Ryan J. Halpin

Standardizing care for high-risk patients in spine surgery: the Northwestern high-risk spine protocol.

Study Design. Review article of current literature on the preoperative evaluation and postoperative management of patients undergoing high-risk spine operations and a presentation of a multidisciplinary protocol for patients undergoing high-risk spine operation. Objective. To provide evidence-based outline of modifiable risk factors and give an example of a multidisciplinary protocol with the goal of improving outcomes. Summary of Background Data. Protocol-based care has been shown to improve outcomes in many areas of medicine. A protocol to evaluate patients undergoing high-risk procedures may ultimately improve patient outcomes. Methods. The English language literature to date was reviewed on modifiable risk factors for spine surgery. A multidisciplinary team including hospitalists, critical care physicians, anesthesiologists, and spine surgeons from neurosurgery and orthopedics established an institutional protocol to provide comprehensive care in the pre-, peri-, and postoperative periods for patients undergoing high-risk spine operations. Results. An example of a comprehensive pre-, peri-, and postoperative high-risk spine protocol is provided, with focus on the preoperative assessment of patients undergoing high-risk spine operations and modifiable risk factors. Conclusion. Standardizing preoperative risk assessment may lead to better outcomes after major spine operations. A high-risk spine protocol may help patients by having dedicated physicians in multiple specialties focusing on all aspects of a patients care in the pre-, intra-, and postoperative phases.

Management of Recurrent Adult Tethered Cord Syndrome

Recurrent tethered cord syndrome (TCS) can lead to significant progressive disability in adults. The diagnosis of TCS is made with a high degree of clinical suspicion. In the adult population, many patients receive inadequate care unless they are seen at a multidisciplinary clinic. Successful detethering procedures require careful intradural dissection and meticulous wound and dural closure. With multiple revision procedures, vertebral column shortening has become an appropriate alternative to surgical detethering.

Piriformis syndrome: a real pain in the buttock?

OBJECTIVEHerein, we provide an unbiased review of piriformis syndrome (PS), a highly controversial syndrome for which no consensus exists regarding diagnostic criteria or pathophysiology. METHODSA review of the literature in the English language. RESULTSA nonpartisan review of the medical literature pertaining to PS revealed that the existence of this entity remains controversial. There is no definitive proof of its existence despite reported series with large numbers of patients. CONCLUSIONPS remains a controversial diagnosis for sciatic pain. The debate regarding the clinical significance of PS remains active. Nonetheless, there may be a subset of patients in whom the piriformis muscle is a source of pain. The syndrome should be considered in the differential diagnosis of patients with unilateral lower extremity pain.

Posterior vertebral column subtraction osteotomy: A novel surgical approach for the treatment of multiple recurrences of tethered cord syndrome - Technical note

Recurrent tethered cord syndrome (TCS) has been reported to develop in 5-50% of patients following initial spinal cord detethering operations. Surgery for multiple recurrences of TCS can be difficult and is associated with significant complications. Using a cadaveric tethered spinal cord model, Grande and colleagues demonstrated that shortening of the vertebral column by performing a 15-25-mm thoracolumbar osteotomy significantly reduced spinal cord, lumbosacral nerve root, and terminal filum tension. Based on this cadaveric study, spinal column shortening by a thoracolumbar subtraction osteotomy may be a viable alternative treatment to traditional surgical detethering for multiple recurrences of TCS. In this article, the authors describe the use of posterior vertebral column subtraction osteotomy (PVCSO) for the treatment of 2 patients with multiple recurrences of TCS. Vertebral column resection osteotomy has been widely used in the surgical correction of fixed spinal deformity. The PVCSO is a novel surgical treatment for multiple recurrences of TCS. In such cases, PVCSO may allow surgeons to avoid neural injury by obviating the need for dissection through previously operated sites and may reduce complications related to CSF leakage. The novel use of PVCSO for recurrent TCS is discussed in this report, including surgical considerations and techniques in performing PVCSO.

