Sigita Burneikiene

Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability.

Objectives Multiple different approaches are used to treat lumbar degenerative disc disease and spinal instability. Both anterior–posterior (AP) reconstructive surgery and transforaminal lumbar interbody fusion (TLIF) provide a circumferential fusion and are considered reasonable surgical options. The purpose of this study was to quantitatively assess clinical parameters such as surgical blood loss, duration of the procedure, length of hospitalization, and complications for TLIF and AP reconstructive surgery for lumbar fusion. Methods A retrospective analysis was completed on 167 consecutive cases performed between January 2002 and March 2004. TLIF surgical procedure was performed on 124 patients, including 73 minimally invasive and 51 open cases. AP surgery was performed on 43 patients. Patients were treated for painful degenerative disc disease, facet arthropathy, degenerative instability, and spinal stenosis. Results The mean operative time for AP reconstruction was 455 minutes, for minimally invasive TLIF 255 minutes, and open TLIF 222 minutes. The mean blood loss for AP fusion surgery was 550 mL, for minimally invasive TLIF 231 mL, and open TLIF 424 mL. The mean hospitalization time for AP reconstruction was 7.2 days, for minimally invasive TLIF 3.1 days, and open TLIF 4.1 days. The total rate of complications was 76.7% for AP reconstruction, including 62.8% major and 13.9% minor complications. The minimally invasive TLIF patients group had the total 30.1% rate of complications, 21.9% of which were minor and 8.2% major complications. There were no major complications in the open TLIF patients group, with 35.3% minor complications. Conclusions AP lumbar interbody fusion surgery is associated with a more than two times higher complication rate, significantly increased blood loss, and longer operative and hospitalization times than both percutaneous and open TLIF for lumbar disc degeneration and instability.

Minimally invasive versus open transforaminal lumbar interbody fusion

Background Available clinical data are insufficient for comparing minimally invasive (MI) and open approaches for transforaminal lumbar interbody fusion (TLIF). To date, a paucity of literature exists directly comparing minimally invasive (MI) and open approaches for transforaminal lumbar interbody fusion (TLIF). The purpose of this study was to directly compare safety and effectiveness for these two surgical approaches. Materials and Methods Open or minimally invasive TLIF was performed in 63 and 76 patients, respectively. All consecutive minimally invasive TLIF cases were matched with a comparable cohort of open TLIF cases using three variables: diagnosis, number of spinal levels, and history of previous lumbar surgery. Patients were treated for painful degenerative disc disease with or without disc herniation, spondylolisthesis, and/or stenosis at one or two spinal levels. Clinical outcome (self-report measures, e.g., visual analog scale (VAS), patient satisfaction, and MacNabs criteria), operative data (operative time, estimated blood loss), length of hospitalization, and complications were assessed. Average follow-up for patients was 37.5 months. Results: The mean change in VAS scores postoperatively was greater (5.2 vs. 4.1) in theopen TLIF patient group (P = 0.3). MacNabs criteria score was excellent/good in 67% and 70% (P = 0.8) of patients in open and minimally invasive TLIF groups, respectively. The overall patient satisfaction was 72.1% and 64.5% (P = 0.4) in open and minimally invasive TLIF groups, respectively. The total mean operative time was 214.9 min for open and 222.5 min for minimally invasive TLIF procedures (P = 0.5). The mean estimated blood loss for minimally invasive TLIF (163.0 ml) was significantly lower (P < 0.0001) than the open approach (366.8 ml). The mean duration of hospitalization in the minimally invasive TLIF (3 days) was significantly shorter (P = 0.02) than the open group (4.2 days). The total rate of neurological deficit was 10.5% in the minimally invasive TLIF group compared to 1.6% in the open group (P = 0.02). Conclusions: Minimally invasive TLIF technique may provide equivalent long-term clinical outcomes compared to open TLIF approach in select population of patients. The potential benefit of minimized tissue disruption, reduced blood loss, and length of hospitalization must be weighted against the increased rate of neural injury-related complications associated with a learning curve.

