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Deng H, Chan AK, Ammanuel SG, Chan AY, Oh T, Skrehot HC, Edwards CS, Kondapavulur S, Nichols AD, Liu C, Yue JK, Dhall SS, Clark AJ, Chou D, Ames CP, Mummaneni PV. Risk factors for deep surgical site infection following thoracolumbar spinal surgery. J Neurosurg Spine 2020. [DOI: 10.3171/2019.8.spine19479] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVESurgical site infection (SSI) following spine surgery causes major morbidity and greatly impedes functional recovery. In the modern era of advanced operative techniques and improved perioperative care, SSI remains a problematic complication that may be reduced with institutional practices. The objectives of this study were to 1) characterize the SSI rate and microbial etiology following spine surgery for various thoracolumbar diseases, and 2) identify risk factors that were associated with SSI despite current perioperative management.METHODSAll patients treated with thoracic or lumbar spine operations on the neurosurgery service at the University of California, San Francisco from April 2012 to April 2016 were formally reviewed for SSI using the National Healthcare Safety Network (NHSN) guidelines. Preoperative risk variables included age, sex, BMI, smoking, diabetes mellitus (DM), coronary artery disease (CAD), ambulatory status, history of malignancy, use of preoperative chlorhexidine gluconate (CHG) showers, and the American Society of Anesthesiologists (ASA) classification. Operative variables included surgical pathology, resident involvement, spine level and surgical technique, instrumentation, antibiotic and steroid use, estimated blood loss (EBL), and operative time. Multivariable logistic regression was used to evaluate predictors for SSI. Odds ratios and 95% confidence intervals were reported.RESULTSIn total, 2252 consecutive patients underwent thoracolumbar spine surgery. The mean patient age was 58.6 ± 13.8 years and 49.6% were male. The mean hospital length of stay was 6.6 ± 7.4 days. Sixty percent of patients had degenerative conditions, and 51.9% underwent fusions. Sixty percent of patients utilized presurgery CHG showers. The mean operative duration was 3.7 ± 2 hours, and the mean EBL was 467 ± 829 ml. Compared to nonfusion patients, fusion patients were older (mean 60.1 ± 12.7 vs 57.1 ± 14.7 years, p < 0.001), were more likely to have an ASA classification > II (48.0% vs 36.0%, p < 0.001), and experienced longer operative times (252.3 ± 120.9 minutes vs 191.1 ± 110.2 minutes, p < 0.001). Eleven patients had deep SSI (0.49%), and the most common causative organisms were methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus. Patients with CAD (p = 0.003) or DM (p = 0.050), and those who were male (p = 0.006), were predictors of increased odds of SSI, and presurgery CHG showers (p = 0.001) were associated with decreased odds of SSI.CONCLUSIONSThis institutional experience over a 4-year period revealed that the overall rate of SSI by the NHSN criteria was low at 0.49% following thoracolumbar surgery. This was attributable to the implementation of presurgery optimization, and intraoperative and postoperative measures to prevent SSI across the authors’ institution. Despite prevention measures, having a history of CAD or DM, and being male, were risk factors associated with increased SSI, and presurgery CHG shower utilization decreased SSI risk in patients.
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Mummaneni PV, Park P, Shaffrey CI, Wang MY, Uribe JS, Fessler RG, Chou D, Kanter AS, Okonkwo DO, Mundis GM, Eastlack RK, Nunley PD, Anand N, Virk MS, Lenke LG, Than KD, Robinson LC, Fu KM, _ _. The MISDEF2 algorithm: an updated algorithm for patient selection in minimally invasive deformity surgery. J Neurosurg Spine 2020; 32:221-228. [DOI: 10.3171/2019.7.spine181104] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 07/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEMinimally invasive surgery (MIS) can be used as an alternative or adjunct to traditional open techniques for the treatment of patients with adult spinal deformity. Recent advances in MIS techniques, including advanced anterior approaches, have increased the range of candidates for MIS deformity surgery. The minimally invasive spinal deformity surgery (MISDEF2) algorithm was created to provide an updated framework for decision-making when considering MIS techniques in correction of adult spinal deformity.METHODSA modified algorithm was developed that incorporates a patient’s preoperative radiographic parameters and leads to one of 4 general plans ranging from basic to advanced MIS techniques to open deformity surgery with osteotomies. The authors surveyed 14 fellowship-trained spine surgeons experienced with spinal deformity surgery to validate the algorithm using a set of 24 cases to establish interobserver reliability. They then re-surveyed the same surgeons 2 months later with the same cases presented in a different sequence to establish intraobserver reliability. Responses were collected and analyzed. Correlation values were determined using SPSS software.RESULTSOver a 3-month period, 14 fellowship-trained deformity surgeons completed the surveys. Responses for MISDEF2 algorithm case review demonstrated an interobserver kappa of 0.85 for the first round of surveys and an interobserver kappa of 0.82 for the second round of surveys, consistent with substantial agreement. In at least 7 cases, there was perfect agreement between the reviewing surgeons. The mean intraobserver kappa for the 2 surveys was 0.8.CONCLUSIONSThe MISDEF2 algorithm was found to have substantial inter- and intraobserver agreement. The MISDEF2 algorithm incorporates recent advances in MIS surgery. The use of the MISDEF2 algorithm provides reliable guidance for surgeons who are considering either an MIS or an open approach for the treatment of patients with adult spinal deformity.
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Horn SR, Passias PG, Oh C, Lafage V, Lafage R, Smith JS, Line B, Anand N, Segreto FA, Bortz CA, Scheer JK, Eastlack RK, Deviren V, Mummaneni PV, Daniels AH, Park P, Nunley PD, Kim HJ, Klineberg EO, Burton DC, Hart RA, Schwab FJ, Bess S, Shaffrey CI, Ames CP, _ _. Predicting the combined occurrence of poor clinical and radiographic outcomes following cervical deformity corrective surgery. J Neurosurg Spine 2020; 32:182-190. [DOI: 10.3171/2019.7.spine18651] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/09/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVECervical deformity (CD) correction is clinically challenging. There is a high risk of developing complications with these highly complex procedures. The aim of this study was to use baseline demographic, clinical, and surgical factors to predict a poor outcome following CD surgery.METHODSThe authors performed a retrospective review of a multicenter prospective CD database. CD was defined as at least one of the following: cervical kyphosis (C2–7 Cobb angle > 10°), cervical scoliosis (coronal Cobb angle > 10°), C2–7 sagittal vertical axis (cSVA) > 4 cm, or chin-brow vertical angle (CBVA) > 25°. Patients were categorized based on having an overall poor outcome or not. Health-related quality of life measures consisted of Neck Disability Index (NDI), EQ-5D, and modified Japanese Orthopaedic Association (mJOA) scale scores. A poor outcome was defined as having all 3 of the following categories met: 1) radiographic poor outcome: deterioration or severe radiographic malalignment 1 year postoperatively for cSVA or T1 slope–cervical lordosis mismatch (TS-CL); 2) clinical poor outcome: failing to meet the minimum clinically important difference (MCID) for NDI or having a severe mJOA Ames modifier; and 3) complications/reoperation poor outcome: major complication, death, or reoperation for a complication other than infection. Univariate logistic regression followed by multivariate regression models was performed, and internal validation was performed by calculating the area under the curve (AUC).RESULTSIn total, 89 patients with CD were included (mean age 61.9 years, female sex 65.2%, BMI 29.2 kg/m2). By 1 year postoperatively, 18 (20.2%) patients were characterized as having an overall poor outcome. For radiographic poor outcomes, patients’ conditions either deteriorated or remained severe for TS-CL (73% of patients), cSVA (8%), horizontal gaze (34%), and global SVA (28%). For clinical poor outcomes, 80% and 60% of patients did not reach MCID for EQ-5D and NDI, respectively, and 24% of patients had severe symptoms (mJOA score 0–11). For the complications/reoperation poor outcome, 28 patients experienced a major complication, 11 underwent a reoperation, and 1 had a complication-related death. Of patients with a poor clinical outcome, 75% had a poor radiographic outcome; 35% of poor radiographic and 37% of poor clinical outcome patients had a major complication. A poor outcome was predicted by the following combination of factors: osteoporosis, baseline neurological status, use of a transition rod, number of posterior decompressions, baseline pelvic tilt, T2–12 kyphosis, TS-CL, C2–T3 SVA, C2–T1 pelvic angle (C2 slope), global SVA, and number of levels in maximum thoracic kyphosis. The final model predicting a poor outcome (AUC 86%) included the following: osteoporosis (OR 5.9, 95% CI 0.9–39), worse baseline neurological status (OR 11.4, 95% CI 1.8–70.8), baseline pelvic tilt > 20° (OR 0.92, 95% CI 0.85–0.98), > 9 levels in maximum thoracic kyphosis (OR 2.01, 95% CI 1.1–4.1), preoperative C2–T3 SVA > 5.4 cm (OR 1.01, 95% CI 0.9–1.1), and global SVA > 4 cm (OR 3.2, 95% CI 0.09–10.3).CONCLUSIONSOf all CD patients in this study, 20.2% had a poor overall outcome, defined by deterioration in radiographic and clinical outcomes, and a major complication. Additionally, 75% of patients with a poor clinical outcome also had a poor radiographic outcome. A poor overall outcome was most strongly predicted by severe baseline neurological deficit, global SVA > 4 cm, and including more of the thoracic maximal kyphosis in the construct.
