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Pivazyan G, Winters CG, Brooks DM, Sandhu FA, Cunningham BW. Cervicothoracic Reconstruction with Quad Rods, Dual Rods, and Tapered Rods: An in Vitro Human Cadaveric Model. World Neurosurg 2023; 180:243-244. [PMID: 37839569 DOI: 10.1016/j.wneu.2023.10.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Affiliation(s)
- Gnel Pivazyan
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA; Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Carlynn G Winters
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Daina M Brooks
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland, USA; Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Bryan W Cunningham
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland, USA; Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
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Toci GR, Karamian BA, Lambrechts MJ, Mao J, Mandel J, Darrach T, Canseco JA, Kaye ID, Woods BI, Rihn J, Kurd MF, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Instrumentation Across the Cervicothoracic Junction Does Not Improve Patient-reported Outcomes in Multilevel Posterior Cervical Decompression and Fusion. Clin Spine Surg 2022; 35:E667-E673. [PMID: 35383594 DOI: 10.1097/bsd.0000000000001335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/01/2022] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective cohort. OBJECTIVE The objective of this study was to determine if instrumentation across the cervicothoracic junction (CTJ) in elective multilevel posterior cervical decompression and fusion (PCF) is associated with improved patient-reported outcome measures (PROMs). SUMMARY OF BACKGROUND DATA Fusion across the CTJ may result in lower revision rates at the expense of prolonged operative duration. However, it is unclear whether constructs crossing the CTJ affect PROMs. MATERIALS AND METHODS Standard Query Language (SQL) identified patients with PROMs who underwent elective multilevel PCF (≥3 levels) at our institution. Patients were grouped based on anatomic construct: crossing the CTJ (crossed) versus not crossing the CTJ (noncrossed). Subgroup analysis compared constructs stopping at C7 or T1. Independent t tests and χ 2 tests were utilized for continuous and categorical data, respectively. Regression analysis controlled for baseline demographics. The α was set at 0.05. RESULTS Of the 160 patients included, the crossed group (92, 57.5%) had significantly more levels fused (5.27 vs. 3.71, P <0.001), longer operative duration (196 vs. 161 min, P =0.003), greater estimated blood loss (242 vs. 160 mL, P =0.021), and a decreased revision rate (1.09% vs. 10.3%, P =0.011). Neither crossing the CTJ (vs. noncrossed) nor constructs spanning C3-T1 (vs. C3-C7) were independent predictors of ∆PROMs (change in preoperative minus postoperative patient-reported outcomes) on regression analysis. However, C3-C7 constructs had a greater revision rate than C3-T1 constructs (15.6% vs. 1.96%, P =0.030). CONCLUSION Crossing the CTJ in patients undergoing elective multilevel PCF was not an independent predictor of improvement in PROMs at 1 year, but they experienced lower revision rates. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Gregory R Toci
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
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Coban D, Faloon M, Changoor S, Saela S, Sahai N, Record N, Sinha K, Hwang K, Emami A. Should we bridge the cervicothoracic junction in long cervical fusions? A meta-analysis and systematic review of the literature. J Neurosurg Spine 2022; 37:166-174. [PMID: 35120314 DOI: 10.3171/2021.12.spine211090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 12/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Long posterior cervical decompression and fusion (PCF) is commonly performed to surgically treat patients with multilevel cervical pathology. In cases in which constructs may necessitate crossing the cervicothoracic junction (CTJ), recommendations for appropriate caudal fusion level vary in the literature. The aim of this study was to report the clinical and radiological outcomes of multilevel PCFs ending at C7 versus those crossing the CTJ. METHODS A systematic search of PubMed, CINAHL Plus, and Scopus was conducted to identify articles that evaluated clinical and radiological outcomes of long PCFs that ended at C7 (cervical group) or crossed the CTJ (thoracic group). Based on heterogeneity, random-effects models of a meta-analysis were used to estimate the pooled estimates and the 95% confidence intervals. RESULTS PCF outcome data of 1120 patients from 10 published studies were included. Compared with the cervical group, the thoracic group experienced greater mean blood loss (453.0 ml [95% CI 333.6-572.5 ml] vs 303.5 ml [95% CI 203.4-403.6 ml]), longer operative times (235.5 minutes [95% CI 187.7-283.3 minutes] vs 198.5 minutes [95% CI 157.9-239.0 minutes]), and a longer length of stay (6.7 days [95% CI 3.3-10.2 days] vs 6.2 days [95% CI 3.8-8.7 days]); however, these differences were not statistically significant. None of the included studies specifically investigated factors that led to the decision of whether to cross the CTJ. The cervical group had a mean fusion rate of 86% (95% CI 71%-94%) compared with the thoracic group with a rate of 90% (95% CI 81%-95%). Of patients in the cervical group, 17% (95% CI 10%-28%) required revision surgery compared with 7% (95% CI 4%-13%) of those in the thoracic group, but this difference was not statistically significant. The proportion of patients who experienced complications in the cervical group was found to be 28% (95% CI 12%-52%) versus 14% (95% CI 7%-26%) in the thoracic group; however, this difference was not statistically significant. There was no significant difference (no overlap of 95% CIs) in the incidence of adjacent-segment disease, pseudarthrosis, or wound-related complications between groups. CONCLUSIONS This meta-analysis suggests similar clinical and radiographic outcomes in multilevel PCF, regardless of inclusion of the CTJ. The lowest instrumented level did not significantly affect revision rates or complications. The ideal stopping point must be tailored to each patient on an individualized basis.
