Ripul R. Panchal

Dysphagia Secondary to Anterior Osteophytes of the Cervical Spine.

Study Design Retrospective case series. Objective Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier disease involves hyperostosis of the spinal column. Hyperostosis involving the anterior margin of the cervical vertebrae can cause dysphonia, dyspnea, and/or dysphagia. However, the natural history pertaining to the risk factors remain unknown. We present the surgical management of two cases of dysphagia secondary to cervical hyperostosis and discuss the etiology and management of DISH based on the literature review. Methods This is a retrospective review of two patients with DISH and anterior cervical osteophytes. We reviewed the preoperative and postoperative images and clinical history. Results Two patients underwent anterior cervical osteophytectomies due to severe dysphagia. At more than a year follow-up, both patients noted improvement in swallowing as well as their associated pain. Conclusion The surgical removal of cervical osteophytes can be highly successful in treating dysphagia if refractory to prolonged conservative therapy.

Cervical spinous process reconstruction

Posterior neck deformity with an unsightly crater-like defect may result after cervicothoracic laminectomies. The authors present a new technique, spinous process reconstruction, to address this problem. A 64-year-old man presented with progressive quadriparesis secondary to cervical spondylotic myelopathy. Previously he had undergone multiple neck surgeries including cervicothoracic decompressive laminectomy. Postoperatively, he developed severe craniocervical spinal deformity and a large painful concave surgical defect in the neck. The authors performed craniocervical decompression and craniocervicothoracic instrumented stabilization. At the same time, cervicothoracic spinous process reconstruction was performed using titanium mesh to address the defect. Cervicothoracic decompressive laminectomy results in varying degrees of neck defect with resulting unsightly and an often painful surgical wound defect despite an appropriate multilayer closure. The presented spinous process reconstruction is a simple technique to address this problem with good clinical outcome.

Preliminary fsLIBS study on bone tumors.

The aim of this study is to evaluate the capability of femtosecond Laser Induced Breakdown Spectroscopy (fsLIBS) to discriminate between normal and cancerous bone, with implications to femtosecond laser surgery procedures. The main advantage of using femtosecond lasers for surgery is that the same laser that is being used to ablate can also be used for a feedback system to prevent ablation of certain tissues. For bone tumor removal, this technique has the potential to reduce the number of repeat surgeries that currently must be performed due to incomplete removal of the tumor mass. In this paper, we performed fsLIBS on primary bone tumor, secondary tumor in bone, and normal bone. These tissues were excised from consenting patients and processed through the UC Davis Cancer Center Biorepository. For comparison, each tumor sample had a matched normal bone sample. fsLIBS was performed to characterize the spectral signatures of each tissue type. A minimum of 20 spectra were acquired for each sample. We did not detect significant differences between the fsLIBS spectra of secondary bone tumors and their matched normal bone samples, likely due to the heterogeneous nature of secondary bone tumors, with normal and cancerous tissue intermingling. However, we did observe an increase in the fsLIBS magnesium peak intensity relative to the calcium peak intensity for the primary bone tumor samples compared to the normal bone samples. These results show the potential of using femtosecond lasers for both ablation and a real-time feedback control system for treatment of primary bone tumors.

Using Titanium Mesh Cage and Anterior Cervical Plate for Cervical Corpectomies

Using Titanium Mesh Cage and Anterior Cervical Plate for Cervical Corpectomies Spondylosis is the most common disease affecting the adult cervical spine. Controversy still exists over performing corpectomy versus discectomy for multilevel cervical disc disease. When the spondylosis leads to spinal cord compression beyond the disc space, removal of the cervical vertebrae may be necessary to achieve adequate decompression. Cervical corpectomy is a well-recognized treatment option for multilevel anterior compression of the cervical spinal cord.

Bilateral Cerebellar Infarcts from Vertebral Artery Insufficiency Caused by Cervical Osteophytes

Abstract Background: In previous reports, the patients are described to have transient symptoms from physiologic rotation or extension of the cervical spine, resulting from a cervical osteophyte compressing the vertebral artery and causing vertebral artery insufficiency, known as Bow Hunter syndrome. Methods: An 85-year-old female presented with new onset occipital headaches, nausea, vomiting and vertigo that were not precipitated by change in head position. Patient had bilateral cerebellar infracts. Patient underwent decompression and instrumented stabilization of the cervical spine from the posterior approach. Results: At one-year follow-up, patient remained stroke free with patent vertebral artery. Conclusion: To our knowledge, this is the first report of bilateral infraction from a vertebral artery insufficiency caused by cervical osteophytes without history of transient symptoms from movement of the head or neck, a variant of the Bow Hunter syndrome. Anterior versus posterior approach for vertebral artery insufficiency from osteophytic compression should be primarily based on location of the pathology and not the cervical level of involvement.

