Swamy Kurra

Intradural Carcinoid Tumor Found in a Patient with No History of Cancer

BACKGROUND Carcinoid tumors are rare neoplasms that often arise from the gastrointestinal or respiratory tracts. They often metastasize to bone tissue and pancreatic and hepatic sites. The central nervous system and most specifically the spinal cord are rarely involved. Primary carcinoid tumors of the central nervous system are even rarer. CASE DESCRIPTION A 58-year-old man presented with progressive bilateral lower extremity weakness and a negative history of cancer. Imaging revealed an intradural mass at the L1 and L2 spinal levels. Surgical resection of the tumor via laminectomy was performed. The tumor was observed to have eroded through the dura and was compressing the spinal nerves. Histopathologically, the mass was observed to be of carcinoid origin. A subsequent octreoscan revealed no primary sites of carcinoid tumor. Postoperatively, the patient was followed for 1.5 years. The patient reported improvement in sensation to his lower extremities with no change in motor findings. CONCLUSIONS Carcinoid tumors of the central nervous system are extremely rare, but they should remain in the differential diagnosis for patients experiencing extremity weakness and back or neck pain with an intradural mass and no primary source of the tumor identified or other manifestations of a primary tumor.

Uniplanar Versus Fixed Pedicle Screws in the Correction of Thoracic Kyphosis in the Treatment of Adolescent Idiopathic Scoliosis (AIS).

Background: The aim of surgical treatment of scoliosis is to obtain fusion of the spinal column, balanced in the coronal and sagittal planes. Great success has been attained with coronal correction; however, the sagittal profile has received less attention, resulting in little correction of sagittal plane alignment. The purpose of this study was to compare uniplanar and fixed pedicle screws in the correction of the thoracic sagittal alignment in the treatment of adolescent idiopathic scoliosis (AIS). Methods: The sagittal profile of 2 groups of patients undergoing posterior spinal fusion (PSF) for AIS was compared. One group had uniplanar screws (n=16) as bone anchors, and the second group had fixed screws (n=20). Consecutive patients with AIS treated by PSF during 2004 to 2006 with fixed screws; and those treated in 2008 with uniplanar screws were included in the study. Data included: patient demographics, medical conditions, curve type, Risser stage, coronal and sagittal curve magnitude, curve flexibility, osteotomies, fusion levels, type and location of instrumentation, curve magnitude at the initial postoperative visit and at final follow-up. ANOVA and &khgr;2 testing was completed. A P<0.05 was considered significant. Results: Both groups were comparable demographically, medically, in relation to the curve characteristics and the surgical treatment. Immediate postcorrection sagittal curvature measurements were greater using the uniplanar than fixed screws, 36 versus 26 degrees and was also statistically significant at final follow-up (P=0.006). There was no difference between groups with respect to coronal thoracic deformity. In the Lenke 1 and Lenke 2 curve population, similar results were found. Conclusions: In patients undergoing PSF for AIS, uniplanar screws achieved superior correction of the sagittal thoracic alignment than fixed screws. This advantage was maintained in the postoperative follow-up period. The ability of the uniplanar screws to adapt to variable sagittal orientation appears to contribute to better radiographic outcomes. Level of Evidence: This is a level III respective review study conducted at a single center from a single, pediatric spine surgeon.

The Effect of Kyphoplasty on Mortality in Symptomatic Vertebral Compression Fractures: A Review

ABSTRACT Background: Vertebral compression fractures (VCFs) are common comorbidities encountered in the elderly, and they are on the rise. Kyphoplasty may be superior in VCF management compared with conservative management. A comprehensive review of literature was conducted, focusing on the effect of kyphoplasty on mortality and overall survivorship in patients with a diagnosis of symptomatic VCFs. Methods: A comprehensive literature search was conducted to find recently published literature on kyphoplasty effects on mortality using the following keywords: “kyphoplasty,” “mortality,” “morbidity,” “vertebral compression fractures,” and “survivorship.” We only included articles that listed one of their primary or secondary outcomes as morbidity and mortality after a kyphoplasty procedure in VCF patients. Results: Of 27 articles, only 6 articles met the inclusion criteria. Studies have reported that surgical procedures have decreased the mortality rate in symptomatic VCF patients. Four studies concluded that the mortality rate was lower after kyphoplasty compared with vertebroplasty and nonoperative treatments. One study reported there was no significant difference between kyphoplasty and nonoperative management. One study summarized that the mortality rate was not significantly different between kyphoplasty and vertebroplasty. Conclusions: Multicenter prospective and randomized control studies are required to fully evaluate the decreasing trend of mortality rates after a kyphoplasty procedure.

