Optimizing surgical management of facet cysts of the lumbar spine: systematic review, meta-analysis, and local case series of 1251 patients

OBJECTIVE

Lumbar facet cysts (LFCs) can cause neurological dysfunction and intractable pain. Surgery is the current standard of care for patients in whom conservative therapy fails, those with neurological deficits, and those with evidence of spinal instability. No study to date has comprehensively examined surgical outcomes comparing the multiple surgical treatment options for LFCs. Therefore, the authors aimed to perform a combined analysis of cases both in the literature and of patients at a single institution to compare the outcomes of various surgical treatment options for LFC.

METHODS

The authors performed a literature review in accordance with PRISMA guidelines and meta-analysis of the PubMed, Embase, and Cochrane Library databases and reviewed all studies from database inception published until February 3, 2023. Studies that did not contain 3 or more cases, clearly specify follow-up durations longer than 6 months, or present new cases were excluded. Bias was evaluated using Cochrane Collaboration's Risk of Bias in Nonrandomised Studies-of Interventions (ROBINS-I). The authors also reviewed their own local institutional case series from 2015 to 2020. Primary outcomes were same-level cyst recurrence, same-level revision surgery, and perioperative complications. ANOVA, common and random-effects modeling, and Wald testing were used to compare treatment groups.

RESULTS

A total of 1251 patients were identified from both the published literature (29 articles, n = 1143) and the authors' institution (n = 108). Patients were sorted into 5 treatment groups: open cyst resection (OCR; n = 720), tubular cyst resection (TCR; n = 166), cyst resection with arthrodesis (CRA; n = 165), endoscopic cyst resection (ECR; n = 113), and percutaneous cyst rupture (PCR; n = 87), with OCR being the analysis reference group. The PCR group had significantly lower complication rates (p = 0.004), higher recurrence rates (p < 0.001), and higher revision surgery rates (p = 0.001) compared with the OCR group. Patients receiving TCR (3.01%, p = 0.021) and CRA (0.0%, p < 0.001) had significantly lower recurrence rates compared with those undergoing OCR (6.36%). The CRA group (6.67%) also had significantly lower rates of revision surgery compared with the OCR group (11.3%, p = 0.037).

CONCLUSIONS

While PCR is less invasive, it may have high rates of same-level recurrence and revision surgery. Recurrence and revision rates for modalities such as ECR were not significantly different from those of OCR. While concomitant arthrodesis is more invasive, it might lead to lower recurrence rates and lower rates of subsequent revision surgery. Given the limitations of our case series and literature review, prospective, randomized studies are needed.

Influence of socioeconomic factors on discharge disposition following traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

BACKGROUND

Discharge to acute rehabilitation is strongly correlated with functional recovery after traumatic injury, including spinal cord injury (SCI). However, services such as acute care rehabilitation and Skilled Nursing Facilities (SNF) are expensive. Our objective was to understand if high-cost, resource-intensive post-discharge rehabilitation or alternative care facilities are utilized at disparate rates across socioeconomic groups after SCI.

METHODS

We performed a cohort analysis using the National Trauma Data Bank® tabulated from 2012-2016. Eligible patients had a diagnosis of cervical or thoracic spine fracture with spinal cord injury (SCI) and were treated surgically. We evaluated associations of sociodemographic and psychosocial variables with non-home discharge (e.g., discharge to SNF, other healthcare facility, or intermediate care facility) via multivariable logistic regression while correcting for injury severity and hospital characteristics.

RESULTS

We identified 3933 eligible patients. Patients who were older, male (OR=1.29 95% Confidence Interval [1.07-1.56], p=.007), insured by Medicare (OR=1.45 [1.08-1.96], p=.015), diagnosed with a major psychiatric disorder (OR=1.40 [1.03-1.90], p=.034), had a higher Injury Severity Score (OR=5.21 [2.96-9.18], p<.001) or a lower Glasgow Coma Score (3-8 points, OR=2.78 [1.81-4.27], p<.001) had a higher chance of a non-home discharge. The only sociodemographic variable associated with lower likelihood of utilizing additional healthcare facilities following discharge was uninsured status (OR=0.47 [0.37-0.60], p<.001).

CONCLUSIONS

Uninsured patients are less likely to be discharged to acute rehabilitation or alternative healthcare facilities following surgical management of SCI. High out-of-pocket costs for uninsured patients in the United States may deter utilization of these services.