Anterior and Lateral Lumbar Interbody Fusion With Supplemental Interspinous Process Fixation: Outcomes from a Multicenter, Prospective, Randomized, Controlled Study

ABSTRACT Background: Rigid interspinous process fixation (ISPF) has received consideration as an efficient, minimally disruptive technique in supporting lumbar interbody fusion. However, despite advantageous intraoperative utility, limited evidence exists characterizing midterm to long-term clinical outcomes with ISPF. The objective of this multicenter study was to prospectively assess patients receiving single-level anterior (ALIF) or lateral (LLIF) lumbar interbody fusion with adjunctive ISPF. Methods: This was a prospective, randomized, multicenter (11 investigators), noninferiority trial. All patients received single-level ALIF or LLIF with supplemental ISPF (n = 66) or pedicle screw fixation (PSF; n = 37) for degenerative disc disease and/or spondylolisthesis (grade ≤2). The randomization patient ratio was 2:1, ISPF/PSF. Perioperative and follow-up outcomes were collected (6 weeks, 3 months, 6 months, and 12 months). Results: For ISPF patients, mean posterior intraoperative outcomes were: blood loss, 70.9 mL; operating time, 52.2 minutes; incision length, 5.5 cm; and fluoroscopic imaging time, 10.4 seconds. Statistically significant improvement in patient Oswestry Disability Index scores were achieved by just 6 weeks after operation (P < .01) and improved out to 12 months for the ISPF cohort. Patient-reported 36-Item Short Form Health Survey and Zurich Claudication Questionnaire scores were also significantly improved from baseline to 12 months in the ISPF cohort (P < .01). A total of 92.7% of ISPF patients exhibited interspinous fusion at 12 months. One ISPF patient (1.5%) required a secondary surgical intervention of possible relation to the posterior instrumentation/procedure. Conclusion: ISPF can be achieved quickly, with minimal tissue disruption and complication. In supplementing ALIF and LLIF, ISPF supported significant improvement in early postoperative (≤12 months) patient-reported outcomes, while facilitating robust posterior fusion.

Stereotactic guidance for navigated percutaneous sacroiliac joint fusion

Abstract Arthrodesis of the sacroiliac joint (SIJ) for surgical treatment of SIJ dysfunction has regained interest among spine specialists. Current techniques described in the literature most often utilize intraoperative fluoroscopy to aid in implant placement; however, image guidance for SIJ fusion may allow for minimally invasive percutaneous instrumentation with more precise implant placement. In the following cases, we performed percutaneous stereotactic navigated sacroiliac instrumentation using O-arm® multidimensional surgical imaging with StealthStation® navigation (Medtronic, Inc. Minneapolis, MN). Patients were positioned prone and an image-guidance reference frame was placed contralateral to the surgical site. O-arm® integrated with StealthStation® allowed immediate auto-registration. The skin incision was planned with an image-guidance probe. An image-guided awl, drill and tap were utilized to choose a starting point and trajectory. Threaded titanium cage(s) packed with autograft and/or allograft were then placed. O-arm® image-guidance allowed for implant placement in the SIJ with a small skin incision. However, we could not track the cage depth position with our current system, and in one patient, the SIJ cage had to be revised secondary to the anterior breach of sacrum.