Assessment of Coronal Spinal Alignment for Adult Spine Deformity Cases After Intraoperative T Square Shaped Use

STUDY DESIGN Retrospectively reviewed surgeries between 2011 and 2015 of patients who underwent posterior spinal deformity instrumentation with constructs involving fusions to pelvis and encompassing at least five levels. OBJECTIVE Measure the radiographic outcomes of coronal malalignment (CM) after use of an intraoperative T square shaped instrument in posterior spinal deformity surgeries with at least five levels of fusion and extension to pelvis. BACKGROUND Neuromuscular children found to benefit from intraoperative T square technique to help achieve proper coronal spinal balance with extensive fusions. This intraoperative technique used in our posterior spine deformity instrumentation surgeries with the aforementioned parameters. METHODS There were 50 patients: n = 16 with intraoperative T square and n = 34 no-T square shaped device. Subgroups divided based on greater than 20 mm displacement and greater than 40 mm displacement of the C7 plumb line to the central sacral vertical line on either side in preoperative radiographs. We analyzed the demographics and the pre- and postoperative radiographic parameters of standing films: standing CM (displacement of C7 plumb line to central sacral vertical line), and major coronal Cobb angles in total sample and subgroups and compared T square shaped device with no-T square shaped device use by analysis of variance. A p value ≤.05 is statistically significant. RESULTS In the total sample, though postoperative CM mean was not statistically different, we observed greater CM corrections in patients where a T square shaped device was used (70%) versus no-T square shaped device used (18%). In >20 mm and >40 mm subgroups, the postoperative mean CM values were statistically lower for the patients where a T square shaped device was used, p = .016 and p = .003, respectively. Cobb corrections were statistically higher for T square shaped device use in both >20 mm and >40 mm subgroups, 68%, respectively. CONCLUSION The intraoperative T square shaped device technique had a positive effect on the amount of spine coronal malalignment correction after its use and for lumbar and thoracic coronal Cobb angles. LEVEL OF EVIDENCE Level III.STUDY DESIGN Retrospectively reviewed surgeries between 2011 and 2015 of patients who underwent posterior spinal deformity instrumentation with constructs involving fusions to pelvis and encompassing at least five levels. OBJECTIVE Measure the radiographic outcomes of coronal malalignment (CM) after use of an intraoperative T square shaped instrument in posterior spinal deformity surgeries with at least five levels of fusion and extension to pelvis. BACKGROUND Neuromuscular children found to benefit from intraoperative T square technique to help achieve proper coronal spinal balance with extensive fusions. This intraoperative technique used in our posterior spine deformity instrumentation surgeries with the aforementioned parameters. METHODS There were 50 patients: n = 16 with intraoperative T square and n = 34 no-T square shaped device. Subgroups divided based on greater than 20 mm displacement and greater than 40 mm displacement of the C7 plumb line to the central sacral vertical line on either side in preoperative radiographs. We analyzed the demographics and the pre- and postoperative radiographic parameters of standing films: standing CM (displacement of C7 plumb line to central sacral vertical line), and major coronal Cobb angles in total sample and subgroups and compared T square shaped device with no-T square shaped device use by analysis of variance. A p value ≤.05 is statistically significant. RESULTS In the total sample, though postoperative CM mean was not statistically different, we observed greater CM corrections in patients where a T square shaped device was used (70%) versus no-T square shaped device used (18%). In >20 mm and >40 mm subgroups, the postoperative mean CM values were statistically lower for the patients where a T square shaped device was used, p = .016 and p = .003, respectively. Cobb corrections were statistically higher for T square shaped device use in both >20 mm and >40 mm subgroups, 68%, respectively. CONCLUSION The intraoperative T square shaped device technique had a positive effect on the amount of spine coronal malalignment correction after its use and for lumbar and thoracic coronal Cobb angles. LEVEL OF EVIDENCE Level III.