The accuracy of pedicle screw placement using intraoperative image guidance systems

OBJECT Several retrospective studies have demonstrated higher accuracy rates and increased safety for navigated pedicle screw placement than for free-hand techniques; however, the accuracy differences between navigation systems has not been extensively studied. In some instances, 3D fluoroscopic navigation methods have been reported to not be more accurate than 2D navigation methods for pedicle screw placement. The authors of this study endeavored to identify if 3D fluoroscopic navigation methods resulted in a higher placement accuracy of pedicle screws. METHODS A systematic analysis was conducted to examine pedicle screw insertion accuracy based on the use of 2D, 3D, and conventional fluoroscopic image guidance systems. A PubMed and MEDLINE database search was conducted to review the published literature that focused on the accuracy of pedicle screw placement using intraoperative, real-time fluoroscopic image guidance in spine fusion surgeries. The pedicle screw accuracy rates were segregated according to spinal level because each spinal region has individual anatomical and morphological variations. Descriptive statistics were used to compare the pedicle screw insertion accuracy rate differences among the navigation methods. RESULTS A total of 30 studies were included in the analysis. The data were abstracted and analyzed for the following groups: 12 data sets that used conventional fluoroscopy, 8 data sets that used 2D fluoroscopic navigation, and 20 data sets that used 3D fluoroscopic navigation. These studies included 1973 patients in whom 9310 pedicle screws were inserted. With conventional fluoroscopy, 2532 of 3719 screws were inserted accurately (68.1% accuracy); with 2D fluoroscopic navigation, 1031 of 1223 screws were inserted accurately (84.3% accuracy); and with 3D fluoroscopic navigation, 4170 of 4368 screws were inserted accurately (95.5% accuracy). The accuracy rates when 3D was compared with 2D fluoroscopic navigation were also consistently higher throughout all individual spinal levels. CONCLUSIONS Three-dimensional fluoroscopic image guidance systems demonstrated a significantly higher pedicle screw placement accuracy than conventional fluoroscopy or 2D fluoroscopic image guidance methods.

Prospective, Randomized, Double-Blind Clinical Study Evaluating the Correlation of Clinical Outcomes and Cervical Sagittal Alignment

BACKGROUND:Sagittal alignment of the cervical spine has received increased attention in the literature as an important determinant of clinical outcomes after anterior cervical diskectomy and fusion. Surgeons use parallel or lordotically fashioned grafts depending on preference or simple availability. OBJECTIVE:To quantitatively assess and compare cervical sagittal alignment and clinical outcome when lordotic or parallel allografts were used for fusion. METHODS:A prospective, randomized, double-blind clinical study that enrolled 122 patients was performed. The mean follow-up was 37.5 months (range, 12-54 months). RESULTS:The mean postoperative cervical sagittal alignment was 19° (range, −7°-36°) and 18° (range, −7°-37°) in the lordotic and parallel graft patient groups, respectively. The mean segmental sagittal alignment was 6° (range, −4°-19°) and 7° (range, −3°-19°) in the lordotic and parallel graft patient groups, respectively. There were no statistically significant differences in clinical outcome scores between the lordotic and parallel graft patient groups. However, patients who had maintained or improved segmental sagittal alignment, regardless of graft type, achieved a higher degree of improvement in Short Form-36 Physical Component Summary and Neck Disability Index scores. This was statistically significant (P < .038). CONCLUSION:The use of lordotically shaped allografts does not increase cervical/segmental sagittal alignment or improve clinical outcomes. Maintaining a consistent segmental sagittal alignment or increasing segmental lordosis was related to a higher degree of improvement in clinical outcomes.

Utility of computerized isocentric fluoroscopy for minimally invasive spinal surgical techniques.

Objective: The purpose of this study was to prospectively evaluate the clinical utility and accuracy of intraoperative three-dimensional fluoroscopy as an adjunct for the placement of a complex spinal instrumentation. Methods: The Siemens Iso-C three-dimensional fluoroscopy unit in the combination with the Stealth Treon computer volumetric navigational system was used. A total of 279 spinal instrumentation screws or transpedicular cannulations were performed in 69 patients. Accuracy, operative time, and amount of fluoroscopy utilization time were assessed for transforaminal lumbar interbody fusion (TLIF) and kyphoplasty cases. Results: Only 4 percutaneous transpedicular lumbar screws out of 265 total (1.5%) were malpositioned. Average operative time for TLIF cases was 185 minutes (range 114-311 minutes) for one-level and 292.6 minutes (range 173-390 minutes) for two-level procedures. Biplanar fluoroscopy utilization time was 93 seconds (range 27-280 seconds) for one-level procedures and 216 seconds (range 80-388 seconds) for two-level procedures. Average surgery duration for kyphoplasty was 60 minutes (range 36-79 minutes) for one-level procedures and 68.5 minutes (range 65-75 minutes) for two-level cases. Biplanar fluoroscopy utilization time was 41.3 seconds per case (range 25-62 seconds). Conclusions: Use of intraoperative three-dimensional fluoroscopy for image guidance in minimally invasive complex spinal instrumentation procedures is feasible and safe. This technique provides excellent visualization of three-dimensional relationships. This potentially results in improved accuracy of screw positioning and the ability to detect misplaced screws prior to wound closure. This technique also potentially results in a significant reduction in radiation exposure for both the patient and the staff.