Influence of Sociodemographic and Psychosocial Factors on Length of Stay After Surgical Management of Traumatic Spine Fracture with Spinal Cord Injury

OBJECTIVE

Identifying patients at risk of increased health care resource utilization is a valuable opportunity to develop targeted preoperative and perioperative interventions. In the present investigation, we sought to examine patient sociodemographic factors that predict prolonged length of stay (LOS) after traumatic spine fracture.

METHODS

We performed a cohort analysis using the National Trauma Data Bank tabulated during 2012-2016. Eligible patients were those who were diagnosed with cervical or thoracic spine fracture with spinal cord injury and who were treated surgically. We evaluated the effects of sociodemographic as well as psychosocial variables on LOS by negative binomial regression and adjusted for injury severity, injury mechanism, and hospital characteristics.

RESULTS

We identified 3856 eligible patients with a median LOS of 9 days (interquartile range, 6-15 days). Patients in older age categories, who were male (incidence rate ratio (IRR), 1.05; 95% confidence interval [CI], 1.01-1.09), black (IRR, 1.12; CI, 1.05-1.19) or Hispanic (IRR, 1.09; CI, 1.03-1.16), insured by Medicaid (IRR, 1.24; CI, 1.17-1.31), or had a diagnosis of alcohol use disorder (IRR, 1.12; CI, 1.06-1.18) were significantly more likely to have a longer LOS. In addition, patients with severe injury on Injury Severity Score (IRR, 1.32; CI, 1.14-1.53) and lower Glasgow Coma Scale (GCS) scores (GCS score 3-8, IRR, 1.44; CI, 1.35-1.55; GCS score 9-11, IRR, 1.40; CI, 1.25-1.58) on admission had a significantly lengthier LOS. Patients admitted to a hospital in the Southern United States (IRR, 1.09; CI, 1.05-1.14) had longer LOS.

CONCLUSIONS

Socioeconomic factors such as race, insurance status, and alcohol use disorder were associated with a prolonged LOS after surgical management of traumatic spine fracture with spinal cord injury.

Awake, Transforaminal Endoscopic Lumbar Decompression Surgery to Treat L5-S1 Adjacent Segment Disease: A Case Series

BACKGROUND

Lumbar radiculopathy secondary to L5-S1 degenerative changes adjacent to a lumbar fusion usually requires extending the fusion to include the degenerative L5-S1 level; this revision surgery can often be a very invasive procedure.

OBJECTIVE

To describe outcomes of awake, transforaminal endoscopic decompression surgery for patients presenting with lumbar radiculopathy as a result of L5-S1 degenerative disc disease below lumbar fusions.

STUDY DESIGN

Retrospective chart review.

METHODS

Awake, endoscopic decompression surgery was performed in 538 patients over a 5-year period from 2014 through 2019 by a single surgeon at a single institution.  The records of 18 consecutive patients who underwent transforaminal lumbar endoscopic decompression surgery to treat radiculopathy secondary to L5-S1 adjacent segment disease were retrospectively reviewed. All included patients were followed for at least 2 years after surgery. All patients were treated at L5-S1 and had fusion constructs that ended at L5.

RESULTS

Thirteen men and 5 women patients ranging in age from 38 to 83 (average age of 68.9 ± 11.5) were treated for symptomatic adjacent segment disease at L5-S1 during the 5-year time period. Surgery was successful in all cases, except 2 patients (11%) at 2 years follow-up had recurrent symptomatic pathology at L5-S1 and required additional surgical treatment. The average preoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were 7.5(± 1.3) and 45.3 (± 12.3) respectively. The average 2-year postoperative VAS and ODI scores were 2.4 (± 1.5) and 22.5 (± 9.6) respectively, excluding the 2 patients with recurrent pathology. The average body mass index (BMI) and L5-S1 disc height in the 2-year successful group (n = 16) were 30.6 (± 7.4) and 8.7 mm (± 3.5 mm) respectively; the average BMI and L5-S1 disc height in the 2-year failure group (n = 2) were 25.8 (± 5.9) and 7.9 (± 2.6) respectively.

LIMITATIONS

This was a retrospective case series.

CONCLUSIONS

Endoscopic spine surgery offers patients with fusions that terminate at L5 a safe and effective option for treatment of lumbar degenerative spine disease at L5-S1 below their fusion constructs. A longer follow-up and a larger prospective study would be necessary to consider the utility of endoscopic compression versus extending the fusion construct.