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Chan AK, Lau D, Osorio JA, Yue JK, Berven SH, Burch S, Hu SS, Mummaneni PV, Deviren V, Ames CP. Asymmetric Pedicle Subtraction Osteotomy for Adult Spinal Deformity with Coronal Imbalance: Complications, Radiographic and Surgical Outcomes. Oper Neurosurg (Hagerstown) 2020; 18:209-216. [PMID: 31214712 DOI: 10.1093/ons/opz106] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/19/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Asymmetric pedicle subtraction osteotomy (APSO) can be utilized for adult spinal deformity (ASD) with fixed coronal plane imbalance. There are few reports investigating outcomes following APSO and no series that include multiple revision cases. OBJECTIVE To detail our surgical technique and experience with APSO. METHODS All thoracolumbar ASD cases with a component of fixed, coronal plane deformity who underwent APSO from 2004 to 2016 at one institution were retrospectively reviewed. Preoperative and latest follow-up radiographic parameters and data on surgical outcomes and complications were obtained. RESULTS Fourteen patients underwent APSO with mean follow-up of 37-mo. Ten (71.4%) were revision cases. APSO involved a mean 12-levels (range 7-25) and were associated with 3.0 L blood loss (range 1.2-4.5) and 457-min of operative time (range 283-540). Surgical complications were observed in 64.3%, including durotomy (35.7%), pleural injury (14.3%), persistent neurologic deficit (14.3%), rod fracture (7.1%), and painful iliac bolt requiring removal (7.1%). Medical complications were observed in 14.3%, comprising urosepsis and 2 cases of pneumonia. Two 90-d readmissions (14.3%) and 5 reoperations (4 patients, 28.6%) occurred. Mean thoracolumbar curve and coronal vertical axis improved from 31.5 to 16.4 degrees and 7.8 to 2.9 cm, respectively. PI-LL mismatch, mean sagittal vertical axis, and pelvic tilt improved from 40.0 to 27.9-degrees, 10.7 to 3.5-cm, and 34.4 to 28.3-degrees, respectively. CONCLUSION The APSO, in both a revision and non-revision ASD population, provides excellent restoration of coronal balance-in addition to sagittal and pelvic parameters. Employment of APSO must be balanced with the associated surgical complication rate (64.3%).
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Chan AK, Mayer RR, Mummaneni PV, Chou D. Conjoined nerve root: case illustration. J Neurosurg Spine 2020; 32:788-789. [PMID: 31978875 DOI: 10.3171/2019.12.spine191226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/03/2019] [Indexed: 11/06/2022]
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Park D, Mummaneni PV, Mehra R, Kwon Y, Kim S, Ruan HB, Chou D. Predictors of the need for laminectomy after indirect decompression via initial anterior or lateral lumbar interbody fusion. J Neurosurg Spine 2020; 32:781-787. [PMID: 31978893 DOI: 10.3171/2019.11.spine19314] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 11/05/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to evaluate factors that are associated with the need for additional posterior direct decompressive surgery after anterior lumbar interbody fusion (ALIF) or lateral lumbar interbody fusion (LLIF). METHODS Eighty-six adult patients who underwent ALIF or LLIF for degenerative spondylolisthesis and foraminal stenosis were enrolled. Patient factors (age, sex, number of surgery levels, and visual analog scale [VAS] score for leg and back pain); procedure-related factors (cage height and lordosis); and radiographic measurements (disc height [DH]; foraminal height [FH], foraminal area [FA], central canal diameter [CCD], and facet joint degeneration [FD]) were analyzed. All patients underwent staged surgery on 2 different days, with the anterior portion first, followed by the posterior portion. RESULTS Of 86 patients, 62 underwent posterior decompression and 24 had no posterior decompression. There were no significant differences between groups with regard to age, sex, preoperative VAS score for back pain, cage height, cage angulation, preoperative DH, FH, FA, CCD, and FD (p > 0.05). The group that underwent posterior decompression showed statistically different numbers of treated segments (1.92 vs 1.21, p < 0.01), preoperative VAS leg score (7.9 vs 6.3), symptom duration (14.2 months vs 9.4 months), postoperative DH improvement (61.3% vs 96.2%), postoperative FH improvement (21.5% vs 32.1%), postoperative FA improvement (24.1% vs 36.9%), and cage height minus preoperative DH (5.3 mm vs 7.5 mm) compared with the nondecompression group. CONCLUSIONS There appears to be some correlation between the need for posterior decompression and the number of treated segments, VAS leg scores, symptom duration, FH, FA, and difference between the cage height and preoperative DH. In selected patients undergoing staged surgery, indirect decompression without direct decompression may be a reasonable option in treating degenerative spinal conditions.
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Chang CC, Mummaneni PV, Rivera J, Mayer R, Chou D. Closure of L3 pedicle subtraction osteotomy via an open-bottom hinged table in 3D video. NEUROSURGICAL FOCUS: VIDEO 2020; 2:V6. [PMID: 36284696 PMCID: PMC9521217 DOI: 10.3171/2020.1.focusvid.19718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 06/16/2023]
Abstract
Iatrogenic flat back deformity generally can be treated with a pedicle subtraction osteotomy (PSO) (Chan et al., 2018; Lu and Chou, 2007). One of the difficulties with PSO is that a controlled closure can sometimes be problematic in that there may be translation of the spine, manual pushing of the spine, and significant stress on the pedicle screws, which may risk loosening. The authors present a video of their surgical technique for PSO closed by passive closure using an open-bottom hinged table. This allows the osteotomy to be closed without any force on the screws and without significant manual forces on the spinal column. The video can be found here: https://youtu.be/pUECEjKdmSk.
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Chang CC, Rivera J, Pennicooke B, Chou D, Mummaneni PV. Navigated oblique lumbar interbody fusion for adult spinal deformity. NEUROSURGICAL FOCUS: VIDEO 2020; 2:V7. [PMID: 36284700 PMCID: PMC9521214 DOI: 10.3171/2020.1.focusvid.19700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 11/19/2022]
Abstract
Adult spinal deformity (ASD) is an increasing disease entity as the population ages. An emerging minimally invasive surgery (MIS) option for the treatment of ASD is the oblique lumbar interbody fusion (OLIF), which allows indirect foraminal decompression of stenosis as well as segmental deformity correction (DiGiorgio et al., 2017). The authors utilize computer-assisted navigation with OLIF to reduce radiation exposure and improve time efficiency. The authors present a video of navigated oblique lumbar interbody fusion at L3–5 followed by open posterior screw-rod fixation. The video can be found here: https://youtu.be/zKDT7PhMYf8.
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Wang M, Chou D, Chang CC, Hirpara A, Liu Y, Chan AK, Pennicooke B, Mummaneni PV. Anterior cervical discectomy and fusion performed using structural allograft or polyetheretherketone: pseudarthrosis and revision surgery rates with minimum 2-year follow-up. J Neurosurg Spine 2019; 32:562-569. [PMID: 31835252 DOI: 10.3171/2019.9.spine19879] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/26/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Both structural allograft and PEEK have been used for anterior cervical discectomy and fusion (ACDF). There are reports that PEEK has a higher pseudarthrosis rate than structural allograft. The authors compared pseudarthrosis, revision, subsidence, and loss of lordosis rates in patients with PEEK and structural allograft. METHODS The authors performed a retrospective review of patients who were treated with ACDF at their hospital between 2005 and 2017. Inclusion criteria were adult patients with either PEEK or structural allograft, anterior plate fixation, and a minimum 2-year follow-up. Exclusion criteria were hybrid PEEK and allograft cases, additional posterior surgery, adjacent corpectomies, infection, tumor, stand-alone or integrated screw and cage devices, bone morphogenetic protein use, or lack of a minimum 2-year follow-up. Demographic variables, number of treated levels, interbody type (PEEK cage vs structural allograft), graft packing material, pseudarthrosis rates, revision surgery rates, subsidence, and cervical lordosis changes were collected. These data were analyzed by Pearson's chi-square test (or Fisher's exact test, according to the sample size and expected value) and Student t-test. RESULTS A total of 168 patients (264 levels total, mean follow-up time 39.5 ± 24.0 months) were analyzed. Sixty-one patients had PEEK, and 107 patients had structural allograft. Pseudarthrosis rates for 1-level fusions were 5.4% (PEEK) and 3.4% (allograft) (p > 0.05); 2-level fusions were 7.1% (PEEK) and 8.1% (allograft) (p > 0.05); and ≥ 3-level fusions were 10% (PEEK) and 11.1% (allograft) (p > 0.05). There was no statistical difference in the subsidence magnitude between PEEK and allograft in 1-, 2-, and ≥ 3-level ACDF (p > 0.05). Postoperative lordosis loss was not different between cohorts for 1- and 2-level surgeries. CONCLUSIONS In 1- and 2-level ACDF with plating involving the same number of fusion levels, there was no statistically significant difference in the pseudarthrosis rate, revision surgery rate, subsidence, and lordosis loss between PEEK cages and structural allograft.