Pharmacology of Inhaled Anesthetics

Inhalational agents are chemical compounds that produce general anesthesia and are delivered via inhalation. They are used in anesthesia primarily to produce a loss of consciousness, but may have other lesser effects such as muscle relaxation and analgesia. Nitrous oxide is the only currently used inorganic inhalational agent. Volatile anesthetics, including halothane, methoxyflurane, enflurane, isoflurane, desflurane, and sevoflurane, exert their effects at multiple sites throughout the central nervous system. Each agent has its own specific chemical structure that leads to different solubilities, potencies, biotransformation, and side effects of each drug. The modern volatile inhalational agents of fluorinated ethers including isoflurane, sevoflurane, and desflurane were introduced in the 1980s. The modern volatile agents mainly resist metabolism and make organ toxicity unlikely. As research continues, the noble gas, xenon, has a potential for future development.

Review of long-term outcomes of disc arthroplasty for symptomatic single level cervical degenerative disc disease

ABSTRACT Introduction: Cervical disc arthroplasty (CDA) was developed as an alternative for anterior cervical discectomy and fusion (ACDF) for nerve root decompression. The rationale behind CDA was to help prevent adjacent segment degeneration which potentially may lead to additional surgery. Multiple randomized controlled trials have evaluated a myriad of disc arthroplasty devices over the past 10 years and provided data regarding clinical benefits and safety. Their long-term data, reporting results at 5–10 years, presents the opportunity to comment on the overall efficacy, safety and reported complications of these devices. This report reviews results of the Prestige, proDisc-C, Mobi-C Disc and various other arthroplasty devices and provides an overall report of the longest term available data and comparisons between devices. Areas covered: This review summarizes previously published articles in a literature search using keywords: ‘cervical disc arthroplasty’, ‘cervical total disc replacement’, ‘anterior cervical decompression and fusion’, ‘anterior cervical arthrodesis’, ‘symptomatic degenerative disc disease’ and commercial names of devices. Expert commentary: CDA, with the devices reviewed, resulted in favorable outcomes in comparison to ACDF for the treatment of symptomatic cervical degenerative disc disease (DDD) taking in to account the long-term functional recovery, adverse events, development of adjacent segment degeneration and subsequent surgical interventions.

Fifth Lumbar L5 Perineural Cyst with Unusual Radiculopathy: Traction Plexopathy

Perineural cysts are cystic dilations and are frequently seen in relation to the lumbosacral spine. We describe a case of a fifth lumbar (L5) perineural cyst with unusual radicular symptoms and discuss the possible role of traction plexopathy caused by the cyst. A 38-year-old male presented with a longstanding history of back pain and right side thigh pain. This pain radiated from the buttocks to the lateral and anterior aspect of the thigh. He described the pain as pins and needles/burning with no significant relief with medications or rest. Imaging of the lumbar spine revealed a cystic lesion on the right side involving the L5 nerve root in the foraminal region. He failed conservative treatment and elected to have the cyst removed even with a guarded prognosis. A wide L5 laminectomy was performed. Due to the size of the cyst which was causing traction on the exiting L5 nerve root, the L5 pedicle was excised in order to delineate the cyst and to prevent any iatrogenic injury to the root. The patient had the dramatic improvement in his radicular pain immediately after the surgery and continues to be pain-free at his latest three-year follow-up. This case highlights the unusual pain pattern distribution from a perineural cyst possibly secondary to traction effect of the tumor.

Long-term outcomes of transforaminal lumbar interbody fusion in patients with spinal stenosis and degenerative scoliosis