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Affiliation(s)
- Daniel Coban
- 1Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey; and
| | - Michael Faloon
- 1Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey; and
| | - Stuart Changoor
- 1Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey; and
| | - Stephen Saela
- 1Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey; and
| | - Nikhil Sahai
- 1Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey; and
| | - Nicole Record
- 2LA Bone and Joint Institute, Department of Orthopaedics, Encino, California
| | - Kumar Sinha
- 1Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey; and
| | - Ki Hwang
- 1Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey; and
| | - Arash Emami
- 1Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey; and
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Pinter ZW, Karamian B, Bou Monsef J, Mao J, Xiong A, Bowles DR, Conaway WK, Reiter DM, Honig R, Currier B, Nassr A, Freedman BA, Bydon M, Elder BD, Kaye ID, Kepler C, Schroeder G, Vaccaro A, Wagner S, Sebastian AS. Cervical Alignment and Proximal and Distal Junctional Failure in Posterior Cervical Fusion: A Multicenter Comparison of 2 Surgical Approaches. Clin Spine Surg 2022; 35:E451-E456. [PMID: 34907934 DOI: 10.1097/bsd.0000000000001281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN This was a multicenter retrospective cohort study. OBJECTIVE The purpose of this study was to compare the surgical and radiographic outcomes of patients undergoing posterior cervical fusion (PCF) with constructs extending from C2 to T2 to patients with constructs extending from C3 to T1. SUMMARY OF BACKGROUND DATA Limited evidence exists regarding the appropriate level of proximal and distal extension of PCF constructs. METHODS A multicenter retrospective cohort study of patients who underwent PCF between 2012 and 2020 was performed. Surgical and radiographic outcomes were compared between those who had C3-T1 or C2-T2 constructs. RESULTS A total of 155 patients were included in the study (C2-T2: 106 patients, C3-T1: 49 patients). There were no significant differences in demographics or preoperative symptoms between cohorts. Fusion rates were significantly higher in the C2-T2 (93%) than the C3-T1 (80%, P=0.040) cohort. When comparing the C2-T2 to the C3-T1 cohort, the C3-T1 cohort had a significantly greater rate of proximal junctional failure (2% vs. 10%, P=0.006), distal junctional failure (1% vs. 20%, P<0.001) and distal screw loosening (4% vs. 15%, P=0.02). Although ∆C2-C7 sagittal vertical axis increased significantly in both cohorts (C2-T2: 6.2 mm, P=0.04; C3-T1: 8.4 mm, P<0.001), correction did not significantly differ between groups (P=0.32). The C3-T1 cohort had a significantly greater increase in ∆C2 slope (8.0 vs. 3.1 degrees, P=0.03) and ∆C0-C2 Cobb angle (6.4 vs. 1.2 degrees, P=0.04). CONCLUSION In patients undergoing PCF, a C2-T2 construct demonstrated lower rates of pseudarthrosis, distal junctional failure, proximal junctional failure, and compensatory upper cervical hyperextension compared with a C3-T1 construct.
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Affiliation(s)
| | - Brian Karamian
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Jad Bou Monsef
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Jennifer Mao
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Ashley Xiong
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Daniel R Bowles
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - William K Conaway
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - David M Reiter
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Rachel Honig
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | | | - Ian D Kaye
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Christopher Kepler
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Gregory Schroeder
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Alexander Vaccaro
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Scott Wagner
- Walter Reed National Military Medical Center, Bethesda, MD
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Abstract
Pseudarthrosis of the cervical spine represents a common and challenging problem for spine surgeons. Rates vary greatly from as low as 0%-20% to >60% and depend heavily on patient factors, approach, and number of levels. While some patients remain asymptomatic from pseudarthrosis, many require revision surgery due to instability, continued neck pain, or radiculopathy/myelopathy. We aimed to provide a practical, narrative review of cervical pseudarthrosis to address the following areas: (1) definitions, (2) incidence, (3) risk factors, (4) presentation and workup, (5) treatment decision-making, and (6) postoperative care. It is our hope the current review provides a concise summary for how to diagnose and treat challenging cervical nonunions.