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Mummaneni PV, Bydon M, Knightly J, Alvi MA, Goyal A, Chan AK, Guan J, Biase M, Strauss A, Glassman S, Foley KT, Slotkin JR, Potts E, Shaffrey M, Shaffrey CI, Haid RW, Fu KM, Wang MY, Park P, Asher AL, Bisson EF. Predictors of nonroutine discharge among patients undergoing surgery for grade I spondylolisthesis: insights from the Quality Outcomes Database. J Neurosurg Spine 2019; 32:523-532. [PMID: 31812142 DOI: 10.3171/2019.9.spine19644] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Discharge to an inpatient rehabilitation facility or another acute-care facility not only constitutes a postoperative challenge for patients and their care team but also contributes significantly to healthcare costs. In this era of changing dynamics of healthcare payment models in which cost overruns are being increasingly shifted to surgeons and hospitals, it is important to better understand outcomes such as discharge disposition. In the current article, the authors sought to develop a predictive model for factors associated with nonroutine discharge after surgery for grade I spondylolisthesis. METHODS The authors queried the Quality Outcomes Database for patients with grade I lumbar degenerative spondylolisthesis who underwent a surgical intervention between July 2014 and June 2016. Only those patients enrolled in a multisite study investigating the impact of fusion on clinical and patient-reported outcomes among patients with grade I spondylolisthesis were evaluated. Nonroutine discharge was defined as those who were discharged to a postacute or nonacute-care setting in the same hospital or transferred to another acute-care facility. RESULTS Of the 608 patients eligible for inclusion, 9.4% (n = 57) had a nonroutine discharge (8.7%, n = 53 discharged to inpatient postacute or nonacute care in the same hospital and 0.7%, n = 4 transferred to another acute-care facility). Compared to patients who were discharged to home, patients who had a nonroutine discharge were more likely to have diabetes (26.3%, n = 15 vs 15.7%, n = 86, p = 0.039); impaired ambulation (26.3%, n = 15 vs 10.2%, n = 56, p < 0.001); higher Oswestry Disability Index at baseline (51 [IQR 42-62.12] vs 46 [IQR 34.4-58], p = 0.014); lower EuroQol-5D scores (0.437 [IQR 0.308-0.708] vs 0.597 [IQR 0.358-0.708], p = 0.010); higher American Society of Anesthesiologists score (3 or 4: 63.2%, n = 36 vs 36.7%, n = 201, p = 0.002); and longer length of stay (4 days [IQR 3-5] vs 2 days [IQR 1-3], p < 0.001); and were more likely to suffer a complication (14%, n = 8 vs 5.6%, n = 31, p = 0.014). On multivariable logistic regression, factors found to be independently associated with higher odds of nonroutine discharge included older age (interquartile OR 9.14, 95% CI 3.79-22.1, p < 0.001), higher body mass index (interquartile OR 2.04, 95% CI 1.31-3.25, p < 0.001), presence of depression (OR 4.28, 95% CI 1.96-9.35, p < 0.001), fusion surgery compared with decompression alone (OR 1.3, 95% CI 1.1-1.6, p < 0.001), and any complication (OR 3.9, 95% CI 1.4-10.9, p < 0.001). CONCLUSIONS In this multisite study of a defined cohort of patients undergoing surgery for grade I spondylolisthesis, factors associated with higher odds of nonroutine discharge included older age, higher body mass index, presence of depression, and occurrence of any complication.
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DiGiorgio AM, Mummaneni PV, Fisher JL, Podet AG, Crutcher CL, Virk MS, Fang Z, Wilson JD, Tender GC, Culicchia F. Change in Policy Allowing Overlapping Surgery Decreases Length of Stay in an Academic, Safety-Net Hospital. Oper Neurosurg (Hagerstown) 2019; 17:543-548. [PMID: 30919890 DOI: 10.1093/ons/opz009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 01/30/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The practice of surgeons running overlapping operating rooms has recently come under scrutiny. OBJECTIVE To examine the impact of hospital policy allowing overlapping rooms in the case of patients admitted to a tertiary care, safety-net hospital for urgent neurosurgical procedures. METHODS The neurosurgery service at the hospital being studied transitioned from routinely allowing 1 room per day (period 1) to overlapping rooms (period 2), with the second room being staffed by the same attending surgeon. Patients undergoing neurosurgical intervention in each period were retrospectively compared. Demographics, indication, case type, complications, outcomes, and total charges were tracked. RESULTS There were 59 urgent cases in period 1 and 63 in period 2. In the case of these patients, the length of stay was significantly decreased in period 2 (13.09 d vs 19.52; P = .006). The time from admission to surgery (wait time) was also significantly decreased in period 2 (5.12 d vs 7.00; P = .04). Total charges also trended towards less in period 2 (${\$}$150 942 vs ${\$}$200 075; P = .05). Surgical complications were no different between the groups (16.9% vs 14.3%; P = .59), but medical complications were significantly decreased in period 2 (14.3% vs 30.5%; P = .009). Significantly more patients were discharged to home in period 2 (69.8% vs 42.4%; P = .003). CONCLUSION As a matter of policy, allowing overlapping rooms significantly reduces the length of stay in the case of a vulnerable population in need of urgent surgery at a single safety-net academic institution. This may be due to a reduction in medical complications in these patients.
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Chan AK, Chan AY, Lau D, Durcanova B, Miller CA, Larson PS, Starr PA, Mummaneni PV. Surgical management of camptocormia in Parkinson's disease: systematic review and meta-analysis. J Neurosurg 2019; 131:368-375. [PMID: 30215560 DOI: 10.3171/2018.4.jns173032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/02/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Camptocormia is a potentially debilitating condition in the progression of Parkinson's disease (PD). It is described as an abnormal forward flexion while standing that resolves when lying supine. Although the condition is relatively common, the underlying pathophysiology and optimal treatment strategy are unclear. In this study, the authors systematically reviewed the current surgical management strategies for camptocormia. METHODS PubMed was queried for primary studies involving surgical intervention for camptocormia in PD patients. Studies were excluded if they described nonsurgical interventions, provided only descriptive data, or were case reports. Secondarily, data from studies describing deep brain stimulation (DBS) to the subthalamic nuclei were extracted for potential meta-analysis. Variables showing correlation to improvement in sagittal plane bending angle (i.e., the vertical angle caused by excessive kyphosis) were subjected to formal meta-analysis. RESULTS The query resulted in 9 studies detailing treatment of camptocormia: 1 study described repetitive trans-spinal magnetic stimulation (rTSMS), 7 studies described DBS, and 1 study described deformity surgery. Five studies were included for meta-analysis. The total number of patients was 66. The percentage of patients with over 50% decrease in sagittal plane imbalance with DBS was 36.4%. A duration of camptocormia of 2 years or less was predictive of better outcomes (OR 4.15). CONCLUSIONS Surgical options include transient, external spinal stimulation; DBS targeting the subthalamic nuclei; and spinal deformity surgery. Benefit from DBS stimulation was inconsistent. Spine surgery corrected spinal imbalance but was associated with a high complication rate.