Foraminal Access Strategies in Patients with Lumbar Posterolateral Fusions in Transforaminal Endoscopic Spine Surgery: Case Series and Technical Note

BACKGROUND

The treatment of post-laminectomy lumbar radiculopathy in the setting of a large posterolateral fusion mass presents an anatomic challenge to the spine interventionalist.

OBJECTIVE

To describe outcomes of awake, transforaminal endoscopic surgical treatment for patients presenting with lumbar radiculopathy after instrumented posterolateral lumbar fusions.

STUDY DESIGN

Retrospective chart review.

SETTING

This study took place in a single-center, academic hospital.

METHODS

The records of 538 patients who underwent awake transforaminal lumbar endoscopic decompression surgery performed by a single surgeon at a single institution between 2014 and 2019 were retrospectively reviewed. Fifteen consecutive patients who required drilling through their posterolateral fusion masses to access the post-fusion foraminal stenosis were included in this study. All included patients were followed for at least one year after surgery.

RESULTS

Fifteen patients (7 male and 8 female) with an average age of 68.1 years (range 38-89, standard deviation 13.4 years) underwent awake transforaminal foraminal decompression surgeries that utilized special techniques to drill through large posterolateral fusion masses to access their foraminal stenosis. One patient (7%) required repeat surgery in the postoperative period due to lack of surgical improvement. For the remaining 14 patients, at one year follow up, the preoperative visual analog scale (VAS) for leg pain and Oswestry disability index (ODI) improved from 7.0 (± 1.7) and 40.7% (± 12.9) to 1.7 (± 1.6) and 12.1% (± 11.3). There were no complications such as infection, durotomy, or neurologic injury.

LIMITATIONS

Retrospective case series.

CONCLUSION

Transforaminal endoscopic spine surgery offers a unique approach to post-laminectomy and post-fusion foraminal compression because it avoids scar tissue resulting from previous posterior approaches. Large posterolateral fusion masses associated with some posterior fusions can be a sizeable bony barrier to transforaminal access. The authors share their techniques and success for navigating large posterior, bony fusion masses in transforaminal post-fusion foraminal decompression.

Awake, Transforaminal Endoscopic Lumbar Spine Surgery in Octogenarians: Case Series

BACKGROUND

Optimal approaches for treating surgical spine pathology in very geriatric patients, such as those over the age of 80, remain unclear.

OBJECTIVE

To describe outcomes of awake, transforaminal endoscopic surgical treatment for patients 80 years old and older presenting with lumbar radiculopathy.

STUDY DESIGN

Retrospective case review.

METHODS

The records of 52 consecutive patients who underwent awake transforaminal lumbar endoscopic decompression surgery performed by a single surgeon at a single institution between 2014 and 2019 were retrospectively reviewed. All included patients were followed for at least one year after surgery.

RESULTS

Transforaminal surgeries performed were discectomies (21), foraminotomies (7), redo foraminotomies post-laminectomy (5), fusion explorations (13), facet cyst resections (3), spondylolisthesis decompressions (2), and a decompression for metastatic disease (1). Seven patients (13.5%) required repeat surgery at the treated level during the one-year follow-up. For the remaining 45 patients, at one-year follow-up, preoperative visual analog scale (VAS) for leg pain and Oswestry disability index (ODI) improved from 6.9 (± 1.4) and 40.5% (± 11.5) to 1.8 (± 1.4) and 12.0% (± 10.8), respectively. The only complication of the procedure was a single durotomy (2%).

LIMITATIONS

Single-center, retrospective case review with a relatively small number of cases with diverse clinical pathology. A multi-center case study with a larger number of patients with a more homogeneous case pathology would be more revealing.

CONCLUSIONS

Endoscopic spine surgery offers octogenarians a safe and effective option for the treatment of lumbar degenerative spine disease and may represent a valuable treatment strategy in a growing patient population.

Influence of psychosocial and sociodemographic factors in the surgical management of traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

Background

Socioeconomic factors can bias clinician decision-making in many areas of medicine. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, and major psychiatric disorder are emerging as potential sources of conscious and unconscious bias. We hypothesized that these psychosocial factors, in addition to socioeconomic factors, may impact the decision to operate on patients with a traumatic cervicothoracic fracture and associated spinal cord injury (SCI).