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Affiliation(s)
- Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
| | - Clinton J Devin
- Steamboat Orthopedic and Spine Institute, Steamboat Springs, CO
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6
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Toll BJ, Samdani AF, Pahys JM, Amanullah AA, Hwang SW. Crossing the cervicothoracic junction in complex pediatric deformity using anterior cervical discectomy and fusion: a case series. Childs Nerv Syst 2021; 37:1957-1964. [PMID: 33730238 DOI: 10.1007/s00381-021-05109-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Proximal instrumentation failure is a challenge in posterior spinal fusions (PSFs) crossing the cervicothoracic junction. High rates of proximal junctional kyphosis (PJK) and loss of fixation have been reported. In this single-center retrospective cohort study, we evaluate the utility of anterior cervical discectomy and fusion (ACDF) in addition to traditional PSF crossing the cervicothoracic junction in order to mitigate implant-related complications. METHODS All patients who underwent PSF across the cervicothoracic junction with ACDF with 2 years of follow-up data were reviewed. We analyzed clinical, surgical, and radiographic measures such as operative details, presence of PJK, complications, instrumentation migration, curve angles, and vertebral translation. Measurements were compared statistically using paired samples t-tests. RESULTS Ten patients (6 girls, 4 boys) met inclusion criteria with a mean age at surgery of 12.8 ± 3.3 years and follow-up of 3.38 ± 0.9 years. All patients underwent ACDF (range 1-3 levels), and 8 (80%) underwent traction. The average number of levels fused posteriorly was 16.7 ± 4.7 and anteriorly was 2.4 ± 0.7. The major coronal curve averaged 48.8 ± 34.7° preoperatively and 23.3±13.3° postoperatively (p = 0.028). The average major sagittal curve was 83.5 ± 24.2° preoperatively, resolving to 53.9 ± 25.5° (p=0.001). One patient suffered rod breakage at T7, and another developed symptomatic PJK 19 months postoperatively. CONCLUSION Our data suggest that ACDF procedures added to PSFs crossing the cervicothoracic junction offer promise for reducing risk for instrumentation-related complications. ACDF also significantly helps improve and maintain both coronal and sagittal correction over 2 years. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Brandon J Toll
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA.
| | - Joshua M Pahys
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Amir A Amanullah
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Steven W Hwang
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
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Hines K, Wilt ZT, Franco D, Mahtabfar A, Elmer N, Gonzalez GA, Montenegro TS, Velagapudi L, Patel PD, Detweiler M, Fatema U, Schroeder GD, Harrop J. Long-segment posterior cervical decompression and fusion: does caudal level affect revision rate? J Neurosurg Spine 2021; 35:1-7. [PMID: 33892477 DOI: 10.3171/2020.10.spine201385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior cervical decompression and fusion (PCDF) is a commonly performed procedure to address cervical myelopathy. A significant number of these patients require revision surgery for adjacent-segment disease (ASD) or pseudarthrosis. Currently, there is no consensus among spine surgeons on the inclusion of proximal thoracic spine instrumentation. This study investigates the benefits of thoracic extension in long-segment cervical fusions and the potential drawbacks. The authors compare outcomes in long-segment subaxial cervical fusion for degenerative cervical myelopathy with caudal vertebral levels of C6, C7, and T1. METHODS A retrospective analysis identified 369 patients who underwent PCDF. Patients were grouped by caudal fusion level. Reoperation rates for ASD and pseudarthrosis, infection, and blood loss were examined. Data were analyzed with chi-square, 1-way ANOVA, and logistic regression. RESULTS The total reoperation rate for symptomatic pseudarthrosis or ASD was 4.8%. Reoperation rates, although not significant, were lower in the C3-6 group (2.6%, vs 8.3% for C3-7 and 3.8% for C3-T1; p = 0.129). Similarly, rates of infection were lower in the shorter-segment fusion without achieving statistical significance (2.6% for C3-6, vs 5.6% for C3-7 and 5.5% for C3-T1; p = 0.573). The mean blood loss was documented as 104, 125, and 224 mL for groups 1, 2, and 3, respectively (p < 0.001). CONCLUSIONS Given the lack of statistical difference in reoperation rates for long-segment cervical fusions ending at C6, C7, or T1, shorter fusions in high-risk surgical candidates or elderly patients may be performed without higher rates of reoperation.
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Affiliation(s)
- Kevin Hines
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Zachary T Wilt
- 2Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel Franco
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Aria Mahtabfar
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Nicholas Elmer
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Glenn A Gonzalez
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Thiago S Montenegro
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Lohit Velagapudi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Parthik D Patel
- 2Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Maxwell Detweiler
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Umma Fatema
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Gregory D Schroeder
- 2Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - James Harrop
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
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Balestrino A, Gondar R, Jannelli G, Zona G, Tessitore E. Surgical challenges in posterior cervicothoracic junction instrumentation. Neurosurg Rev 2021; 44:3447-3458. [PMID: 33754193 DOI: 10.1007/s10143-021-01520-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/08/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
The cervicothoracic junction (CTJ) is a region of the spine submitted to significant mechanical stress. The peculiar anatomical and biomechanical characteristics make posterior surgical stabilization of this area particularly challenging. We present and discuss our surgical series highlighting the specific surgical challenges provided by this region of the spine. We have analyzed and reported retrospective data from patients who underwent a posterior cervicothoracic instrumentation between 2011 and 2019 at the Neurosurgical Department of the Geneva University Hospitals. We have discussed C7 and Th1 instrumentation techniques, rods design, extension of constructs, and spinal navigation. Thirty-six patients were enrolled. We have preferentially used lateral mass (LM) screws in the subaxial spine and pedicle screws (PS) in C7, Th1, and upper thoracic spine. We have found no superiority of 3D navigation techniques over 2D fluoroscopy guidance in PS placement accuracy, probably due to the relatively small case series. Surgical site infection was the most frequent complication, significantly associated with tumor as diagnosis. When technically feasible, PS represent the technique of choice for C7 and Th1 instrumentation although other safe techniques are available. Different rod constructs are described although significant differences in biomechanical stability still need to be clarified. Spinal navigation should be used whenever available even though 2D fluoroscopy is still a safe option. Posterior instrumentation of the CTJ is a challenging procedure, but with correct surgical planning and technique, it is safe and effective.