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Sloan EA, Cooney T, Oberheim Bush NA, Buerki R, Taylor J, Clarke JL, Torkildson J, Kline C, Reddy A, Mueller S, Banerjee A, Butowski N, Chang S, Mummaneni PV, Chou D, Tan L, Theodosopoulos P, McDermott M, Berger M, Raffel C, Gupta N, Sun PP, Li Y, Shah V, Cha S, Braunstein S, Raleigh DR, Samuel D, Scharnhorst D, Fata C, Guo H, Moes G, Kim JYH, Koschmann C, Van Ziffle J, Onodera C, Devine P, Grenert JP, Lee JC, Pekmezci M, Phillips JJ, Tihan T, Bollen AW, Perry A, Solomon DA. Recurrent non-canonical histone H3 mutations in spinal cord diffuse gliomas. Acta Neuropathol 2019; 138:877-881. [PMID: 31515627 DOI: 10.1007/s00401-019-02072-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/01/2019] [Accepted: 09/02/2019] [Indexed: 01/17/2023]
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Devin CJ, Bydon M, Alvi MA, Kerezoudis P, Khan I, Sivaganesan A, McGirt MJ, Archer KR, Foley KT, Mummaneni PV, Bisson EF, Knightly JJ, Shaffrey CI, Asher AL. A predictive model and nomogram for predicting return to work at 3 months after cervical spine surgery: an analysis from the Quality Outcomes Database. Neurosurg Focus 2019; 45:E9. [PMID: 30453462 DOI: 10.3171/2018.8.focus18326] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 08/20/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEBack pain and neck pain are two of the most common causes of work loss due to disability, which poses an economic burden on society. Due to recent changes in healthcare policies, patient-centered outcomes including return to work have been increasingly prioritized by physicians and hospitals to optimize healthcare delivery. In this study, the authors used a national spine registry to identify clinical factors associated with return to work at 3 months among patients undergoing a cervical spine surgery.METHODSThe authors queried the Quality Outcomes Database registry for information collected from April 2013 through March 2017 for preoperatively employed patients undergoing cervical spine surgery for degenerative spine disease. Covariates included demographic, clinical, and operative variables, and baseline patient-reported outcomes. Multiple imputations were used for missing values and multivariable logistic regression analysis was used to identify factors associated with higher odds of returning to work. Bootstrap resampling (200 iterations) was used to assess the validity of the model. A nomogram was constructed using the results of the multivariable model.RESULTSA total of 4689 patients were analyzed, of whom 82.2% (n = 3854) returned to work at 3 months postoperatively. Among previously employed and working patients, 89.3% (n = 3443) returned to work compared to 52.3% (n = 411) among those who were employed but not working (e.g., were on a leave) at the time of surgery (p < 0.001). On multivariable logistic regression the authors found that patients who were less likely to return to work were older (age > 56-65 years: OR 0.69, 95% CI 0.57-0.85, p < 0.001; age > 65 years: OR 0.65, 95% CI 0.43-0.97, p = 0.02); were employed but not working (OR 0.24, 95% CI 0.20-0.29, p < 0.001); were employed part time (OR 0.56, 95% CI 0.42-0.76, p < 0.001); had a heavy-intensity (OR 0.42, 95% CI 0.32-0.54, p < 0.001) or medium-intensity (OR 0.59, 95% CI 0.46-0.76, p < 0.001) occupation compared to a sedentary occupation type; had workers' compensation (OR 0.38, 95% CI 0.28-0.53, p < 0.001); had a higher Neck Disability Index score at baseline (OR 0.60, 95% CI 0.51-0.70, p = 0.017); were more likely to present with myelopathy (OR 0.52, 95% CI 0.42-0.63, p < 0.001); and had more levels fused (3-5 levels: OR 0.46, 95% CI 0.35-0.61, p < 0.001). Using the multivariable analysis, the authors then constructed a nomogram to predict return to work, which was found to have an area under the curve of 0.812 and good validity.CONCLUSIONSReturn to work is a crucial outcome that is being increasingly prioritized for employed patients undergoing spine surgery. The results from this study could help surgeons identify at-risk patients so that preoperative expectations could be discussed more comprehensively.
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Lau D, DiGiorgio AM, Chan AK, Dalle Ore CL, Virk MS, Chou D, Bisson EF, Mummaneni PV. Applicability of cervical sagittal vertical axis, cervical lordosis, and T1 slope on pain and disability outcomes after anterior cervical discectomy and fusion in patients without deformity. J Neurosurg Spine 2019; 32:23-30. [PMID: 31628295 DOI: 10.3171/2019.7.spine19437] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Understanding what influences pain and disability following anterior cervical discectomy and fusion (ACDF) in patients with degenerative cervical spine disease is critical. This study examines the timing of clinical improvement and identifies factors (including spinal alignment) associated with worse outcomes. METHODS Consecutive adult patients were enrolled in a prospective outcomes database from two academic centers participating in the Quality Outcomes Database from 2013 to 2016. Demographics, surgical details, radiographic data, arm and neck pain (visual analog scale [VAS] scores), and disability (Neck Disability Index [NDI] and EQ-5D scores) were reviewed. Multivariate analysis was used. RESULTS A total of 186 patients were included, and 48.4% were male. Their mean age was 55.4 years, and 45.7% had myelopathy. Preoperative cervical sagittal vertical axis (cSVA), cervical lordosis (CL), and T1 slope values were 24.9 mm (range 0-55 mm), 10.4° (range -6.0° to 44°), and 28.3° (range 14.0°-51.0°), respectively. ACDF was performed at 1, 2, and 3 levels in 47.8%, 42.0%, and 10.2% of patients, respectively. Preoperative neck and arm VAS scores were 5.7 and 5.4, respectively. NDI and EQ-5D scores were 22.1 and 0.5, respectively. There was significant improvement in all outcomes at 3 months (p < 0.001) and 12 months (p < 0.001). At 3 months, neck VAS (3.0), arm VAS (2.2), NDI (12.7), and EQ-5D (0.7) scores were improved, and at 12 months, neck VAS (2.8), arm VAS (2.3), NDI (11.7), and EQ-5D (0.8) score improvements were sustained. Improvements occurred within the first 3-month period; there was no significant difference in outcomes between the 3-month and 12-month mark. There was no correlation among cSVA, CL, or T1 slope with any outcome endpoint. The most consistent independent preoperative factors associated with worse outcomes were high neck and arm VAS scores and a severe NDI result (p < 0.001). Similar findings were seen with worse NDI and EQ-5D scores (p < 0.001). A significant linear trend of worse NDI and EQ-5D scores at 3 and 12 months was associated with worse baseline scores. Of the 186 patients, 171 (91.9%) had 3-month follow-up data, and 162 (87.1%) had 12-month follow-up data. CONCLUSIONS ACDF is effective in improving pain and disability, and improvement occurs within 3 months of surgery. cSVA, CL, and T1 slope do not appear to influence outcomes following ACDF surgery in the population with degenerative cervical disease. Therefore, in patients with relatively normal cervical parameters, augmenting alignment or lordosis is likely unnecessary. Worse preoperative pain and disability were independently associated with worse outcomes.
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Chan AK, Bisson EF, Bydon M, Glassman SD, Foley KT, Potts EA, Shaffrey CI, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KM, Slotkin JR, Asher AL, Virk MS, Kerezoudis P, Chotai S, DiGiorgio AM, Haid RW, Mummaneni PV. Laminectomy alone versus fusion for grade 1 lumbar spondylolisthesis in 426 patients from the prospective Quality Outcomes Database. J Neurosurg Spine 2019; 30:234-241. [PMID: 30544348 DOI: 10.3171/2018.8.spine17913] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe AANS launched the Quality Outcomes Database (QOD), a prospective longitudinal registry that includes demographic, clinical, and patient-reported outcome (PRO) data to measure the safety and quality of spine surgery. Registry data offer "real-world" insights into the utility of spinal fusion and decompression surgery for lumbar spondylolisthesis. Using the QOD, the authors compared the initial 12-month outcome data for patients undergoing fusion and those undergoing laminectomy alone for grade 1 degenerative lumbar spondylolisthesis.METHODSData from 12 top enrolling sites were analyzed and 426 patients undergoing elective single-level spine surgery for degenerative grade 1 lumbar spondylolisthesis were found. Baseline, 3-month, and 12-month follow-up data were collected and compared, including baseline clinical characteristics, readmission rates, reoperation rates, and PROs. The PROs included Oswestry Disability Index (ODI), back and leg pain numeric rating scale (NRS) scores, and EuroQol-5 Dimensions health survey (EQ-5D) results.RESULTSA total of 342 (80.3%) patients underwent fusion, with the remaining 84 (19.7%) undergoing decompression alone. The fusion cohort was younger (60.7 vs 69.9 years, p < 0.001), had a higher mean body mass index (31.0 vs 28.4, p < 0.001), and had a greater proportion of patients with back pain as a major component of their initial presentation (88.0% vs 60.7%, p < 0.001). There were no differences in 12-month reoperation rate (4.4% vs 6.0%, p = 0.93) and 3-month readmission rates (3.5% vs 1.2%, p = 0.45). At 12 months, both cohorts improved significantly with regard to ODI, NRS back and leg pain, and EQ-5D (p < 0.001, all comparisons). In adjusted analysis, fusion procedures were associated with superior 12-month ODI (β -4.79, 95% CI -9.28 to -0.31; p = 0.04).CONCLUSIONSSurgery for grade 1 lumbar spondylolisthesis-regardless of treatment strategy-was associated with significant improvements in disability, back and leg pain, and quality of life at 12 months. When adjusting for covariates, fusion surgery was associated with superior ODI at 12 months. Although fusion procedures were associated with a lower rate of reoperation, there was no statistically significant difference at 12 months. Further study must be undertaken to assess the durability of either surgical strategy in longer-term follow-up.