Methods

We performed a cohort analysis using clinical data from 2012-2016 in the American College of Surgeons (ACS) National Trauma Data Bank at academic level I and II trauma centers. Patients were eligible if they had a diagnosis of cervicothoracic fracture with SCI. Using ICD codes, we evaluated baseline characteristics including race; insurance status; diagnosis of alcoholism, substance abuse, or major psychiatric disorder; admission drug screen and blood alcohol level; injury characteristics and severity; and hospital characteristics including geographic region, non-profit status, university affiliation, and trauma level. Factors significantly associated with surgical intervention in univariate analysis were eligible for inclusion in multivariate logistic regression.

Results

We identified 6,655 eligible patients, of whom 62% underwent surgical treatment (n=4,137). Patients treated non-operatively were more likely to be older; be female; be Black or Hispanic; have Medicare, Medicaid, or no insurance; have been assaulted; have been injured by a firearm; have thoracic fracture; have less severe injuries; have severe TBI; be treated at non-profit hospitals; and be in the Northeast or Western U.S. (all P<0.01). After adjusting for confounders in multivariate analysis, only insurance status remained associated with operative treatment. Medicaid patients (OR=0.81; P=0.021) and uninsured patients (OR=0.63; P<0.001) had lower odds of surgery relative to patients with private insurance. Injury severity and facility characteristics also remained significantly associated with surgical management following multivariate regression.

Conclusions

Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, or psychiatric illness do not appear to bias the decision to operate after traumatic cervicothoracic fracture with SCI. Baseline sociodemographic imbalances were explained largely by insurance status, injury, and facility characteristics in multivariate analysis.

Supplementation of Screw-Rod C1-C2 Fixation With Posterior Arch Femoral Head Allograft Strut

BACKGROUND

Numerous C1-C2 fixation techniques exist for the treatment of atlantoaxial instability. Limitations of screw-rod and sublaminar wiring techniques include C2 nerve root sacrifice and dural injury, respectively. We present a novel technique that utilizes a femoral head allograft cut with a keyhole that rests posteriorly on the arches of C1 and C2 and straddles the C2 spinous process, secured by sutures.

OBJECTIVE

To offer increased fusion across C1-C2 without the passage of sublaminar wiring or interarticular arthrodesis.

METHODS

A total of 6 patients with atlantoaxial instability underwent C1-C2 fixation using our method from 2015 to 2016. After placement of a C1-C2 screw/rod construct, a cadaveric frozen femoral head allograft was cut into a half-dome with a keyhole and placed over the already decorticated dorsal C1 arch and C2 spinous process. Notches were created in the graft and sutures were placed in the notches and around the rods to secure it firmly in place.

RESULTS

The femoral head's shape allowed for creation of a graft that provides excellent surface area for fusion across C1-C2. There were no intraoperative complications, including dural tears. Postoperatively, no patients had sensorimotor deficits, pain, or occipital neuralgia. 5 patients demonstrated clinical resolution of symptoms by 3 mo and radiographic (computed tomography) evidence of fusion at 1 yr. One patient had good follow-up at 1 mo but died due to complications of Alzheimer disease.

CONCLUSION

The posterior arch femoral head allograft strut technique with securing sutures is a viable option for supplementing screw-rod fixation in the treatment of complex atlantoaxial instability.

Existing clinical evidence on the use of cellular bone matrix grafts in spinal fusion: updated systematic review of the literature

OBJECTIVE

Spinal fusion surgery is increasingly common; however, pseudarthrosis remains a common complication affecting as much as 15% of some patient populations. Currently, no clear consensus on the best bone graft materials to use exists. Recent advances have led to the development of cell-infused cellular bone matrices (CBMs), which contain living components such as mesenchymal stem cells (MSCs). Relatively few clinical outcome studies on the use of these grafts exist, although the number of such studies has increased in the last 5 years. In this study, the authors aimed to summarize and critically evaluate the existing clinical evidence on commercially available CBMs in spinal fusion and reported clinical outcomes.

METHODS

The authors performed a systematic search of the MEDLINE and PubMed electronic databases for peer-reviewed, English-language original articles (1970-2020) in which the articles' authors studied the clinical outcomes of CBMs in spinal fusion. The US National Library of Medicine electronic clinical trials database (www.ClinicalTrials.gov) was also searched for relevant ongoing clinical trials.