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Affiliation(s)
- Alberto Balestrino
- Department of Neurosurgery, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy. .,Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS San Martino Polyclinic Hospital, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
| | - Renato Gondar
- Neurosurgical Unit, Geneva University Hospitals, Geneva, Switzerland
| | | | - Gianluigi Zona
- Department of Neurosurgery, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy
| | - Enrico Tessitore
- Neurosurgical Unit, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Truumees E, Singh D, Lavelle W, Riesenburger R, Geck M, Kurra S, Yu A, Grits D, Dowd R, Winkelman R, Mroz T, Stokes J. Is it safe to stop at C7 during multilevel posterior cervical decompression and fusion? - multicenter analysis. Spine J 2021; 21:90-95. [PMID: 32890781 DOI: 10.1016/j.spinee.2020.08.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/13/2020] [Accepted: 08/29/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite a number of studies addressing the anatomical and biomechanical challenges of long segment, posterior cervical fusion surgery, recommendations for appropriate caudal "end level" vary widely. PURPOSE Compare revision rates, patient reported outcomes and radiographic outcomes in patients in whom 3+ level posterior fusions ended in the cervical spine versus those in whom the fusion was extended into the thoracic spine. STUDY DESIGN Multicenter retrospective analysis. OUTCOME MEASURES Visual analog scale (VAS), Oswestry disability index (ODI), cervical lordosis, C2-C7 sagittal plumbline, T1 slope, and revision rate. METHODS We assembled a radiographic and clinical database of patients that had undergone three or more level posterior cervical fusions for degenerative disease from January 2013 to May 2015 at one of four busy spine centers. Only those patients with at least 2 years of postoperative (postop) follow-up were included. Patients were divided into two groups: group I (fusion ending at C6 or C7) and group II (fusion extending into the thoracic spine). All radiographic measurements (cervical lordosis, T1 slope, and C2-C7 sagittal plumbline) were performed by an independent experienced clinical researcher. RESULTS Two hundred and sixty-four patient cases were reviewed and sorted into the two outlined groups, Group I (n=168) and Group II (n=96). Demographically, mean age, percentage of females, non-smokers and anterior support were greater in Group II than in Groups I (p<.05). Mean estimated blood loss (EBL), operative time (OR) and length of hospital stay (LOS) were significantly higher in Group II (p<.05). Rate of revision was not clinically or statistically significantly different (p>.05) between Group I (11.1%) and Group II (9.4%). The majority of the revision surgeries occurred between 2 to 5 years postop. A greater number of subjacent degeneration/spondylolisthesis events were noted in Group I compared with Group II (3.6% vs. 1.2%). There were significant improvements in mean clinical outcomes (ie, VAS and ODI) at two years postop in both groups, but there were no statistically significant differences between the groups (p>.05). Mean cervical lordosis at 2 years postop improved in all groups (12.8° vs. 14.1°); however, there was no significant statistical difference in change for mean cervical lordosis (2 weeks vs. 2 year postop) between the two groups. Similary, there were no significant statistical differences in change for mean C2-C7 sagittal plumbline and T1 slope (2 weeks vs. 2 year postop) between the two groups(p>.05). CONCLUSIONS Caudal end level did not significantly affect revision rates, patient reported outcomes or radiographic outcomes. Higher EBL, OR, and LOS in group II suggest that, absent focal C7-T1 pathology, extension of posterior cervical fusions into the thoracic spine may not be necessary. Extension of posterior cervical fusions into the thoracic spine may be recommended for higher risk patients with limitations to strong C7 bone anchorage. In others, it is safe to stop at C7.
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Affiliation(s)
- Eeric Truumees
- The University of Texas Dell Medical School, Ascension Texas Spine and Scoliosis, Austin, TX, USA.
| | - Devender Singh
- Ascension Texas Spine and Scoliosis, 1600 West 38(th) St Suite 200, Austin TX 78731, USA
| | - William Lavelle
- State University of New York Upstate Medical University, 750 East Adams St, Syracuse, NY 13210-2375, USA
| | | | - Matthew Geck
- The University of Texas Dell Medical School, Ascension Texas Spine and Scoliosis, Austin, TX, USA
| | - Swamy Kurra
- State University of New York Upstate Medical University, 750 East Adams St, Syracuse, NY 13210-2375, USA
| | - Anthony Yu
- Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Daniel Grits
- Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Richard Dowd
- Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Robert Winkelman
- Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA
| | - Thomas Mroz
- Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - John Stokes
- Ascension Texas Spine and Scoliosis, 1600 West 38(th) St Suite 200, Austin TX 78731, USA
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Fayed I, Toscano DT, Triano MJ, Makariou E, Lee C, Spitz SM, Anaizi AN, Nair MN, Sandhu FA, Voyadzis JM. Crossing the Cervicothoracic Junction During Posterior Cervical Decompression and Fusion: Is It Necessary? Neurosurgery 2020; 86:E544-E550. [PMID: 32315427 DOI: 10.1093/neuros/nyaa078] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 02/02/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Posterior cervical fusion (PCF) is performed to treat cervical myelopathy, radiculopathy, and/or deformity. Constructs ending at the cervicothoracic junction (CTJ) may lead to higher rates of adjacent segment disease, and much debate exists regarding crossing the CTJ due to paucity of data in the literature. OBJECTIVE To determine whether extension of PCF constructs across the CTJ decreases incidence of adjacent segment disease and need for revision surgery. METHODS A single-center retrospective case series of patients undergoing multilevel PCFs since 2011 with at least 6-mo follow-up was conducted. Outcomes were analyzed and compared based on caudal extent of instrumentation via multivariate regression. RESULTS A total of 149 patients underwent PCF, with a mean follow-up of 18.9 mo. A total of 15 (10.1%) revisions were performed, 7 (4.7%) of which were related to the construct. Five (8.3%) revisions were performed for constructs ending at C6, 1 (5.3%) at C7, 1 (2.6%) at T1, and none (0%) at T2 (P = .035). Mean procedure duration was 215 min at C6, 214 min at C7, 239 min at T1, and 343 min at T2 (P = .001). Mean estimated blood loss was 224 mL at C6, 178 mL at C7, 308 mL at T1, and 575 mL at T2 (P = .001). There was no difference in length of stay, disposition, surgical site infection, or radiographic parameters. CONCLUSION Extension of PCFs across the CTJ leads to lower early revision rates, but also to increased procedure duration and estimated blood loss. As such, decisions regarding caudal extent of instrumentation must weigh the risk of pseudarthrosis against that of longer procedures with higher blood loss.