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Badiee RK, Chan AK, Rivera J, Molinaro A, Doherty BR, Riew KD, Chou D, Mummaneni PV, Tan LA. Preoperative Narcotic Use, Impaired Ambulation Status, and Increased Intraoperative Blood Loss Are Independent Risk Factors for Complications Following Posterior Cervical Laminectomy and Fusion Surgery. Neurospine 2019; 16:548-557. [PMID: 31607087 PMCID: PMC6790747 DOI: 10.14245/ns.1938198.099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/20/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This retrospective cohort study seeks to identify risk factors associated with complications following posterior cervical laminectomy and fusion (PCLF) surgery. METHODS Adults undergoing PCLF from 2012 through 2018 at a single center were identified. Demographic and radiographic data, surgical characteristics, and complication rates were compared. Multivariate logistic regression models identified independent predictors of complications following surgery. RESULTS A total of 196 patients met the inclusion criteria and were included in the study. The medical, surgical, and overall complication rates were 10.2%, 23.0%, and 29.1% respectively. Risk factors associated with medical complications in multivariate analysis included impaired ambulation status (odds ratio [OR], 2.27; p=0.02) and estimated blood loss over 500 mL (OR, 3.67; p=0.02). Multivariate analysis revealed preoperative narcotic use (OR, 2.43; p=0.02) and operative time (OR, 1.005; p=0.03) as risk factors for surgical complication, whereas antidepressant use was a protective factor (OR, 0.21; p=0.01). Overall complication was associated with preoperative narcotic use (OR, 1.97; p=0.04) and higher intraoperative blood loss (OR, 1.0007; p=0.03). CONCLUSION Preoperative narcotic use and estimated blood loss predicted the incidence of complications following PCLF for CSM. Ambulation status was a significant predictor of the development of a medical complication specifically. These results may help surgeons in counseling patients who may be at increased risk of complication following surgery.
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Yue JK, Hemmerle DD, Winkler EA, Thomas LH, Fernandez XD, Kyritsis N, Pan JZ, Pascual LU, Singh V, Weinstein PR, Talbott JF, Huie JR, Ferguson AR, Whetstone WD, Manley GT, Beattie MS, Bresnahan JC, Mummaneni PV, Dhall SS. Clinical Implementation of Novel Spinal Cord Perfusion Pressure Protocol in Acute Traumatic Spinal Cord Injury at U.S. Level I Trauma Center: TRACK-SCI Study. World Neurosurg 2019; 133:e391-e396. [PMID: 31526882 DOI: 10.1016/j.wneu.2019.09.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We sought to report the safety of implementation of a novel standard of care protocol using spinal cord perfusion pressure (SCPP) maintenance for managing traumatic spinal cord injury (SCI) in lieu of mean arterial pressure goals at a U.S. Level I trauma center. METHODS Starting in December 2017, blunt SCI patients presenting <24 hours after injury with admission American Spinal Injury Association Impairment Scale (AIS) A-C (or AIS D at neurosurgeon discretion) received lumbar subarachnoid drain (LSAD) placement for SCPP monitoring in the intensive care unit and were included in the TRACK-SCI (Transforming Research and Clinical Knowledge in Spinal Cord Injury) data registry. This SCPP protocol comprises standard care at our institution. SCPPs were monitored for 5 days (goal ≥65 mm Hg) achieved through intravenous fluids and vasopressor support. AISs were assessed at admission and day 7. RESULTS Fifteen patients enrolled to date were aged 60.5 ± 17 years. Injury levels were 93.3% (cervical) and 6.7% (thoracic). Admission AIS was 20.0%/20.0%/26.7%/33.3% for A/B/C/D. All patients maintained mean SCPP ≥65 mm Hg during monitoring. Fourteen of 15 cases required surgical decompression and stabilization with time to surgery 8.8 ± 7.1 hours (71.4% <12 hours). At day 7, 33.3% overall and 50% of initial AIS A-C had an improved AIS. Length of stay was 14.7 ± 8.3 days. None had LSAD-related complications. There were 7 respiratory complications. One patient expired after transfer to comfort care. CONCLUSIONS In our initial experience of 15 patients with acute SCI, standardized SCPP goal-directed care based on LSAD monitoring for 5 days was feasible. There were no SCPP-related complications. This is the first report of SCPP implementation as clinical standard of care in acute SCI.
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Mummaneni PV, Bydon M, Knightly JJ, Goyal A, Alvi MA, Chan AKH, Guan J, Glassman SD, Foley KT, Slotkin J, Potts EA, Shaffrey ME, Shaffrey CI, Haid RW, Fu KMG, Wang MY, Park P, Asher AL, Bisson EF. Predictive Model for Length of Stay Among Patients Undergoing Surgery for Grade I Spondylolisthesis: Analysis From the Quality Outcomes Database. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Bydon M, Mummaneni PV, Kerezoudis P, Chan AKH, Glassman SD, Foley KT, Slotkin JR, Potts EA, Shaffrey ME, Shaffrey CI, Coric D, Knightly JJ, Park P, Fu KMG, Devin CJ, Asher AL, Bisson EF. Factors Associated with 12-month Return to Work Following One-level Posterior Lumbar Fusion for Grade 1 Degenerative Spondylolisthesis: An Analysis of the Quality Outcomes Database. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Karsy M, Chan AKH, Virk MS, Mummaneni PV, Bydon M, Glassman SD, Foley KT, Potts EA, Shaffrey CI, Shaffrey ME, Coric D, Asher AL, Knightly JJ, Park P, Fu KMG, Slotkin J, Haid RW, Wang MY, Bisson EF. Outcomes and Risks With Age in Spondylolisthesis: A Comparison of the Elderly From the Quality Outcomes Database. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Mummaneni PV, Shaffrey CI, Eastlack R, Uribe JS, Fessler RG, Park P, Robinson L, Rivera J, Chou D, Fu KMG, Kanter AS. The Minimally Invasive Interbody Selection Algorithm (MIISA) for Spinal Deformity. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Guan J, Bisson EF, Bydon M, Alvi MA, Glassman SD, Foley KT, Potts EA, Shaffrey CI, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KMG, Slotkin JR, Asher AL, Virk MS, Kerezoudis P, Haid RW, Chan AKH, Mummaneni PV. Addition of Fusion to Decompression for Grade I Degenerative Lumbar Spondylolisthesis is Associated With Greater Patient-Reported Outcome Improvements at Twenty-Four-Month Follow-Up: A Multicenter Study Using the Quality Outcomes Database. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chan AKH, Bisson EF, Bydon M, Glassman SD, Foley KT, Shaffrey CI, Potts EA, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KMG, Slotkin J, Asher AL, Virk MS, Kerezoudis P, Alvi MA, Guan J, Haid RW, Mummaneni PV. A Comparison of Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Grade 1 Degenerative Lumbar Spondylolisthesis: An Analysis of the Prospective Quality Outcomes Database. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Chan AKH, Bisson EF, Bydon M, Glassman SD, Foley KT, Shaffrey CI, Potts EA, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KMG, Slotkin J, Asher AL, Virk MS, Kerezoudis P, Alvi MA, Guan J, Haid RW, Mummaneni PV. A Comparison of Minimally Invasive Transforaminal Lumbar Interbody Fusion and Decompression Alone for Degenerative Lumbar Spondylolisthesis. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Eastlack R, Uribe JS, Fessler RG, Than KD, Tran S, Fu KMG, Park P, Wang MY, Kanter AS, Okonkwo DO, Nunley PD, Anand N, Mundis GM, Mummaneni PV, Chou D. Treatment of Adult Scoliosis Fractional Curve With Minimally Invasive Surgery: Anterior Versus Posterior Approach? Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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227
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Sivaganesan A, Wright A, Haid RW, Mummaneni PV, Berkman R. Towards Opioid-Free Elective Spine Surgery: A Prospective Cohort Study. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Mummaneni PV, Bydon M, Knightly J, Alvi MA, Goyal A, Chan AK, Guan J, Biase M, Strauss A, Glassman S, Foley K, Slotkin JR, Potts E, Shaffrey M, Shaffrey CI, Haid RW, Fu KM, Wang MY, Park P, Asher AL, Bisson EF. Predictors of Nonroutine Discharge Among Patients Undergoing Surgery for Grade I Spondylolisthesis: Insights From the Quality Outcomes Database (QOD). Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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229