RESULTS

Twelve published studies of 6 different CBM products met inclusion criteria: 5 studies of Osteocel Plus/Osteocel (n = 354 unique patients), 3 of Trinity Evolution (n = 114), 2 of ViviGen (n = 171), 1 of map3 (n = 41), and 1 of VIA Graft (n = 75). All studies reported high radiographic fusion success rates (range 87%-100%) using these CBMs. However, this literature was overwhelmingly limited to single-center, noncomparative studies. Seven studies disclosed industry funding or conflicts of interest (COIs). There are 4 known trials of ViviGen (3 trials) and Bio4 (1 trial) that are ongoing.

CONCLUSIONS

CBMs are a promising technology with the potential of improving outcome after spinal fusion. However, while the number of studies conducted in humans has tripled since 2014, there is still insufficient evidence in the literature to recommend for or against CBMs relative to cheaper alternative materials. Comparative, multicenter trials and outcome registries free from industry COIs are indicated.

A transpedicular approach to complex ventrally situated thoracic intradural extramedullary tumors: technique, indications, and multiinstitutional case series

OBJECTIVE

Ventrally situated thoracic intradural extramedullary tumors are surgically challenging and difficult to access, and they may be complicated by extensive adhesions and calcifications. Selecting an approach for adequate ventral access is key to complete resection and optimization of outcomes. The authors present a case series of patients who underwent resection of ventral thoracic intradural extramedullary tumors and discuss indications and considerations for this technique. Additionally, they describe the use of a posterolateral transpedicular approach for resection of ventral thoracic intradural extramedullary tumors compared with other techniques, and they summarize the literature supporting its application.

METHODS

From May 2017 to August 2020, 5 patients with ventral thoracic intradural extramedullary tumors underwent resection at one of the two academic institutions.

RESULTS

Patient ages ranged from 47 to 75 (mean 63.4) years. All tumors were diagnosed as meningiomas or schwannomas by histological examination. Three of the 5 patients had evidence of partial or extensive tumor calcification. Four of the 5 patients underwent an initial posterolateral transpedicular approach for resection, with positive radiographic and clinical outcomes from surgery. One patient initially underwent an unsuccessful traditional direct posterior approach and required additional resection 2 years later after interval disease progression. There were no postoperative wound infections, CSF leaks, or other complications related to the transpedicular approach.

CONCLUSIONS

Posterolateral transpedicular tumor resection is a safe technique for the treatment of complex ventrally situated thoracic intradural extramedullary tumors compared with the direct posterior approach. Anecdotally, this approach appears to be particularly beneficial in patients with calcified tumors.

A minimally invasive lateral approach with CT navigation for open biopsy and diagnosis of Nocardia nova L4–5 discitis osteomyelitis: illustrative case

BACKGROUND

Lumbar spine osteomyelitis can be refractory to conventional techniques for identifying a causal organism. In cases in which a protracted antibiotic regimen is indicated, obtaining a conclusive yield on biopsy is particularly important. Although lateral transpsoas approaches and intraoperative computed tomography (CT) navigation are well documented as techniques used for spinal arthrodesis, their utility in vertebral biopsy has yet to be reported in any capacity.

OBSERVATIONS

In a 44-year-old male patient with a history of Nocardia bacteremia, CT-guided biopsy failed to confirm the microbiology of an L4–5 discitis osteomyelitis. The patient underwent a minimally invasive open biopsy in which a lateral approach with intraoperative guidance was used to access the infected disc space retroperitoneally. A thin film was obtained and cultured Nocardia nova, and the patient was treated accordingly with a long course of trimethoprim-sulfamethoxazole.

LESSONS

The combination of a lateral transpsoas approach with intraoperative navigation is a valuable technique for obtaining positive yield in cases of discitis osteomyelitis of the lumbar spine refractory to CT-guided biopsy.

A modern multidisciplinary approach to a large cervicothoracic chordoma using staged en bloc resection with intraoperative image-guided navigation and 3D-printed modeling: illustrative case

BACKGROUND

Cervicothoracic junction chordomas are uncommon primary spinal tumors optimally treated with en bloc resection. Although en bloc resection is the gold standard for treatment of mobile spinal chordoma, tumor location, size, and extent of involvement frequently complicate the achievement of negative margins. In particular, chordoma involving the thoracic region can require a challenging anterior access, and en bloc resection can lead to a highly destabilized spine.

OBSERVATIONS

Modern technological advances make en bloc resection more technically feasible than ever before. In this case, the successful en bloc resection of a particularly complex cervicothoracic junction chordoma was facilitated by a multidisciplinary surgical approach that maximized the use of intraoperative computed tomography–guided spinal navigation and patient-specific three-dimensional–printed modeling.