BACKGROUND CONTEXT Patients with spinal deformity may present with complaints related to either the deformity itself or the manifestations of the coexisting spinal stenosis. There are reports of successful management of lumbar pathology in the absence of global sagittal or coronal imbalance, with limited decompression and fusion, addressing only the symptomatic segment. PURPOSE Our study examined the long-term outcomes of transforaminal lumbar interbody fusion (TLIF), a less extensive procedure, based on the experience of the senior author over the past 10 years. STUDY DESIGN/SETTING This was a retrospective study of symptomatic lumbar spinal stenosis and spinal deformity managed by one surgeon at The Cleveland Clinic since 2003. PATIENT SAMPLE Forty-one patients were included in the study. OUTCOME MEASURES The present study measures the long-term clinical functional outcomes of these patients through EQ-5D (EuroQol five dimensions questionnaire), PHQ-9 (Patient Health Questionnaire), and PDQ (Pain Disability Questionnaire) forms, along with documented radiographic parameters and Charlson Comorbidity Index (CCI). METHODS There were no funding or potential conflicts of interest associated biases in the present study. Patients with symptomatic lumbar spinal stenosis with neutral global alignment in the sagittal and coronal planes and symptomatic stenosis at the deformity level were treated by limited fusion and TLIF, and had a follow-up period of at least 5 years. Excluded were patients under 18 years of age, had more than three levels of fusion, and had an active spinal malignancy or recent spinal trauma. The grouping variables were curve magnitude, revision surgeries, and TLIF levels. Clinical outcomes were compared in all the grouping variables. Analysis of variance (ANOVA) and chi-square tests were utilized; p<.05 was considered statistically significant. RESULTS The average age and follow-up period were 66±10 and 7.5 years, respectively. There was no statistical difference between patients with curves measuring between 10° and 20° and greater than 20° for EQ-5D, PHQ-9, and PDQ. Patients had worse PDQ data with larger curves compared with smaller curves at both 5 years and final follow-up. Although there was no statistical significance between preoperative coronal curve magnitude and revision surgeries, patients with curves greater than 20° had higher rates of revision surgeries (75%; p=.343) in the global lumbar curve deformity group. Although there was no statistical significance for patients who underwent revision surgeries,those patients had low PHQ-9 values at the final follow-up (p=.09). The revision surgery rate was 48% in one-level TLIF and 18% in two-level TLIF. Moderate pain disability scores were noticed for one-level TLIF patients (mean=75) compared with two-level TLIF patients (mean=27) at the final follow-up, and approached statistical significance in this comparison (p=.06). CONCLUSION Although this topic has a limited audience to spinal deformity surgeons, the prevalence of patients who present with adult spinal deformities has been increasing. Short segment fusion, in the setting of modest spinal deformity, is a reasonable and safe option. Further study on the concept of short segment fusions in the growing patient population is required as more comprehensive fusions do have noted complication rates, and a compromise must be reached between the extent of surgery that is enough to provide pain relief and disability and the degree of surgery that is too much to be tolerated in terms of complication rates.

Lumbar vertebral body and pars fractures following laminectomy

Abstract A 56-year-old alcoholic male incurred L5 vertebral body and bilateral L4 pars fractures with progressive L4 on L5 anterolisthesis following low-energy falls while intoxicated. Recently, he had a L3–S1 laminectomy for lumbar spinal stenosis with claudication. Preoperative imaging and radiographs were negative for pars defects and instability, so an isolated decompressive surgery was performed. Following low-energy falls, his outpatient work-up revealed fractures through the bilateral L4 pedicles and posterior third of L5 vertebral body, with recurrence of axial back pain and bilateral lower extremity radiculopathy. He underwent revision decompression from L4–S1 and posterior instrumented fusion with transforaminal lumbar interbody fusion performed at each revised level. His axial back pain and radiculopathy improved postoperatively. Instability of a lumbar spine fracture pattern can be due to the remote or prior iatrogenic disruption of the posterior ligamentous complex. Our patient benefitted from surgery and his low back pain was resolved.

Magnetically controlled growing rods for scoliosis surgery

ABSTRACT Introduction: Early onset scoliosis can be both a disfiguring as well as a life threatening condition. When more conservative treatments fail, pediatric spinal surgeons are forced to consider operative interventions. Traditionally, these interventions have involved the insertion of a variety of implants into the patient with a limited number of anchor points controlling the spine. In the past, these pediatric patients have had multiple surgeries for elective lengthening of these devices to facilitate their growth while attempting to control the scoliosis. These patients often experience a physical and emotional toll from their multiple repeated surgeries. Growing spine techniques have also had a noted high complication rate due to implant dislodgement and infections. Recently, the development of non-invasively, self-lengthening growing rods has occurred. These devices have the potential to allow for the devices to be lengthened magnetically in a conscious patient in the surgeon’s office. Areas covered: This review summarized previously published articles in the English literature using a key word search in PubMed for: ‘magnetically controlled growing rods’, ‘Magec rods’, ‘magnetic growing rods’ and ‘growing rods’. Expert commentary: Magnetically controlled growing rods have an advantage over growing rods in lengthening the growing spine in the absence of repetitive surgeries.