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Walker CT, Kim HJ, Park P, Lenke L, Smith JS, Sciubba DM, Wang MY, Shaffrey CI, Deviren V, Mummaneni PV, Than KD, Eastlack R, Mundis GM, Kanter AS, Okonkwo DO, Shin JH, Koski TR, Glassman SD, Daniels AH, Turner JD, Uribe JS. Neuroanesthesia Guidelines for Optimizing Transcranial Motor Evoked Potentials Neuromonitoring During Deformity and Complex Spinal Surgery: A Delphi Consensus Study. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chan AKH, Bisson EF, Fu KMG, Park P, Robinson L, Bydon M, Glassman SD, Foley KT, Shaffrey CI, Potts EA, Shaffrey ME, Coric D, Knightly JJ, Wang MY, Slotkin J, Asher AL, Virk MS, Kerezoudis P, Alvi MA, Guan J, Haid RW, Mummaneni PV. Sexual Dysfunction: Prevalence and Prognosis in Patients Operated for Degenerative Lumbar Spondylolisthesis. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Vargas E, Braunstein S, Susko M, Mummaneni PV, Chou D. Stereotactic Radiation Therapy (SBRT) Versus External Beam (EB) Radiation for Metastatic Spine Disease: Comparing Fracture Rates and Local Control. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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232
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Edwards CS, Chan AKH, Chou D, Mummaneni PV. Comparing Radiographic Parameters for Single-Level L5-S1 Interbody Fusion: Anterior Lumbar (ALIF) Versus Transforaminal Lumbar Interbody Fusion (TLIF). Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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233
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Safaee M, Tenorio A, Amara D, Lai L, Molinaro A, Hu S, Tay B, Burch S, Berven S, Deviren V, Dhall SS, Chou D, Mummaneni PV, Eichler CM, Ames CP, Clark AJ. Perioperative Complications in Obese Patients Undergoing Anterior Lumbar Interbody Fusion: Results From 938 Patients. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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234
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Yue JK, Hemmerle DP, Deng H, Winkler EA, Thomas LH, Fernandez XD, Upadhyayula PS, Kyritsis N, Pascual LU, Singh V, Weinstein PR, Talbott J, Huie RJ, Ferguson A, Whetstone W, Manley GT, Beattie M, Bresnahan J, Mummaneni PV, Dhall SS. Initial Experience of Spinal Cord Perfusion Pressure Goals in Lieu of Mean Arterial Pressure Goals in Acute Traumatic Spinal Cord Injury at a United States Level I Trauma Center: A Transforming Research and Clinical Knowledge-Spinal Cord Injury Study. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Badiee RK, Chan AKH, Rivera J, Chang CC, Chou D, Mummaneni PV, Tan LA. C2 Versus C3 as the Upper Instrumented Vertebra for Cervicothoracic Posterior Laminectomy and Fusion Demonstrate Equivalent Postoperative Outcomes. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Kanter AS, Eastlack R, Uribe JS, Fessler RG, Than KD, Tran S, Chou D, Fu K, Park P, Wang MY, Okonkwo DO, Nunley PD, Anand NN, Mundis GM, Mummaneni PV. Does Anterior Column Realignment Result in Greater Morbidity than Lateral Lumbar Interbody Fusion Alone When Treating Adult Spinal Deformity? Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Than KD, Tran S, Chou D, Fu KMG, Park P, Fessler RG, Wang MY, Kanter AS, Okonkwo DO, Nunley PD, Anand N, Uribe JS, Eastlack R, Mundis GM, Mummaneni PV. Body Mass Index Greater Than 35 Is Associated With Increased Major and Radiographic Complications After Minimally Invasive Adult Spinal Deformity Surgery. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Wang MY, Tran S, Brusko GD, Eastlack R, Park P, Nunley PD, Kanter AS, Uribe JS, Anand N, Okonkwo DO, Than KD, Shaffrey CI, Lafage V, Mundis GM, Mummaneni PV. Less invasive spinal deformity surgery: the impact of the learning curve at tertiary spine care centers. J Neurosurg Spine 2019; 31:865-872. [PMID: 31443084 DOI: 10.3171/2019.6.spine19531] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/05/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The past decade has seen major advances in techniques for treating more complex spinal disorders using minimally invasive surgery (MIS). While appealing from the standpoint of patient perioperative outcomes, a major impediment to adoption has been the significant learning curve in utilizing MIS techniques. METHODS Data were retrospectively analyzed from a multicenter series of adult spinal deformity surgeries treated at eight tertiary spine care centers in the period from 2008 to 2015. All patients had undergone a less invasive or hybrid approach for a deformity correction satisfying the following inclusion criteria at baseline: coronal Cobb angle ≥ 20°, sagittal vertical axis (SVA) > 5 cm, or pelvic tilt > 20°. Analyzed data included baseline demographic details, severity of deformity, surgical metrics, clinical outcomes (numeric rating scale [NRS] score and Oswestry Disability Index [ODI]), radiographic outcomes, and complications. A minimum follow-up of 2 years was required for study inclusion. RESULTS Across the 8-year study period, among 222 patients, there was a trend toward treating increasingly morbid patients, with the mean age increasing from 50.7 to 62.4 years (p = 0.013) and the BMI increasing from 25.5 to 31.4 kg/m2 (p = 0.12). There was no statistical difference in the severity of coronal and sagittal deformity treated over the study period. With regard to radiographic changes following surgery, there was an increasing emphasis on sagittal correction and, conversely, less coronal correction. There was no statistically significant difference in clinical outcomes over the 8-year period, and meaningful improvements were seen in all years (ODI range of improvement: 15.0-26.9). Neither were there statistically significant differences in major complications; however, minor complications were seen less often as the surgeons gained experience (p = 0.064). Operative time was decreased on average by 47% over the 8-year period.Trends in surgical practice were seen as well. Total fusion construct length was unchanged until the last year when there was a marked decrease in conjunction with a decrease in interbody levels treated (p = 0.004) while obtaining a higher degree of sagittal correction, suggesting more selective but powerful interbody reduction methods as reflected by an increase in the lateral and anterior column resection techniques being utilized. CONCLUSIONS The use of minimally invasive methods for adult spinal deformity surgery has evolved over the past decade. Experienced surgeons are treating older and more morbid patients with similar outcomes. A reliance on selective, more powerful interbody approaches is increasing as well.
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Xi Z, Burch S, Chang CC, Ruan HB, Eichler CM, Mummaneni PV, Chou D. Anterior Lumbar Interbody Fusion (ALIF) versus Oblique Lateral Interbody Fusion (OLIF) at L5-S1: A Comparison of Two Approaches to the Lumbosacral Junction. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Abstract
INTRODUCTION
The oblique lateral interbody fusion OLIF is an alternative anterior approach to the lumbar spine at L5-S1, and it is unknown how it compares to anterior lumbar interbody fusion ALIF. This abstract is to compare the radiographic and clinical factors of ALIF and OLIF at L5-S1 only.
METHODS
A retrospective review of patients who underwent ALIF or OLIF at L5-S1 only at the University of California San Francisco (2013-2018) was performed. Data collected were demographics, cage parameters, perioperative factors, and radiographic parameters.
RESULTS
A total of 58 patients were included (33 ALIF and 25 OLIF). The average surgical time was 211.94 min for ALIF and 154.86 min for OLIF (P < .001). The average blood loss was 214 ml for ALIF and 74 ml for OLIF (P < .001). The average day to solid food was 2.55 for ALIF and 0.8 for OLIF (P < .001). The average cage height was 14.78 mm for ALIF and 12.9 mm (P < .001) for OLIF. The average cage lordosis was 15.45° for ALIF and 12.68° (P = .76) for OLIF. Average anterior L5-S1 disc height increase was 8.52 mm (ALIF) and 5.02 mm (OLIF) (P = .018), and average posterior L5-S1 disc height increase was 3.34 mm (ALIF) and 1.30 mm (OLIF) (P = .034). The average L5-S1 segmental lordosis increase was 6.82° for ALIF and 7.63° for OLIF (P = .638).
CONCLUSION
Patients who underwent OLIF at L5-S1 had shorter ileus duration compared to ALIF and comparable operative times and blood loss. ALIF afforded larger cages to be placed, resulting in greater disc height, but there was no significant difference in L5-S1 segmental lordosis.
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Chan AK, Sharma V, Robinson LC, Mummaneni PV. Summary of Guidelines for the Treatment of Lumbar Spondylolisthesis. Neurosurg Clin N Am 2019; 30:353-364. [PMID: 31078236 DOI: 10.1016/j.nec.2019.02.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Degenerative lumbar spondylolisthesis is a common cause of low back pain, affecting about 11.5% of the United States population. Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate. This article summarizes the guidelines for the treatment of lumbar spondylolisthesis.