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Affiliation(s)
- Islam Fayed
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Daniel T Toscano
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Matthew J Triano
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Erini Makariou
- Department of Radiology, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Christabel Lee
- Department of Radiology, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Steven M Spitz
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Amjad N Anaizi
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - M Nathan Nair
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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11
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Woodroffe RW, Helland LC, Grossbach AJ, Nourski KV, Hitchon PW. Risk factors associated with reoperation in posterior cervical fusions: A large-scale retrospective analysis. Clin Neurol Neurosurg 2020; 195:105828. [PMID: 32344282 DOI: 10.1016/j.clineuro.2020.105828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To identify risk factors for reoperation in patients who have undergone posterior cervical fusion (PCF). PATIENTS AND METHODS A retrospective cohort analysis was performed of patients undergoing PCF during a 12-year period at a single institution. Demographic and surgical characteristics were collected from electronic medical records. This study addressed reoperations, from all causes, of PCF. Different strategies, including the addition of anterior fusion, were also compared. RESULTS Of the 370 patients meeting inclusion criteria there were 44 patients (11.9 %) that required a revision and of those 5 required a second revision. The most common reasons for revision were adjacent segment disease and infection, 13 (3.5 %) and 11 patients (3.0 %), respectively. There was not a higher revision rate (for any cause) for patients who had a subaxial fusion and compared with those that included C2 or those that failed to cross the cervicothoracic junction. Of patients who required reoperation, there was a statistically significant higher fraction of smokers (p = 0.023). CONCLUSION The risks and benefits of posterior cervical instrumentation and fusion should be thoroughly discussed with patients. This report implicates smoking as a risk factor for all-cause reoperation in patients who have had this PCF and provides surgeons with additional data regarding this complication. When possible, preoperative optimization should include smoking cessation therapy.
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Affiliation(s)
- Royce W Woodroffe
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Logan C Helland
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Andrew J Grossbach
- Department of Neurosurgery, The Ohio State University, Columbus, OH, USA
| | - Kirill V Nourski
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Patrick W Hitchon
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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12
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Huang PJ, Lin JH, Chiang YH. Miniplate-Augmented Interlaminar Fusion in C1-C2 Screwing. World Neurosurg 2020; 138:e634-e641. [PMID: 32173550 DOI: 10.1016/j.wneu.2020.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The interlaminar fusion combination involving C1-C2 screwing fixation is one of the most effective techniques for atlantoaxial dislocation or subluxation, and the bone graft is usually stabilized by wiring constructs. However, some adverse events were reported during the insertion of sublaminar wiring, such as accidentally damaging the spinal cord or dura. Thus we used the miniplate to stabilize the harvest bone graft on the C1-C2 laminar, which led to a shorter operation time and prevented spinal canal violation. This study investigated the safety and efficacy of the novel surgical technique, namely miniplate-augmented interlaminar fusion. METHODS We retrospectively reviewed 43 patients who underwent posterior atlantoaxial fusion with the miniplate-augmented iliac crest autograft at our institute. Complications related to surgery were recorded and calculated. After operation, patients were followed up through routine radiography to examine whether the fusion of the atlantoaxial segment was achieved. Success of fusion was defined as follows: 1) the presence of bone bridging between the bone graft and both the atlas and axis; and 2) the absence of movement of the atlantoaxial spinous process on flexion-extension radiography, which meant that the variation of length measured in 2 views, respectively, was <1 mm. The first time when radiography showed successful fusion after surgery was termed as fusion time and was recorded individually. In addition, overall fusion rates and mean fusion times were analyzed. RESULTS Of 43 patients, long-term follow-up data were available for 31 patients, whereas the remaining 12 patients had dropped out (mean follow-up duration, 24.91 months; range, 6-72 months). Among 31 patients, 22 (70.96%) were women and 9 (29.03%) were men. The mean age was 63.33 years. Regarding the etiology, atlantoaxial dislocations or subluxations were caused due to degeneration, rheumatoid arthritis, odontoid fracture, trauma, and os odontoideum in 14 (45%), 3 (10%), 5 (16%), 8 (26%), and 1 (3%) patient(s), respectively. Successful fusion was achieved in 30 (96.77%) patients, with a mean fusion time of 6.23 months, whereas only 1 (3.23%) patient did not meet the fusion criteria. No complications related to the miniplate occurred. We noted vertebral artery rupture not requiring blood transfusion in 1 patient, aspiration pneumonia in 1 patient, urinary tract infection in 1 patient, anemia requiring transfusion in 1 patient, and leg dysesthesia in 1 patient. No neurologic deficit was found. CONCLUSIONS Miniplate-augmented interlaminar fusion with C1-C2 screwing resulted in excellent fusion rates with a considerably low probability of complications. Hence this novel technique for bone graft fixation with atlantoaxial screwing has a good efficacy and safety and can serve as an alternative for bone graft fixation during C1-C2 fusion.