LESSONS

The authors review the surgical planning and specific techniques that facilitated the successful en bloc resection of this right-sided chordoma via image-guided parasagittal osteotomy across 2 stages. The integration of emerging visualization technologies into complex spinal column tumor management may help to provide optimal oncological care for patients with challenging primary tumors of the mobile spine.

Two-Level Separation Surgery for Thoracic Epidural Metastatic Disease: An Operative Video Demonstration

The spinal column is one of the most common regions of cancer metastasis. Spinal metastases typically occur in the vertebral body, and due to direct posterior extension or retropulsed pathological fractures, they often present with signs and symptoms of epidural spinal cord compression. This scenario requires surgical management to relieve compression and stabilize the spine. Separation surgery establishes a corridor to the ventral epidural space via pediculectomy, which allows for circumferential decompression and creation of a tumor-free margin around the thecal sac. Separation surgery is an increasingly popular method for the management of spinal metastases, particularly due to potentially reduced morbidity versus en bloc tumor resection, and its proven effectiveness when combined with spinal radiosurgery. Thus, separation surgery should be considered in patients with high-grade metastatic ventral epidural spinal cord compression. In this video, we present the case of a 61-year-old woman with metastatic hepatocellular carcinoma found to have severe spinal cord compression due to pathological vertebral body fractures at T10-T12, and ventral epidural disease at T10 and T12. The patient received T8-L2 posterior instrumented fusion and T10 and T12 separation surgery, with intraoperative cement embolization. We demonstrate the operative steps required to complete this procedure (Video 1).

Three-Dimensional Printed Anatomic Modeling for Surgical Planning and Real-Time Operative Guidance in Complex Primary Spinal Column Tumors: Single-Center Experience and Case Series

OBJECTIVE

Three-dimensional (3D) printing has emerged as a visualization tool for clinicians and patients. We sought to use patient-specific 3D-printed anatomic modeling for preoperative planning and live intraoperative guidance in a series of complex primary spine tumors.

METHODS

Over 9 months, patients referred to a single neurosurgical provider for complex primary spinal column tumors were included. Most recent spinal magnetic resonance and computed tomography (CT) imaging were semiautomatically segmented for relevant anatomy and models were printed using polyjet multicolor printing technology. Models were available to surgical teams before and during the operative procedure. Patients also viewed the models preoperatively during surgeon explanation of disease and surgical plan to aid in their understanding.

RESULTS

Tumor models were prepared for 9 patients, including 4 with chordomas, 2 with schwannomas, 1 with osteosarcoma, 1 with chondrosarcoma, and 1 with Ewing-like sarcoma. Mean age was 50.7 years (range, 15-82 years), including 6 males and 3 females. Mean tumor volume was 129.6 cm³ (range, 3.3-250.0 cm³). Lesions were located at cervical, thoracic, and sacral levels and were treated by various surgical approaches. Models were intraoperatively used as patient-specific anatomic references throughout 7 cases and were found to be technically useful by the surgical teams.

CONCLUSIONS

We present the largest case series of 3D-printed spine tumor models reported to date. 3D-printed models are broadly useful for operative planning and intraoperative guidance in spinal oncology surgery.

Traumatic unilateral jumped facet joint in the upper thoracic spine: Case presentation and literature review

Background:

A jumped facet joint is defined by when the inferior articular process of the superior vertebra becomes locked anterior to the superior articular process of the inferior vertebra. These typically traumatic lesions are exceedingly rare in the thoracic spine. Here, we present a patient with a unilateral jumped facet joint in the upper thoracic spine treated with open reduction and an instrumented fusion.

Case Description:

A 45-year-old male presented after a significant motor vehicle accident. In the emergency room, he had a Glasgow Coma Score of 13 without any neurologic deficit. The thoracic computed tomography (CT) showed a significant jumped left facet at the T2-T3 level. Two days later, utilizing intraoperative CT-guided navigation and neuromonitoring, he underwent open reduction of the T2-T3 jumped facet plus an instrumented T1-T5 fusion. X-rays taken 3-month postoperatively showed a stable construct. Six months postoperatively, he remained neurologically intact.

Conclusion:

A unilateral jumped thoracic facet may be present in patients with fractured ribs. The mechanism of injury is most likely axial rotation. Both CT and magnetic resonance imaging studies allow for early detection of these very rare lesions and warrant open reduction and instrumented fusion.

