics such as age, operative time and time in the recovery room was significantly different between the two groups. In each group there was one readmission during the 30 day postoperative period and the SDA group had one additional readmission in the 90 day postoperative period. This resulted in an overall, noninferior readmission rate of 0.8% in the SDD group and 0.6% in the SDA group (p=.86). CONCLUSIONS Proper identification of patients suitable for outpatient ACDF using our protocol for patient selection and discharge results in a noninferior readmission rate.

A radiographic follow-up study of stand-alone-cage and graftplate constructs for single-level anterior cervical discectomy and fusion

Background Anterior cervical discectomy and fusion (ACDF) may be performed using an interbody cage or graft with an anterior plate or with a stand-alone (SA) interbody device without the anterior plate. The pros and cons of each vary. This study examined the radiographic outcome of the two techniques with a focus on implant subsidence. Methods A retrospective review of cases of singe level ACDF by a single surgeon was undertaken. Medical and radiographic records were reviewed to determine subsidence, pre- and post-operative segmental and total lordosis in cohorts of both stand-alone and graft-and-plate constructs. Results The post-operative radiographs of 35 patients with a SA cage were compared with 41 patients with an allograft block and anterior plate (graft and plate; GP). There was no significant difference in overall subsidence between the two groups although there was a trend toward less clinically significant subsidence (2 mm) in the SA group. For single level ACDF, a SA device appears to be comparable in terms of undesired subsidence. Conclusions Further studies with different implants and materials may offer further insight.

Arthroscopic Repair of Hip Labrum With Suture Anchors

The acetabular labrum and the transverse acetabular ligament form a continuous ring of tissue on the periphery of the acetabulum that provides a seal for the hip joint and increases the surface area to spread load distribution during weight-bearing. When a labral tear is suspected, the treatment algorithm always begins with conservative management, including physical therapy and nonsteroidal anti-inflammatory drugs. When conservative management fails, patients become candidates for arthroscopic labral repair. In the last 2 decades, the rate of hip arthroscopy has increased nearly 4-fold. However, as hip arthroscopy is performed more frequently, there is a need for a proper technique to minimize morbidity, because hip arthroscopy has been known to have a steep learning curve. We present a method for arthroscopic hip labral repair using suture anchors without a capsular repair. This Technical Note highlights our technique for labral repair, along with pearls and pitfalls of hip arthroscopy.