Luis M. Tumialán

Management of unilateral cervical radiculopathy in the military: the cost effectiveness of posterior cervical foraminotomy compared with anterior cervical discectomy and fusion

OBJECTnTo review the cost effectiveness for the management of a unilateral cervical radiculopathy with either posterior cervical foraminotomy (PCF) or anterior cervical discectomy and fusion (ACDF) in military personnel, with a particular focus on time required to return to active-duty service.nnnMETHODSnFollowing internal review board approval, the authors conducted a retrospective review of 38 cases in which patients underwent surgical management of unilateral cervical radiculopathy. Nineteen patients who underwent PCF were matched for age, treatment level, and surgeon to 19 patients who had undergone ACDF. Successful outcome was determined by return to full, unrestricted active-duty military service. The difference in time of return to active duty was compared between the groups. In addition, a cost analysis consisting of direct and indirect costs was used to compare the PCF group to the ACDF group.nnnRESULTSnA total of 21 levels were operated on in each group. There were 17 men and 2 women in the PCF group, whereas all 19 patients in the ACDF group were men. The average age at the time of surgery was 41.5 years (range 27-56 years) and 39.3 years (range 24-52 years) for the PCF and ACDF groups, respectively. There was no statistically significant difference in operating room time, estimated blood loss, or postoperative narcotic refills. Complications included 2 cases of transient recurrent laryngeal nerve palsy in the ACDF group. The average time to return to unrestricted full duty was 4.8 weeks (range 1-8 weeks) in the PCF group and 19.6 weeks (range 12-32 weeks) in the ACDF group, a difference of 14.8 weeks (p < 0.001). The direct costs of each surgery were

Progressive vertebral body osteolysis after cervical disc arthroplasty.

3570 for the PCF and

Arthroplasty in the military: A preliminary experience with ProDisc-C and ProDisc-L

10,078 for the ACDF, a difference of

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Surgical Techniques and Technologies for the Management of Patients With Nonfunctioning Pituitary Adenomas

6508. Based on the 14.8-week difference in time to return to active duty, the indirect cost was calculated to range from

Minimally invasive transforaminal lumbar interbody fusions and fluoroscopy: a low-dose protocol to minimize ionizing radiation

13,586 to

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Posttreatment Follow-up Evaluation of Patients With Nonfunctioning Pituitary Adenomas.

24,045 greater in the ACDF group. Total cost (indirect plus direct) ranged from

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Primary Management of Patients With Nonfunctioning Pituitary Adenomas.

20,094 to

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Preoperative Imaging Assessment of Patients With Suspected Nonfunctioning Pituitary Adenomas.

30,553 greater in the ACDF group.nnnCONCLUSIONSnIn the management of unilateral posterior cervical radiculopathy for military active-duty personnel, PCF offers a benefit relative to ACDF in immediate short-term direct and long-term indirect costs. The indirect cost of a service member away from full, unrestricted active duty 14.8 weeks longer in the ACDF group was the main contributor to this difference.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Management of Patients With Residual or Recurrent Nonfunctioning Pituitary Adenomas.

Study Design. Case report. Objective. To review the management of a patient with progressive osteolysis of the vertebral body after undergoing cervical arthroplasty for management of a refractory radiculopathy. Summary of Background Data. Since the Food and Drug Administrations (FDA) approval of cervical arthroplasty devices in 2007, many surgeons have incorporated this technology into clinical practice. As arthroplasty becomes more widespread, complications unique to this technology are inevitable. To date, only a limited number of complications have been reported in the literature suggesting the safety of this device. To the authors knowledge, this report represents the first complication of osteolysis from a keel based arthroplasty device. Methods. A 30-year-old man underwent an uneventful C5–C6 total disc arthroplasty with initial benefit. Progressively worsening neck pain prompted repeat imaging at 9 and 15 months, which showed a progressive osteolytic process in the vicinity of the keel of the superior alloy endplate. This necessitated exploration of the surgical site, explantation of the implant and conversion of the disc arthroplasty to an arthrodesis. Results. Examination of the osteolytic area did not reveal any gross abnormalities. Testing of the device by the manufacturer did not reveal any defects. A comprehensive infectious workup was negative. The osteolytic process halted after the explantation of the device. A bony arthrodesis was achieved at 6 months and the patient remains symptom free 29 months after the initial procedure and 14 months after the revision. Conclusion. This report illustrates an exceptional case of a progressive osteolysis with a keel based arthroplasty device. An immune mediated osteolytic process appears to be a plausible explanation for the clinical symptoms and radiographic progression seen in this case. Given the years of use of the ProDisc-C since its FDA approval in 2007, complications with this device are rare. This represents the first reported case of osteolysis from such an implant.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Pretreatment Ophthalmology Evaluation in Patients With Suspected Nonfunctioning Pituitary Adenomas.

OBJECTnThe introduction of cervical and lumbar arthroplasty has allowed for management of cervical radiculopathy and lumbar degenerative disease in patients with the preservation of motion at the affected segment. While the early clinical outcomes of this technology appear promising, it remains unclear what activity limitations should be imposed after surgery in patients with these implants. This is of particular interest in military personnel, who may be required to return to a rigorous level of activity after surgery. The goals of the FDA trials evaluating various disc arthroplasty devices were to establish safety, efficacy, and equivalency to arthrodesis. Information regarding the level of physical performance attained and restrictions or limitations is lacking, as these were outside the objectives of these trials. Nevertheless, there data are essential for the military surgeon, who is tasked with guiding the postoperative management of patients treated with arthroplasty and returning them to full duty. While there is a single report of clinical results of lumbar arthroplasty in athletes, at this writing, there are no reports of either cervical or lumbar arthroplasty in active duty military personnel.nnnMETHODSnThe surgical database at a single, tertiary care military treatment facility was queried for all active-duty patients who underwent placement of either a cervical or lumbar arthroplasty device over a 3-year period. The authors performed a retrospective chart review to collect patient and procedural data including blood loss, length of hospital stay, tobacco use, age, rank, complications, and ability to return to full unrestricted active duty. Arthroplasty cohorts were then compared to historical controls of arthrodesis to ascertain differences in the time required to return to full duty.nnnRESULTSnTwelve patients were identified who underwent cervical arthroplasty. All patients returned to unrestricted full duty. This cohort was then compared with 12 patients who had undergone a single-level anterior cervical discectomy and fusion. The average time to return to unrestricted full duty for the arthroplasty group was 10.3 weeks (range 7-13 weeks), whereas that in the fusion group was 16.5 weeks. This difference between these 2 groups was statistically significant (p = 0.008). Twelve patients were identified who underwent lumbar arthroplasty. Ten (83%) of 12 patients in this group returned to unrestricted full duty. In patients who returned to full duty, it took an average of 22.6 weeks (range 12-29 weeks). This cohort was then compared with one in which patients had undergone anterior lumbar interbody fusion. Eight (67%) of 12 patients in the lumbar arthrodesis group returned to unrestricted full duty. In patients who returned to full duty, it took an average of 32.4 weeks (range 25-41 weeks). This difference was not statistically significant (p = 0.156).nnnCONCLUSIONSnThe preliminary experience with cervical and lumbar arthroplasty at the authors institution indicates that arthroplasty is comparable with arthrodesis and may actually expedite return to active duty. Patients are capable of returning to a high level of rigorous training and physical performance. There are no apparent restrictions or limitations that are required after 3 months in the cervical patient and after 6 months in the lumbar patient. Further prospective studies with long-term follow-up are indicated and will be of value when determining the role of arthroplasty compared to arthrodesis in the active-duty population.