Complex wound closure by plastic surgery following resection of spinal neoplasms minimizes postoperative wound complications in high-risk patients

OBJECTIVE

Wound breakdown and infection are common postoperative complications following resection of spinal neoplasms. Accordingly, it has become common practice at some centers for plastic surgeons to assist with closure of large posterior defects after spine tumor resection. In this study, the authors tested the hypothesis that plastic surgery closure of complex spinal defects improves wound outcomes following resection of spinal neoplastic disease.

METHODS

Electronic medical records of consecutive patients who underwent resection of a spinal neoplasm between June 2015 and January 2019 were retrospectively reviewed. Patients were separated into two subpopulations based on whether the surgical wound was closed by plastic surgery or neurosurgery. Patient demographics, preoperative risk factors, surgical details, and postoperative outcomes were collected in a central database and summarized using descriptive statistics. Outcomes of interest included rates of wound complication, reoperation, and mortality. Known preoperative risk factors for wound complication in spinal oncology were identified based on literature review and grouped categorically. The presence of each category of risk factors was then compared between groups. Univariate and multivariate linear regressions were applied to define associations between individual risk factors and wound complications.

RESULTS

One hundred six patients met inclusion criteria, including 60 wounds primarily closed by plastic surgery and 46 by neurosurgery. The plastic surgery population included more patients with systemic metastases (58% vs 37%, p = 0.029), prior radiation (53% vs 17%, p < 0.001), prior chemotherapy (37% vs 15%, p = 0.014), and sacral region tumors (25% vs 7%, p = 0.012), and more patients who underwent procedures requiring larger incisions (7.2 ± 3.6 vs 4.5 ± 2.6 levels, p < 0.001), prolonged operative time (413 ± 161 vs 301 ± 181 minutes, p = 0.001), and greater blood loss (906 ± 1106 vs 283 ± 373 ml, p < 0.001). The average number of risk factor categories present was significantly greater in the plastic surgery group (2.57 vs 1.74, p < 0.001). Despite the higher relative risk, the plastic surgery group did not experience a significantly higher rate of wound complication (28% vs 17%, p = 0.145), reoperation (17% vs 9%, p = 0.234), or all-cause mortality (30% vs 13%, p = 0.076). One patient died from wound-related complications in each group (p = 0.851). Regression analyses identified diabetes, multilevel instrumentation, and BMI as the factors associated with the greatest wound complications.

CONCLUSIONS

Involving plastic surgery in the closure of spinal wounds after resection of neoplasms may ameliorate expected increases in wound complications among higher-risk patients.

Validating the Transformation of PROMIS-GH to EQ-5D in Adult Spine Patients

Spinal disorders and associated interventions are costly in the United States, putting them in the limelight of economic analyses. The Patient-Reported Outcomes Measurement Information System Global Health Survey (PROMIS-GHS) requires mapping to other surveys for economic investigation. Previous studies have proposed transformations of PROMIS-GHS to EuroQol 5-Dimension (EQ-5D) health index scores. These models require validation in adult spine patients. In our study, PROMIS-GHS and EQ-5D were randomly administered to 121 adult spine patients. The actual health index scores were calculated from the EQ-5D instrument and estimated scores were calculated from the PROMIS-GHS responses with six models. Goodness-of-fit for each model was determined using the coefficient of determination (R²), mean squared error (MSE), and mean absolute error (MAE). Among the models, the model treating the eight PROMIS-GHS items as categorical variables (CAT_Reg) was the optimal model with the highest R² (0.59) and lowest MSE (0.02) and MAE (0.11) in our spine sample population. Subgroup analysis showed good predictions of the mean EQ-5D by gender, age groups, education levels, etc. The transformation from PROMIS-GHS to EQ-5D had a high accuracy of mean estimate on a group level, but not at the individual level.

Tubular approach to minimally invasive microdiscectomy for pediatric lumbar disc herniation