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Affiliation(s)
- Po-Jen Huang
- Department of Neurosurgery, Taipei Medical University, Taipei, Taiwan
| | - Jiann-Her Lin
- Department of Neurosurgery, Taipei Medical University, Taipei, Taiwan; Department of Surgery, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.
| | - Yung-Hsiao Chiang
- Department of Neurosurgery, Taipei Medical University, Taipei, Taiwan; Department of Surgery, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
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13
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Safaee MM, Dalle Ore CL, Zygourakis CC, Deviren V, Ames CP. Estimating a price point for cost-benefit of bone morphogenetic protein in pseudarthrosis prevention for adult spinal deformity surgery. J Neurosurg Spine 2019; 30:814-821. [PMID: 30849745 DOI: 10.3171/2018.12.spine18613] [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: 05/15/2018] [Accepted: 12/17/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Bone morphogenetic protein (BMP) is associated with reduced rates of pseudarthrosis and has the potential to decrease the need for revision surgery. There are limited data evaluating the cost-benefit of BMP for pseudarthrosis-related prevention surgery in adult spinal deformity. METHODS The authors performed a single-center retrospective review of 200 consecutive patients with adult spinal deformity. Demographic data and costs of BMP, primary surgery, and revision surgery for pseudarthrosis were collected. Patients with less than 12 months of follow-up or with infection, tumor, or neuromuscular disease were excluded. RESULTS One hundred fifty-one patients (107 [71%] women) with a mean age of 65 years met the inclusion criteria. The mean number of levels fused was 10; BMP was used in 98 cases (65%), and the mean follow-up was 23 months. Fifteen patients (10%) underwent surgical revision for pseudarthrosis; BMP use was associated with an 11% absolute risk reduction in the rate of reoperation (17% vs 6%, p = 0.033), with a number needed to treat of 9.2. There were no significant differences in age, sex, upper instrumented vertebra, or number of levels fused in patients who received BMP. In a multivariate model including age, sex, number of levels fused, and the upper instrumented vertebra, only BMP (OR 0.250, 95% CI 0.078-0.797; p = 0.019) was associated with revision surgery for pseudarthrosis. The mean direct cost of primary surgery was $87,653 ± $19,879, and the mean direct cost of BMP was $10,444 ± $4607. The mean direct cost of revision surgery was $52,153 ± $26,985. The authors independently varied the efficacy of BMP, cost of BMP, and cost of reoperation by ± 50%; only reductions in the cost of BMP resulted in a cost savings per 100 patients. Using these data, the authors estimated a price point of $5663 in order for BMP to be cost-neutral. CONCLUSIONS Use of BMP was associated with a significant reduction in the rates of revision surgery for pseudarthrosis. At its current price, the direct in-hospital costs for BMP exceed the costs associated with revision surgery; however, this likely underestimates the true value of BMP when considering the savings associated with reductions in rehabilitation, therapy, medication, and additional outpatient costs.