CyberKnife radiosurgery for trigeminal neuralgia treatment: A preliminary multicenter experience

OBJECTIVERadiosurgery has gained acceptance as a treatment option for trigeminal neuralgia. We report our preliminary multicenter experience treating trigeminal neuralgia with the CyberKnife (Accuray, Inc., Sunnyvale, CA). METHODSA total of 95 patients were treated for idiopathic trigeminal neuralgia between May 2002 and October 2005. Radiosurgical dose and volume parameters were retrospectively analyzed in relation to pain response, complications, and recurrence of symptoms. Optimal treatment parameters were identified for patients who had excellent and sustained pain relief with no complications, including severe or moderate hypesthesia. RESULTSExcellent pain relief was initially experienced by 64 out of 95 patients (67%). The median time to pain relief was 14 days (range, 0.3–180 d). Posttreatment numbness occurred in 45 (47%) of the patients treated. Using higher radiation doses and treating longer segments of the nerve led to both better pain relief and a higher incidence of hypesthesia. The presence of posttreatment numbness was predictive of better pain relief. The overall rate of complications was 18%. At the mean follow-up time of 2 years, 47 of the 95 patients (50%) had sustained pain relief, all of whom were completely off pain medications. CONCLUSIONThe results of this study suggest the following optimal radiosurgical treatment parameters for treatment of idiopathic trigeminal neuralgia: a median maximal dose of 78 Gy (range, 70–85.4 Gy) and a median length of the nerve treated of 6 mm (range, 5–12 mm).

Complications in patients undergoing combined transforaminal lumbar interbody fusion and posterior instrumentation with deformity correction for degenerative scoliosis and spinal stenosis.

Background: Utilization of the transforaminal lumbar interbody fusion (TLIF) approach for scoliosis offers the patients deformity correction and interbody fusion without the additional morbidity associated with more invasive reconstructive techniques. Published reports on complications associated with these surgical procedures are limited. The purpose of this study was to quantify the intra- and postoperative complications associated with the TLIF surgical approach in patients undergoing surgery for spinal stenosis and degenerative scoliosis correction. Methods: This study included patients undergoing TLIF for degenerative scoliosis with neurogenic claudication and painful lumbar degenerative disc disease. The TLIF technique was performed along with posterior pedicle screw instrumentation. The average follow-up time was 30 months (range, 15–47). Results: A total of 29 patients with an average age of 65.9 years (range, 49–83) were evaluated. TLIFs were performed at 2.2 levels on average (range, 1–4) in addition to 6.0 (range, 4–9) levels of posterolateral instrumented fusion. The preoperative mean lumbar lordosis was 37.6° (range, 16°–55°) compared to 40.5° (range, 26°–59.2°) postoperatively. The preoperative mean coronal Cobb angle was 32.3° (range, 15°–55°) compared to 15.4° (range, 1°–49°) postoperatively. The mean operative time was 528 min (range, 276–906), estimated blood loss was 1091.7 mL (range, 150–2500), and hospitalization time was 8.0 days (range, 3–28). A baseline mean Visual Analog Scale (VAS) score of 7.6 (range, 4–10) decreased to 3.6 (range, 0–8) postoperatively. There were a total of 14 (49%) hardware and/or surgical technique related complications, and 8 (28%) patients required additional surgeries. Five (17%) patients developed pseudoarthrosis. The systemic complications (31%) included death (1), cardiopulmonary arrest with resuscitation (1), myocardial infarction (1), pneumonia (5), and pulmonary embolism (1). Conclusion: This study suggests that although the TLIF approach is a feasible and effective method to treat degenerative adult scoliosis, it is associated with a high rate of intra- and postoperative complications and a long recovery process.

Neck pain in multisport athletes

OBJECT The sport of triathlon is very physically demanding and has experienced rapid growth in recent years. The number of triathletes seen for spine disorders at neurosurgery clinics is increasing. Neck pain and overuse injuries have not been adequately studied in multisport athletes. The authors undertook an epidemiological study to establish the lifetime incidence of neck pain and the prevalence of possible discogenic pain, and to identify risk factors among triathletes in the Boulder, Colorado area. METHODS An online questionnaire was developed to collect information about physical characteristics, training habits, athletic status, number of races completed, and neck pain among triathletes. The incidence of possible cervical discogenic pain was defined according to the duration of symptoms for the most recent pain episode. RESULTS One hundred and sixty-four athletes responded to the questionnaire. The lifetime incidence of neck pain was 47.6% (78 athletes), with 15.4% possibly being of discogenic origin based on the duration of symptoms. Approximately 64% of responding athletes reported that their neck pain was sports related. Although the number of previous triathlons was not predictive of neck pain, total years in the sport (p = 0.029) and number of previous sports-related injuries (p < 0.0001) were. CONCLUSIONS Two major risk factors for long-term spinal problems in triathletes are sports-related injuries and overuse. This report is one of the first comprehensive studies of neck pain and overuse injury in multisport athletes.