Relief of Cervicogenic Headaches after Single-Level and Multilevel Anterior Cervical Diskectomy: A 5-Year Post Hoc Analysis

Study Design Prospective study. Objective Because single-level disk arthroplasty or arthrodesis in the lower subaxial spine improves headaches after surgery, we studied whether this effect may be better appreciated after two-level arthroplasty. Methods We performed an independent post hoc analysis of two concurrent prospective randomized investigational device exemption trials for cervical spondylosis, one for single-level treatment and the other for two adjacent-level treatments. Results For the one-level study, baseline mean headache scores significantly improved at 60 months for both the cervical disk arthroplasty (CDA) and anterior cervical diskectomy and fusion (ACDF) groups (p < 0.0001). However, mean improvement in headache scores was not statistically different between the investigational and control groups from 6 months through 60 months. For the two-level study, baseline mean headache scores significantly improved at 60 months for both the CDA and ACDF groups (p < 0.0001). The CDA group demonstrated greater improvement from baseline at all points; this difference was statistically significant at 6, 12, 24, 36, and 48 months but not at 18 and 60 months. Conclusion Both CDA and ACDF at either one or two levels are associated with sustained headache relief from baseline. Patients undergoing two-level arthroplasty had significantly greater improvement in headache at all points except for at 18 and 60 months. This difference in improvement was not observed in patients undergoing single-level arthroplasty. The mechanism of greater headache relief after two-level arthroplasty remains unclear.

A Biomechanical Evaluation of a Versatile and Novel Anterior Cervical Fusion Device Possessing Modular and Integrated Fixation Capabilities

Introduction A novel ACDF (anterior cervical discectomy and fusion) construct possessing integrated screw and modular plate fixation (MPF) capabilities has been introduced in an effort to provide versatility when selecting a stabilization mechanism. Construct features allow the surgeon to switch between zero-profile (2 screws), half-plate (3 screws), and full-plate (4 screws) system. Inherently, the device can be readily adapted to the patients anatomical landscape, accommodating adjacent level fixation, as well as diminishing hardware prominences when necessary. Additionally, the MPF technology, which creates a singular rigid body about the index level, affords ideal plate orientation/alignment, eliminates potential for cage migration/subsidence, and ensures physiological compression of the cage/graft. However, the translated effects of such novel features on segmental stability have not yet been characterized in the literature. The objective of this study was to assess the segmental rigidity achieved by the novel ACDF device iterations as compared with traditional ACDF (cage and anterior cervical plate system) and supplementation with posterior cervical constructs with lateral mass screws (LMS). Material and Methods Eighteen human cervical spine specimens (C3-T1) were tested. Osseous integrity was confirmed via DEXA scans and radiographs. Specimens were divided into three groups (n = 6) such that the mean bone quality across each group was consistent. The C3 and T1 vertebral bodies were potted. Each spine was first tested in an intact state. An anterior discectomy (C5/C6) was then performed, followed by sequential iterative construct instrumentation and testing (see Results for sequence). The three group protocol was executed such that each respective group would receive only integrated zero-profile, integrated half-plate, or integrated full-plate fixation (Alta ACDF System – Zimmer-Biomet Spine); diminishing vertebral body compromise due to excessive screw removal/placement. For posterior supplemented constructs, lateral mass screws (Lineum – Zimmer-Biomet Spine) were placed bilaterally at the index level. A 2Nm moment was applied in flexion-extension (FE), lateral-bending (LB), and axial-rotation (AR) using a six degree-of-freedom Bionix® Spine Kinematics System (MTS, Systems, MN). Segmental range-of-motion (ROM) was tracked using Optotrak Certus (NDI, Inc, Canada) motion analysis software. Mean ROM relative to intact conditions (100%) was measured. Results ROM (% Intact): FE/LB/AR. Integrated Zero Profile ACDF (n = 6): 69 / 48 / 76. Integrated Half-Plate ACDF (n = 6): 42/ 25 / 67. Integrated Full-Plate ACDF (n = 6): 32 / 29 / 40. Traditional ACDF (n = 18): 37 / 39 / 61. Traditional ACDF + LMS (n = 18): 12 / 11 / 22. Integrated Zero Profile ACDF + LMS (n = 6): 14 / 13 / 31. Integrated Half-Plate ACDF + LMS (n = 6): 18 / 10 / 31. Integrated Full-Plate ACDF + LMS (n = 6): 12 / 10 / 16. Conclusion The full-plate and half-plate constructs both appeared advantageous in comparison to the traditional ACDF construct (MaxAn – Zimmer-Biomet Spine) when used without posterior supplementation, demonstrating an inherent benefit of the MPF technology. Motion reductions with zero-profile fixation were not as robust; however, it can be argued that clinically significant stability was still achieved. Lastly, supplemental fixation with LMS appeared to be a clear leveling factor across all constructs, facilitating significant motion reduction in all directions.