OBJECTIVE Lumbar disc herniation (LDH) in the pediatric population is rare and exhibits unique characteristics compared with adult LDH. There are limited data regarding the safety and efficacy of minimally invasive surgery (MIS) using tubular retractors in pediatric patients with LDH. Here, the outcomes of MIS tubular microdiscectomy for the treatment of pediatric LDH are evaluated. METHODS Twelve consecutive pediatric patients with LDH were treated with MIS tubular microdiscectomy at the authors' institution between July 2011 and October 2015. Data were gathered from retrospective chart review and from mail or electronic questionnaires. The Macnab criteria and the Oswestry Disability Index (ODI) were used for outcome measurements. RESULTS The mean age at surgery was 17 ± 1.6 years (range 13-19 years). Seven patients were female (58%). Prior to surgical intervention, 100% of patients underwent conservative treatment, and 50% had epidural steroid injections. Preoperative low-back and leg pain, positive straight leg raise, and myotomal leg weakness were noted in 100%, 83%, and 67% of patients, respectively. The median duration of symptoms prior to surgery was 9 months (range 1-36 months). The LDH level was L5-S1 in 75% of patients and L4-5 in 25%. The mean ± SD operative time was 90 ± 21 minutes, the estimated blood loss was ≤ 25 ml in 92% of patients (maximum 50 ml), and no intraoperative or postoperative complications were noted at 30 days. The median hospital length of stay was 1 day (range 0-3 days). The median follow-up duration was 2.2 years (range 0-5.8 years). One patient experienced reherniation at 18 months after the initial operation and required a second same-level MIS tubular microdiscectomy to achieve resolution of symptoms. Of the 11 patients seen for follow-up, 10 patients (91%) reported excellent or good satisfaction according to the Macnab criteria at the last follow-up. Only 1 patient reported a fair level of satisfaction by using the same criteria. Seven patients completed an ODI evaluation at the last follow-up. For these 7 patients, the mean ODI low-back pain score was 19.7% (SEM 2.8%). CONCLUSIONS To the authors' knowledge, this is the longest outcomes study and the largest series of pediatric patients with LDH who were treated with MIS microdiscectomy using tubular retractors. These data suggest that MIS tubular microdiscectomy is safe and efficacious for pediatric LDH. Larger prospective cohort studies with longer follow-up are needed to better evaluate the long-term efficacy of MIS tubular microdiscectomy versus other open and MIS techniques for the treatment of pediatric LDH.

Fungal infection of a ventriculoperitoneal shunt: histoplasmosis diagnosis and treatment

BACKGROUND

Histoplasmosis is a fungal disease caused by Histoplasma capsulatum, commonly found in the Americas, and Histoplasma duboisii, located in Africa. In the United States, H. capsulatum is prevalent in the Ohio and Mississippi river valleys. In rare circumstances, central nervous system (CNS) histoplasmosis infection can be caused by shunt placement. We present a case report of a 45-year-old woman in whom CNS histoplasmosis developed after having a ventriculoperitoneal (VP) shunt placed for communicating hydrocephalus. A review of the literature on fungal infections after CNS shunt placement as well as treatment options for this subset of patients was undertaken.

METHODS

The PubMed database current to 1958 was filtered and limited to English-language articles. Fifty-eight articles were selected for review based on evidence of information regarding the fungal organism responsible for shunt infection, symptoms, treatment, and/or outcomes. Also included in this review is our case study.

RESULTS

A thorough analysis of the PubMed database revealed 58 reported cases of CNS shunt-related fungal infections in the English-language medical literature as well as 7 therapeutic agents used to treat patients in whom postshunt fungal infections developed.

CONCLUSIONS

We describe the steps in diagnosis of histoplasmosis after shunt placement, provide an effective therapeutic regimen, and review the present understanding of CNS fungal infections. The medical literature was surveyed to compare and analyze various CNS fungal infections that can arise from shunt placement as well as treatments rendered.

Cervicomedullary decompression for foramen magnum stenosis in achondroplasia

OBJECT

Achondroplasia is the most common hereditary form of dwarfism, and is characterized by short stature, macrocephaly, and a myriad of skeletal abnormalities. In the pediatric population, stenosis and compression at the level of the cervicomedullary junction commonly occurs. The goal in this study was to assess the outcomes in children with achondroplasia who underwent cervicomedullary decompression.

METHODS

Forty-three pediatric patients with heterozygous achondroplasia and foramen magnum stenosis underwent 45 cervicomedullary decompressions at the authors' institution over an 11-year period. After surgical decompression, complete resolution or partial improvement in the preoperative symptoms was observed in all patients. There were no deaths in the treated patients. The surgical morbidity rate was low and usually consisted of a cerebrospinal fluid (CSF) leak in patients in whom the dura mater had been opened (either intentionally or accidentally). This problem was successfully managed in all cases with local measures (wound oversewing) or CSF diversion.

CONCLUSIONS

In this review the authors demonstrate that decompression of the cervicomedullary junction in the setting of achondroplasia may be accomplished safely with significant clinical benefit and minimal morbidity.