The duration of symptoms and clinical outcomes in patients undergoing anterior cervical discectomy and fusion for degenerative disc disease and radiculopathy

BACKGROUND CONTEXT There have been controversial reports published in the literature on the duration of symptoms (DOS) and clinical outcome correlation in patients undergoing anterior cervical discectomy and fusion (ACDF) for painful degenerative disc disease and radiculopathy. PURPOSE The primary purpose of this study was to analyze if the DOS has any effect on clinical outcomes. STUDY DESIGN/SETTING A post hoc analysis was performed on an original prospective clinical study analyzing clinical outcomes and cervical sagittal alignment correlations. PATIENTS SAMPLE Fifty-eight patients undergoing one- or two-level ACDF surgeries for cervical degenerative radiculopathy were analyzed. OUTCOME MEASURES Standardized questionnaires were used to evaluate clinical outcomes. Neck and arm pain was evaluated using (Visual Analog Scale [VAS]). Two scales of Health-Related Quality-of-Life Questionnaire (Short-Form 36 Health Survey [SF-36]) were used for this study: the physical component summary (PCS) and mental component summary (MCS). Neck disability index (NDI) was used to evaluate chronic disability in activities of daily living. The patients completed a self-reported Patient Satisfaction with Results Survey. METHODS Patients who had previous or redo surgeries, were diagnosed with myelopathy or had more than two-level ACDF surgeries were excluded, leaving a total of 58 patients. The mean follow-up was 37.2 months (range 12-54). Patients were divided into two groups for clinical outcome analyses according to the DOS: patients who had surgery within 6 months (n=29) or more than 6 months (n=29) after becoming symptomatic. RESULTS There were no statistically significant differences in any demographic or clinical parameters among the patient groups. Controlling for preoperative scores, the patients who had surgery within 6 months reported significantly higher reduction (p=.04) in arm pain scores compared with the patients who waited more than 6 months. No significant differences were detected in postoperative neck pain VAS (p=.3), NDI (p=.06), SF-36 PCS (p=.08), and MCS (p=.8) scores. CONCLUSIONS Neck and upper extremity pain can be successfully treated conservatively. In those cases, when surgical intervention is pursued, patients with shorter DOS have better improvement in radiculopathy symptoms that is statistically significant.

Prediction based on preoperative opioid use of clinical outcomes after transforaminal lumbar interbody fusions

OBJECTIVE Opioid analgesics have become some of the most prescribed drugs in the world, despite the lack of long-term studies evaluating the benefits of opioid medications versus their risks associated with chronic use. In addition, long-term opioid use may be associated with worse long-term clinical outcomes. The primary objective of this study was to evaluate whether preoperative opioid use predicted inferior clinical outcomes among patients undergoing transforaminal lumbar interbody fusion (TLIF) for symptomatic lumbar degenerative disc disease. METHODS The authors of this observational study prospectively enrolled 93 patients who underwent 1-level to 2-level TLIFs in 2011-2014; the patient cohort was divided into 2 groups according to preoperative opioid use or no such use. Visual analog scale (VAS) scores for low-back pain and leg pain, Oswestry Disability Index scores, and the scores of the mental component summary (MCS) and physical component summary (PCS) on the 36-Item Short Form Health Survey were used to assess pain, disability, and health-related quality of life outcomes, respectively. The clinical scores for the 2 groups were determined preoperatively and at a 12-month follow-up examination. RESULTS In total, 60 (64.5%) patients took prescribed opioid medications preoperatively. Compared with those not taking opioids preoperatively, these patients had significantly higher VAS scores for low-back pain (p = 0.016), greater disability (p = 0.013), and lower PCS scores (p = 0.03) at the 12-month follow-up. The postoperative MCS scores were also significantly lower (p = 0.035) in the opioid-use group, but these lower scores were due to significantly lower baseline MCS scores in this group. A linear regression analysis did not detect opioid dose-related effects on leg and back pain, disability, and MCS and PCS scores, suggesting that poorer outcomes are not significantly correlated with higher opioid doses taken by the patients. CONCLUSIONS The use of opioid medications to control pain before patients underwent lumbar fusion for degenerative lumbar conditions was associated with less favorable clinical outcomes postoperatively. This is the first study that has demonstrated this association in a homogeneous cohort of patients undergoing TLIF; this association should be studied further to evaluate the conclusions of the present study. Clinical trial registration no.: NCT01406405 ( clinicaltrials.gov ).