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Affiliation(s)
| | | | - Corinna C Zygourakis
- 2Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Vedat Deviren
- 3Orthopedic Surgery, University of California, San Francisco, California; and
| | - Christopher P Ames
- Departments of1Neurological Surgery and
- 3Orthopedic Surgery, University of California, San Francisco, California; and
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14
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Kennamer BT, Arginteanu MS, Moore FM, Steinberger AA, Yao KC, Gologorsky Y. Complications of Poor Cervical Alignment in Patients Undergoing Posterior Cervicothoracic Laminectomy and Fusion. World Neurosurg 2019; 122:e408-e414. [DOI: 10.1016/j.wneu.2018.10.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/06/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022]
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15
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Hofler RC, Swong K, Martin B, Wemhoff M, Jones GA. Risk of Pseudoarthrosis After Spinal Fusion: Analysis From the Healthcare Cost and Utilization Project. World Neurosurg 2018; 120:e194-e202. [DOI: 10.1016/j.wneu.2018.08.026] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/03/2018] [Accepted: 08/05/2018] [Indexed: 11/29/2022]
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16
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Koller H, Ames C, Mehdian H, Bartels R, Ferch R, Deriven V, Toyone H, Shaffrey C, Smith J, Hitzl W, Schröder J, Robinson Y. Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:324-344. [PMID: 30483961 DOI: 10.1007/s00586-018-5835-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/25/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND PURPOSE Little information exists on surgical characteristics, complications and outcomes with corrective surgery for rigid cervical kyphosis (CK). To collate the experience of international experts, the CSRS-Europe initiated an international multi-centre retrospective study. METHODS Included were patients at all ages with rigid CK. Surgical and patient specific characteristics, complications and outcomes were studied. Radiographic assessment included global and regional sagittal parameters. Cervical sagittal balance was stratified according to the CSRS-Europe classification of sagittal cervical balance (types A-D). RESULTS Eighty-eight patients with average age of 58 years were included. CK etiology was ankylosing spondlitis (n = 34), iatrogenic (n = 25), degenerative (n = 9), syndromatic (n = 6), neuromuscular (n = 4), traumatic (n = 5), and RA (n = 5). Blood loss averaged 957 ml and the osteotomy grade 4.CK-correction and blood loss increased with osteotomy grade (r = 0.4/0.6, p < .01). Patients with different preop sagittal balance types had different approaches, preop deformity parameters and postop alignment changes (e.g. C7-slope, C2-7 SVA, translation). Correction of the regional kyphosis angle (RKA) was average 34° (p < .01). CK-correction was increased in patients with osteoporosis and osteoporotic vertebrae (POV, p = .006). 22% of patients experienced a major long-term complication and 14% needed revision surgery. Patients with complications had larger preop RKA (p = .01), RKA-change (p = .005), and postop increase in distal junctional kyphosis angle (p = .02). The POV-Group more often experienced postop complications (p < .0001) and revision surgery (p = .02). Patients with revision surgery had a larger RKA-change (p = .003) and postop translation (p = .04). 21% of patients had a postop segmental motor deficit and the risk was elevated in the POV-Group (p = .001). CONCLUSIONS Preop patient specific, radiographic and surgical variables had a significant bearing on alignment changes, outcomes and complication occurrence in the treatment of rigid CK.
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Affiliation(s)
- H Koller
- Spine and Scoliosis Center, Schön Klinik Vogtareuth, Krankenhausstrasse 20, 83569, Vogtareuth, Germany. .,Department for Trauma and Sports Injuries, Paracelsus Medical University, Salzburg, Austria.
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17
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Wilson PJ, Selby MD. C7 intra-laminar screws for complex cervicothoracic spine surgery-a case series. JOURNAL OF SPINE SURGERY 2018; 3:561-566. [PMID: 29354732 DOI: 10.21037/jss.2017.10.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background C7 has relatively unique anatomy compared to the remainder of the subaxial cervical spine (C3-C6) and upper thoracic spine. The C7 laminar has been previously reported in feasibility and biomechanical studies as an adequate fixation point in contrast to the lateral mass or pedicles, with few reports of its use in clinical practice. The purpose of this study was to review the safety and efficacy of using the C7 laminar as a fixation point in constructs involving the cervical spine and cervicothoracic junction. Methods Between February 2013 and July 2016, 10 patients (6 males, 4 females) had 19 C7 intra-laminar screws sited (bilateral in 9 patients, unilateral in 1 patient). Six patients had trauma as an underlying etiology, 2 of which had pseudoarthrosis from prior surgery. Three patients had cervical myelopathy from degenerative disease, 2 of which required anterior and posterior instrumentation for correction of deformity and 1 which had stand-alone posterior fixation. One patient had stabilization for an underlying malignancy. Results One patient died 2 weeks following their high cervical injury secondary to complications of respiratory failure. None of the remaining 9 patients were noted to have construct failure at a median follow up of 1 year (range, 6 months to 4 years) and all were noted to have satisfactory positioning of the instrumentation on post-operative imaging. The patient with malignancy died 6 months later from extra-spinal disease, there was one wound breakdown requiring debridement without infection in a revision case, and one patient required laminectomy for post-traumatic syrinx formation. Conclusions The C7 laminar provides an alternative fixation point for constructs involving the subaxial cervical spine and cervicothoracic junction, with excellent safety and efficacy in this small series. Larger series are required to more clarify the risk profile of this technique.
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Affiliation(s)
- Peter John Wilson
- Department of Neurosurgery, Prince of Wales Public and Private Hospitals, Sydney, Australia
| | - Michael Derrick Selby
- Department of Orthopaedics, Royal Adelaide Hospital, Adelaide, Australia.,Women's and Children's Hospital, Adelaide, Australia.,Queen Elizabeth Hospital, Adelaide, Australia.,Calvary-Wakefield Hospital, Adelaide, Australia.,St Andrew's Hospital, Adelaide, Australia.,Memorial Hospital, Adelaide, Australia
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18
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Kleinhenz DT, Eltorai AEM, Huo S, Daniels AH. Traumatic cervical epidural hematoma due to fusion mass fracture following elective rod removal. J Orthop 2017; 14:548-549. [PMID: 28878514 DOI: 10.1016/j.jor.2017.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 04/18/2017] [Accepted: 07/30/2017] [Indexed: 11/26/2022] Open
Abstract
Many studies have examined complications associated with spinal instrumentation, however, few have analyzed complications associated with removal. In this case report, we outline the course of a patient who presented with cervical epidural hematoma secondary to fusion mass fracture five years after removal of spinal hardware.