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Chang CC, Mummaneni PV. The Nuances of Occipitocervical Instability and Stenosis in Patients With Basilar Invagination and Atlantoaxial Dislocation. Neurospine 2019; 16:255-256. [PMID: 31261464 PMCID: PMC6603844 DOI: 10.14245/ns.19edi.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Chan AK, Bisson EF, Bydon M, Glassman SD, Foley KT, Potts EA, Shaffrey CI, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KM, Slotkin JR, Asher AL, Virk MS, Kerezoudis P, Alvi MA, Guan J, Haid RW, Mummaneni PV. A comparison of minimally invasive transforaminal lumbar interbody fusion and decompression alone for degenerative lumbar spondylolisthesis. Neurosurg Focus 2019; 46:E13. [DOI: 10.3171/2019.2.focus18722] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 02/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe optimal minimally invasive surgery (MIS) approach for grade 1 lumbar spondylolisthesis is not clearly elucidated. In this study, the authors compared the 24-month patient-reported outcomes (PROs) after MIS transforaminal lumbar interbody fusion (TLIF) and MIS decompression for degenerative lumbar spondylolisthesis.METHODSA total of 608 patients from 12 high-enrolling sites participating in the Quality Outcomes Database (QOD) lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis, of whom 143 underwent MIS (72 MIS TLIF [50.3%] and 71 MIS decompression [49.7%]). Surgeries were classified as MIS if there was utilization of percutaneous screw fixation and placement of a Wiltse plane MIS intervertebral body graft (MIS TLIF) or if there was a tubular decompression (MIS decompression). Parameters obtained at baseline through at least 24 months of follow-up were collected. PROs included the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain, NRS for leg pain, EuroQol-5D (EQ-5D) questionnaire, and North American Spine Society (NASS) satisfaction questionnaire. Multivariate models were constructed to adjust for patient characteristics, surgical variables, and baseline PRO values.RESULTSThe mean age of the MIS cohort was 67.1 ± 11.3 years (MIS TLIF 62.1 years vs MIS decompression 72.3 years) and consisted of 79 (55.2%) women (MIS TLIF 55.6% vs MIS decompression 54.9%). The proportion in each cohort reaching the 24-month follow-up did not differ significantly between the cohorts (MIS TLIF 83.3% and MIS decompression 84.5%, p = 0.85). MIS TLIF was associated with greater blood loss (mean 108.8 vs 33.0 ml, p < 0.001), longer operative time (mean 228.2 vs 101.8 minutes, p < 0.001), and longer length of hospitalization (mean 2.9 vs 0.7 days, p < 0.001). MIS TLIF was associated with a significantly lower reoperation rate (14.1% vs 1.4%, p = 0.004). Both cohorts demonstrated significant improvements in ODI, NRS back pain, NRS leg pain, and EQ-5D at 24 months (p < 0.001, all comparisons relative to baseline). In multivariate analyses, MIS TLIF—as opposed to MIS decompression alone—was associated with superior ODI change (β = −7.59, 95% CI −14.96 to −0.23; p = 0.04), NRS back pain change (β = −1.54, 95% CI −2.78 to −0.30; p = 0.02), and NASS satisfaction (OR 0.32, 95% CI 0.12–0.82; p = 0.02).CONCLUSIONSFor symptomatic, single-level degenerative spondylolisthesis, MIS TLIF was associated with a lower reoperation rate and superior outcomes for disability, back pain, and patient satisfaction compared with posterior MIS decompression alone. This finding may aid surgical decision-making when considering MIS for degenerative lumbar spondylolisthesis.
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Mummaneni PV, Bydon M, Alvi MA, Chan AK, Glassman SD, Foley KT, Potts EA, Shaffrey CI, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KM, Slotkin JR, Asher AL, Virk MS, Kerezoudis P, Guan J, Haid RW, Bisson EF. Predictive model for long-term patient satisfaction after surgery for grade I degenerative lumbar spondylolisthesis: insights from the Quality Outcomes Database. Neurosurg Focus 2019; 46:E12. [DOI: 10.3171/2019.2.focus18734] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVESince the enactment of the Affordable Care Act in 2010, providers and hospitals have increasingly prioritized patient-centered outcomes such as patient satisfaction in an effort to adapt the “value”-based healthcare model. In the current study, the authors queried a prospectively maintained multiinstitutional spine registry to construct a predictive model for long-term patient satisfaction among patients undergoing surgery for Meyerding grade I lumbar spondylolisthesis.METHODSThe authors queried the Quality Outcomes Database for patients undergoing surgery for grade I lumbar spondylolisthesis between July 1, 2014, and June 30, 2016. The primary outcome of interest for the current study was patient satisfaction as measured by the North American Spine Surgery patient satisfaction index, which is measured on a scale of 1–4, with 1 indicating most satisfied and 4 indicating least satisfied. In order to identify predictors of higher satisfaction, the authors fitted a multivariable proportional odds logistic regression model for ≥ 2 years of patient satisfaction after adjusting for an array of clinical and patient-specific factors. The absolute importance of each covariate in the model was computed using an importance metric defined as Wald chi-square penalized by the predictor degrees of freedom.RESULTSA total of 502 patients, out of a cohort of 608 patients (82.5%) with grade I lumbar spondylolisthesis, undergoing either 1- or 2-level decompression (22.5%, n = 113) or 1-level decompression and fusion (77.5%, n = 389), met the inclusion criteria; of these, 82.1% (n = 412) were satisfied after 2 years. On univariate analysis, satisfied patients were more likely to be employed and working (41.7%, n = 172, vs 24.4%, n = 22; overall p = 0.001), more likely to present with predominant leg pain (23.1%, n = 95, vs 11.1%, n = 10; overall p = 0.02) but more likely to present with lower Numeric Rating Scale score for leg pain (median and IQR score: 7 [5–9] vs 8 [6–9]; p = 0.05). Multivariable proportional odds logistic regression revealed that older age (OR 1.57, 95% CI 1.09–2.76; p = 0.009), preoperative active employment (OR 2.06, 95% CI 1.27–3.67; p = 0.015), and fusion surgery (OR 2.3, 95% CI 1.30–4.06; p = 0.002) were the most important predictors of achieving satisfaction with surgical outcome.CONCLUSIONSCurrent findings from a large multiinstitutional study indicate that most patients undergoing surgery for grade I lumbar spondylolisthesis achieved long-term satisfaction. Moreover, the authors found that older age, preoperative active employment, and fusion surgery are associated with higher odds of achieving satisfaction.
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Than KD, Park P, Tran S, Mundis GM, Fu KM, Uribe JS, Okonkwo DO, Nunley PD, Fessler RG, Eastlack RK, Kanter A, Anand N, LaMarca F, Passias PG, Mummaneni PV. Analysis of Complications with Staged Surgery for Less Invasive Treatment of Adult Spinal Deformity. World Neurosurg 2019; 126:e1337-e1342. [PMID: 30898739 DOI: 10.1016/j.wneu.2019.03.090] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Spinal deformity surgery is often invasive and lengthy. Staging surgery over separate operative days may reduce complications. Staging is often used in minimally invasive treatment of adult spinal deformity (ASD). OBJECTIVE To investigate the impact of staging on complication rates between hybrid (HYB; minimally invasive interbody with open posterior screw and rod fixation) and circumferential minimally invasive surgery (cMIS; minimally invasive interbody and screw/rod placement) procedures in patients with ASD. METHODS A multicenter database of patients with ASD was reviewed. Patients who underwent staging (at least 3 levels) and 2 years of follow-up were analyzed. A total of 99 patients underwent staging: 53 cMIS and 46 HYB surgeries. Propensity matching for levels fused resulted in 19 patients in each group. Intra- and perioperative complications were assessed. RESULTS Three HYB but no cMIS intraoperative complications occurred. More HYB patients had perioperative complications than cMIS patients. Neurologic complications were more frequent in HYB versus cMIS. Other complications did not differ significantly. Thirty-day reoperations were higher with cMIS than HYB, but there was no difference in reoperation rate at long-term follow-up. cMIS patients had greater improvement in the Oswestry Disability Index. There was no difference in complications between staged versus unstaged cMIS surgeries. CONCLUSIONS cMIS staged surgeries appear safer than HYB staged surgeries, and equally safe to cMIS unstaged surgeries. Perioperative complications were significantly higher for HYB staged surgeries. HYB surgeries may have better results when performed in a single setting, whereas cMIS surgeries can be performed in 1 or 2 stages depending on surgeon preference.