Comprehensive assessment of prophylactic preoperative inferior vena cava filters for major spinal reconstruction in adults

Study Design. A retrospective data analysis. Objective. To report a comprehensive assessment of preoperative prophylactic inferior vena cava (IVC) filter placement in spine surgery. Summary of Background Data. Venous thromboembolism (VTE) is a serious complication after major spinal reconstructive surgery in adults. Specifically, pulmonary embolism (PE) can result in significant morbidity and mortality, and it has been reported in up to 13% of patients. Prophylactic IVC filter placement was initiated for all “high-risk” spinal surgery patients after a pilot study demonstrated decreased VTE-related morbidity and mortality. Methods. After institutional review board approval, the medical records of all patients receiving an IVC filter at a single institution from 2000 to 2007 were reviewed. Age, sex, surgical approach, postoperative deep vein thrombosis (DVT), postoperative superficial thrombus, presence of pulmonary or paradoxical embolus, mortality, and IVC filter complications were all evaluated. Indications for IVC filter placement included history of DVT or PE, malignancy, hypercoagulability, prolonged immobilization, staged procedures of longer than 5 segment levels, combined anterior-posterior approaches, iliocaval manipulation during exposure, and anesthetic time of more than 8 hours. Descriptive statistics were used for the analysis of patient characteristics. Nonparametric frequency statistics (odds ratios [OR], &khgr;2) were used for analysis of main outcomes. Results. A total of 219 patients (150 women, 69 men) with a mean age of 58.8 (range, 17–86) years, were analyzed. There were 2 complications from IVC filter placement (66 Greenfield filters; 157 retrievable filters). The incidence of lower extremity DVT was 18.7% (41/219) in 36 patients. PE incidence was 3.7% (8/219 patients), and the paradoxical embolus rate was 0.5% (1 patient). Prophylactic IVC filter use reduced the odds of developing a pulmonary embolus (OR = 3.7, P < 0.05) compared with population controls. Patients receiving Greenfield filters had significantly higher VTE incidence than those receiving retrievable filters (OR = 2.8, P = 0.008). Anesthesia duration of more than 8 hours significantly increases VTE incidence (P = 0.029). No statistical significance (P < 0.05) was noted with combined anterior-posterior approach (118 patients) versus posterior-only approach (101 patients) and the incidence of DVT (24/118, 20.3% for former; 17/101, 16.8% for latter). There were a total of 14 deaths; none related to PE or paradoxical embolism during an 8-year period. Mean and median follow-up was 2.8 and 2.4 years, respectively, with 126 achieving 2 or more years of follow-up. Conclusion. VTE-related morbidity and mortality have heightened the awareness within the spine community to the perioperative management of patients undergoing major spinal reconstruction. Prophylactic IVC filter placement significantly lowers VTE-related events, including PE development, than population controls.

Redefining global spinal balance: Normative values of cranial center of mass from a prospective cohort of asymptomatic individuals

Study Design. Prospective radiographical analysis of cranial center of mass (CCOM), C2, and C7 plumb lines in young and elderly asymptomatic individuals. Objective. To establish a normal range for craniosagittal balance for both young and elderly asymptomatic individuals. Summary of Background Data. Global sagittal balance must account for the position of the head in relation to the spine and pelvis. The C7 plumb line defines thoracolumbar sagittal balance and has been shown to have significant impact on patient outcomes. However, the C7 plumb line fails to take into consideration the position of the head in relation to the pelvis. Methods. A total of 100 asymptomatic 20- to 40-year-old patients and 100 asymptomatic 60- to 80-year-old patients were enrolled. Standing plain radiographs of 14 × 36 in were obtained. CCOM, C2, and C7 plumb lines were drawn and measured from the superoposterior endplate of S1. Results. A total of 78 asymptomatic 20- to 40-year-old patients and 62 asymptomatic 60- to 80-year-old patients had adequate radiographs. The mean plumb line values in the 20- to 40-year-old patients and 60- to 80-year-old patients, respectively, were as follows; CCOM 9.0 mm (SD, 31.5 mm) and 41.2 mm (SD, 35.7 mm); C2 −2.7 mm (SD, 32.7 mm) and 32.1 mm (SD, 33.6 mm); and C7 −16.4 mm (SD, 31.5 mm) and 10.6 mm (SD, 27.8 mm). One-way analysis of variance and Student t tests confirmed that these mean plumb line values were significantly different between young and elderly patients (P < 0.001). The change at each level over time was highly correlated with the other levels (r > 0.97; P < 0.001) as did the degree of change between groups (r > 0.90, P < 0.001). Conclusion. Spinopelvic alignment in conjunction with CCOM has increased our understanding of spinal balance by including the head and may better represent true global spinal balance. CCOM is an easily measured parameter by using the nasion-inion technique.

Treatment Algorithms and Protocol Practice in High-Risk Spine Surgery

The practice of appropriate evidence-based medicine should be a goal for all physicians. By using protocols in areas where strong evidence-based medicine exists, physicians have reliably shown they can improve patient outcomes while reducing complications, cost, and hospital stay. Evidence-based protocols in complex spinal care are rare. At Northwestern University the authors have developed a multidisciplinary protocol for the preoperative, intraoperative, and postoperative workup and care of complex spine patients. The rationale and use of the High-Risk Spine Protocol is discussed.