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Affiliation(s)
- Dominic T Kleinhenz
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Adam E M Eltorai
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Stephen Huo
- Division of Spine Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan H Daniels
- Division of Spine Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
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19
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Schroeder GD, Kepler CK, Kurd MF, Mead L, Millhouse PW, Kumar P, Nicholson K, Stawicki C, Helber A, Fasciano D, Patel AA, Woods BI, Radcliff KE, Rihn JA, Anderson DG, Hilibrand AS, Vaccaro AR. Is It Necessary to Extend a Multilevel Posterior Cervical Decompression and Fusion to the Upper Thoracic Spine? Spine (Phila Pa 1976) 2016; 41:1845-1849. [PMID: 27898600 DOI: 10.1097/brs.0000000000001864] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort analysis. OBJECTIVE The aim of this study was to determine if there is a difference in the revision rate in patients who undergo a multilevel posterior cervical fusions ending at C7, T1, or T2-T4. SUMMARY OF BACKGROUND DATA Multilevel posterior cervical decompression and fusion is a common procedure for patients with cervical spondylotic myelopathy, but there is little literature available to help guide the surgeon in choosing the caudal level of a multilevel posterior cervical fusion. METHODS Patients who underwent a three or more level posterior cervical fusion with at least 1 year of clinical follow-up were identified. Patients were separated into three groups on the basis of the caudal level of the fusion, C7, T1, or T2-T4, and the revision rate was determined. In addition, the C2-C7 lordosis and the C2-C7 sagittal vertical axis (SVA) was recorded for patients with adequate radiographic follow-up at 1 year. RESULTS The overall revision rate was 27.8% (61/219 patients); a significant difference in the revision rates was identified between fusions terminating at C7, T1, and T2-T4 (35.3%, 18.3%, and 40.0%, P = 0.008). When additional variables were taken into account utilizing multivariate linear regression modeling, patients whose construct terminated at C7 were 2.29 (1.16-4.61) times more likely to require a revision than patients whose construct terminated at T1 (P = 0.02), but no difference between stopping at T1 and T2-T4 was identified. CONCLUSION Multilevel posterior cervical fusions should be extended to T1, as stopping a long construct at C7 increases the rate of revision. LEVEL OF EVIDENCE 3.
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Affiliation(s)
| | | | - Mark F Kurd
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Loren Mead
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Paul W Millhouse
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Priyanka Kumar
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Kristen Nicholson
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Christie Stawicki
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Andrew Helber
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Daniella Fasciano
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alpesh A Patel
- The Northwestern University Feinberg School of Medicine, Department of Orthopaedic Surgery, Chicago, IL
| | - Barret I Woods
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Kris E Radcliff
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jeffery A Rihn
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - D Greg Anderson
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alan S Hilibrand
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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20
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Guppy KH, Harris J, Chen J, Paxton EW, Bernbeck JA. Reoperation rates for symptomatic nonunions in posterior cervicothoracic fusions with and without bone morphogenetic protein in a cohort of 450 patients. J Neurosurg Spine 2016; 25:309-17. [DOI: 10.3171/2016.1.spine151330] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Fusions across the cervicothoracic junction have been challenging because of the large biomechanical forces exerted resulting in frequent reoperations for nonunions. The objective of this study was to investigate a retrospective cohort using chart review of posterior cervicothoracic spine fusions with and without bone morphogenetic protein (BMP) and to determine the reoperation rates for symptomatic nonunions in both groups.
METHODS
Between January 2009 and September 2013, posterior cervicothoracic spine fusion cases were identified from a large spine registry (Kaiser Permanente). Demographics, diagnoses, operative times, lengths of stay, and reoperations were extracted from the registry. Reoperations for symptomatic nonunions were adjudicated via chart review. Logistic regression was used to estimate odds ratios and 95% confidence intervals. Kaplan-Meier curves for the non-BMP and BMP groups were generated and compared using the log-rank test.
RESULTS
In this cohort there were 450 patients (32.7% with BMP) with a median follow-up of 1.4 years (interquartile range [IQR] 0.5–2.7 years). Kaplan-Meier curves showed no significant difference in reoperation rates for nonunions using the log-rank test (p = 0.088). In a subset of patients with more than 1 year of follow-up, 260 patients were identified (43.1% with BMP) with a median follow-up duration of 2.4 years (IQR 1.6–3.3 years). There was no statistically significant difference in the symptomatic operative nonunion rates for posterior cervicothoracic fusions with and without BMP (0.0% vs 2.7%, respectively; p = 0.137) for more than 1 year of follow-up.
CONCLUSIONS
This study presents the largest series of patients using BMP in posterior cervicothoracic spine fusions. Reoperation rates for symptomatic nonunions with more than 1 year of follow-up were 0% with BMP and 2.7% without BMP. No statistically significant difference in the reoperation rates for symptomatic nonunions with or without BMP was found.
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Affiliation(s)
- Kern H. Guppy
- 1Department of Neurosurgery, Kaiser Permanente Medical Group, Sacramento
| | - Jessica Harris
- 2Surgical Outcomes & Analysis Unit of Clinical Analysis, Kaiser Permanente, San Diego; and
| | - Jason Chen
- 2Surgical Outcomes & Analysis Unit of Clinical Analysis, Kaiser Permanente, San Diego; and
| | - Elizabeth W. Paxton
- 2Surgical Outcomes & Analysis Unit of Clinical Analysis, Kaiser Permanente, San Diego; and
| | - Johannes A. Bernbeck
- 3Department of Orthopaedics, Kaiser Permanente Southern California, Baldwin Park, California
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