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Dhall SS, Kurpad SN, Hurlbert RJ, Mummaneni PV. Introduction. Acute spinal cord injury. Neurosurg Focus 2019; 46:E1. [PMID: 30835672 DOI: 10.3171/2019.1.focus1912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Zhou RP, Mummaneni PV, Chen KY, Lau D, Cao K, Amara D, Zhang C, Dhall S, Chou D. Outcomes of Posterior Thoracic Corpectomies for Metastatic Spine Tumors: An Analysis of 90 Patients. World Neurosurg 2019; 123:e371-e378. [DOI: 10.1016/j.wneu.2018.11.172] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 11/17/2018] [Accepted: 11/19/2018] [Indexed: 01/22/2023]
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Park P, Fu KM, Eastlack RK, Tran S, Mundis GM, Uribe JS, Wang MY, Than KD, Okonkwo DO, Kanter AS, Nunley PD, Anand N, Fessler RG, Chou D, Oppenlander ME, Mummaneni PV. Is achieving optimal spinopelvic parameters necessary to obtain substantial clinical benefit? An analysis of patients who underwent circumferential minimally invasive surgery or hybrid surgery with open posterior instrumentation. J Neurosurg Spine 2019; 30:833-838. [PMID: 30797202 DOI: 10.3171/2018.11.spine181261] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE It is now well accepted that spinopelvic parameters are correlated with clinical outcomes in adult spinal deformity (ASD). The purpose of this study was to determine whether obtaining optimal spinopelvic alignment was absolutely necessary to achieve a minimum clinically important difference (MCID) or substantial clinical benefit (SCB). METHODS A multicenter retrospective review of patients who underwent less-invasive surgery for ASD was conducted. Inclusion criteria were age ≥ 18 years and one of the following: coronal Cobb angle > 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 20°, or pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°. A total of 223 patients who were treated with circumferential minimally invasive surgery or hybrid surgery and had a minimum 2-year follow-up were identified. Based on optimal spinopelvic parameters (PI-LL mismatch ± 10° and SVA < 5 cm), patients were divided into aligned (AL) or malaligned (MAL) groups. The primary clinical outcome studied was the Oswestry Disability Index (ODI) score. RESULTS There were 74 patients in the AL group and 149 patients in the MAL group. Age and body mass index were similar between groups. Although the baseline SVA was similar, PI-LL mismatch (9.9° vs 17.7°, p = 0.002) and PT (19° vs 24.7°, p = 0.001) significantly differed between AL and MAL groups, respectively. As expected postoperatively, the AL and MAL groups differed significantly in PI-LL mismatch (-0.9° vs 13.1°, p < 0.001), PT (14° vs 25.5°, p = 0.001), and SVA (11.8 mm vs 48.3 mm, p < 0.001), respectively. Notably, there was no difference in the proportion of AL or MAL patients in whom an MCID (52.75% vs 61.1%, p > 0.05) or SCB (40.5% vs 46.3%, p > 0.05) was achieved for ODI score, respectively. Similarly, no differences in percentage of patients obtaining an MCID or SCB for visual analog scale back and leg pain score were observed. On multivariate analysis controlling for surgical and preoperative demographic differences, achieving optimal spinopelvic parameters was not associated with achieving an MCID (OR 0.645, 95% CI 0.31-1.33) or an SCB (OR 0.644, 95% CI 0.31-1.35) for ODI score. CONCLUSIONS Achieving optimal spinopelvic parameters was not a predictor for achieving an MCID or SCB. Since spinopelvic parameters are correlated with clinical outcomes, the authors' findings suggest that the presently accepted optimal spinopelvic parameters may require modification. Other factors, such as improvement in neurological symptoms and/or segmental instability, also likely impacted the clinical outcomes.
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Amara D, Mummaneni PV, Ames CP, Tay B, Deviren V, Burch S, Berven SH, Chou D. Treatment of only the fractional curve for radiculopathy in adult scoliosis: comparison to lower thoracic and upper thoracic fusions. J Neurosurg Spine 2019; 30:506-514. [PMID: 30717041 DOI: 10.3171/2018.9.spine18505] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 09/26/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Many options exist for the surgical management of adult spinal deformity. Radiculopathy and lumbosacral pain from the fractional curve (FC), typically from L4 to S1, is frequently a reason for scoliosis patients to pursue surgical intervention. The purpose of this study was to evaluate the outcomes of limited fusion of the FC only versus treatment of the entire deformity with long fusions. METHODS All adult scoliosis patients treated at the authors' institution in the period from 2006 to 2016 were retrospectively analyzed. Patients with FCs from L4 to S1 > 10° and radiculopathy ipsilateral to the concavity of the FC were eligible for study inclusion and had undergone three categories of surgery: 1) FC only (FC group), 2) lower thoracic to sacrum (LT group), or 3) upper thoracic to sacrum (UT group). Primary outcomes were the rates of revision surgery and complications. Secondary outcomes were estimated blood loss, length of hospital stay, and discharge destination. Spinopelvic parameters were measured, and patients were stratified accordingly. RESULTS Of the 99 patients eligible for inclusion in the study, 27 were in the FC group, 46 in the LT group, and 26 in the UT group. There were no significant preoperative differences in age, sex, smoking status, prior operation, FC magnitude, pelvic tilt (PT), sagittal vertical axis (SVA), coronal balance, pelvic incidence-lumbar lordosis (PI-LL) mismatch, or proportion of well-aligned spines (SVA < 5 cm, PI-LL mismatch < 10°, and PT < 20°) among the three treatment groups. Mean follow-up was 30 (range 12-112) months, with a minimum 1-year follow-up. The FC group had a lower medical complication rate (22% [FC] vs 57% [LT] vs 58% [UT], p = 0.009) but a higher rate of extension surgery (26% [FC] vs 13% [LT] vs 4% [UT], p = 0.068). The respective average estimated blood loss (592 vs 1950 vs 2634 ml, p < 0.001), length of hospital stay (5.5 vs 8.3 vs 8.3 days, p < 0.001), and rate of discharge to acute rehabilitation (30% vs 46% vs 85%, p < 0.001) were all lower for FC and highest for UT. CONCLUSIONS Treatment of the FC only is associated with a lower complication rate, shorter hospital stay, and less blood loss than complete scoliosis treatment. However, there is a higher associated rate of extension of the construct to the lower or upper thoracic levels, and patients should be counseled when considering their options.
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Eastlack RK, Srinivas R, Mundis GM, Nguyen S, Mummaneni PV, Okonkwo DO, Kanter AS, Anand N, Park P, Nunley P, Uribe JS, Akbarnia BA, Chou D, Deviren V. Early and Late Reoperation Rates With Various MIS Techniques for Adult Spinal Deformity Correction. Global Spine J 2019; 9:41-47. [PMID: 30775207 PMCID: PMC6362559 DOI: 10.1177/2192568218761032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN A multicenter retrospective review of an adult spinal deformity database. OBJECTIVE We aimed to characterize reoperation rates and etiologies of adult spinal deformity surgery with circumferential minimally invasive surgery (cMIS) and hybrid (HYB) techniques. METHODS Inclusion criteria were age ≥18 years, and one of the following: coronal Cobb >20°, sagittal vertical axis >5 cm, pelvic tilt >20°, and pelvic incidence-lumbar lordosis >10°. Patients with either cMIS or HYB surgery, ≥3 spinal levels treated with 2-year minimum follow-up were included. RESULTS A total of 133 patients met inclusion for this study (65 HYB and 68 cMIS). Junctional failure (13.8%) was the most common reason for reoperation in the HYB group, while fixation failure was the most common reason in the cMIS group (14.7%). There was a higher incidence of proximal junctional failure (PJF) than distal junctional failure (DJF) within HYB (12.3% vs 3.1%), but no significant differences in PJF or DJF rates when compared to cMIS. Early (<30 days) reoperations were less common (cMIS = 1.5%; HYB = 6.1%) than late (>30 days) reoperations (cMIS = 26.5%; HYB = 27.7%), but early reoperations were more common in the HYB group after propensity matching, largely due to infection rates (10.8% vs 0%, P = .04). CONCLUSIONS Adult spinal deformity correction with cMIS and HYB techniques result in overall reoperation rates of 27.9% and 33.8%, respectively, at minimum 2-year follow-up. Junctional failures are more common after HYB approaches, while pseudarthrosis/fixation failures happen more often with cMIS techniques. Early reoperations were less common than later returns to the operating room in both groups, but cMIS demonstrated less risk of infection and early reoperation when compared with the HYB group.
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Chang CC, Huang WC, Wu JC, Mummaneni PV. The Option of Motion Preservation in Cervical Spondylosis: Cervical Disc Arthroplasty Update. Neurospine 2018; 15:296-305. [PMID: 30545210 PMCID: PMC6347355 DOI: 10.14245/ns.1836186.093] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/28/2018] [Indexed: 12/22/2022] Open
Abstract
Cervical disc arthroplasty (CDA), or total disc replacement, has emerged as an option in the past two decades for the management of 1- and 2-level cervical disc herniation and spondylosis causing radiculopathy, myelopathy, or both. Multiple prospective randomized controlled trials have demonstrated CDA to be as safe and effective as anterior cervical discectomy and fusion, which has been the standard of care for decades. Moreover, CDA successfully preserved segmental mobility in the majority of surgical levels for 5–10 years. Although CDA has been suggested to have long-term efficacy for the reduction of adjacent segment disease in some studies, more data are needed on this topic. Surgery for CDA is more demanding for decompression, because indirect decompression by placement of a tall bone graft is not possible in CDA. The artificial discs should be properly sized, centered, and installed to allow movement of the vertebrae, and are commonly 6 mm high or less in most patients. The key to successful CDA surgery includes strict patient selection, generous decompression of the neural elements, accurate sizing of the device, and appropriately centered implant placement.
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