Prophylactic intraoperative powdered vancomycin and postoperative deep spinal wound infection: 1,512 consecutive surgical cases over a 6-year period

PURPOSE

The purpose of this study is to evaluate the effect of intraoperative powdered vancomycin on the rates of postoperative deep spinal wound infection. The use of intraoperative powdered vancomycin as a prophylactic measure in an attempt to reduce the incidence of postoperative spinal wound infection has not been sufficiently evaluated in the existing literature. A retrospective review of a large clinical database was performed to determine the rates of deep wound infection associated with the use of intraoperative operative site powdered vancomycin.

MATERIALS AND METHODS

During the period from 2005 to 2010, 1,512 consecutive spinal surgery cases were performed by the same fellowship-trained spinal surgeon (RWM) at a level 1 trauma-university medical center. One gram of powdered vancomycin was placed in all surgical sites prior to wound closure. Eight hundred forty-nine cases were uninstrumented, 478 cases were instrumented posterior thoracic or lumbar, 12 were instrumented anterior thoracic or lumbar, 126 were instrumented anterior cervical, and 47 were instrumented posterior cervical cases. Fifty-eight cases were combined anterior and posterior surgery and 87 were revision surgeries. A retrospective operative database and medical record review was performed to evaluate for evidence of postoperative deep wound infection.

RESULTS

15 of the 1,512 patients (0.99%) were identified as having evidence of postoperative deep wound infection. At least one pre-existing risk factor for deep infection was present in 8/15 pts (54%). Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) were the most commonly identified organisms (11/15 cases). The rate of deep wound infection was 1.20% (8/663) for instrumented spinal surgeries, and 0.82% (7/849) for uninstrumented surgeries. Deep infection occurred in only 1.23% (4/324) of multilevel instrumented posterior spinal fusions, 1.37% (1/73) of open PLIF procedures, and 1.23% (1/81) of single-level instrumented posterior fusions. Deep infection was not observed in any patient who had uninstrumented spinal fusion (0/64). The deep infection rate for revision surgeries was 1.15% (1/87) and 0.55% (1/183) for trauma surgery. Increased rates of complications related to powdered vancomycin use were not identified in this series. Conclusion In this series of 1,512 consecutive spinal surgeries, the use of 1 g of powdered intraoperative vancomycin placed in the wound prior to wound closure appears to associated with a low rate deep spinal wound infection for both instrumented and uninstrumented cases. Rates of deep infection for instrumented fusion surgery, trauma, and revision surgery appear to be among the lowest reported in the existing literature. Further investigation of this prophylactic adjunctive measure is warranted.

Complications in the surgical treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis. A comparison of three surgical approaches

STUDY DESIGN

An analysis of consecutive pediatric patients treated surgically for high-grade spondylolisthesis by one of three surgical procedures with emphasis on complications and functional outcomes.

OBJECTIVE

Complications, radiographic results and patient-assessed function, pain, and satisfaction were assessed among three surgical procedures.

SUMMARY OF BACKGROUND DATA

The existing literature is in disagreement about whether it is better to fuse without instrumented reduction or to use instrumentation and reduce high-grade dysplastic spondylolisthesis.

METHODS

Thirty-two patients had 37 surgical procedures for Meyerding Grade 3 or 4 isthmic dysplastic spondylolisthesis. Eleven patients were treated with an in situ L4-sacrum posterior fusion without decompression (Group 1), 7 had posterior decompression with posterior instrumentation and posterior fusion (Group 2), and 19 patients had reduction and a circumferential fusion procedure (Group 3). All patients had new radiographs taken at time of follow-up (average, 3.1 years; range, 2 years-10 years, 1 month) and completed a functional outcome questionnaire.

RESULTS

The incidence of pseudarthrosis was 45% (5 of 11) in Group 1, 29% (2 of 7) in Group 2, and 0% (0 of 19) in Group 3. All seven who had pseudarthrosis had small L5 transverse process surface area (< 2 cm2; P = 0.004). Only one patient had a neurologic deficit (unilateral extensor hallucis longus weakness) at time of follow-up. There were no significant differences among the groups in function, pain, and satisfaction in patients in whom solid fusion was obtained, but the scores were highest in Group 3.

CONCLUSIONS

In situ fusion surgery in patients with high-grade spondylolisthesis with small L5 transverse processes (surface area, < 2 cm2) results in a high rate of pseudarthrosis. Circumferential procedures result in the highest rate of fusion and are effective in achieving fusion in those patients with established pseudarthrosis. The use of long (> 60 mm) iliac screws bilaterally (n = 21) in addition to bicortical sacral screws (four-point sacral-pelvis fixation) along with anterior column fusion reduces the risk of instrumentation failure in a decompression and reduction procedure. Outcomes of function, pain, and satisfaction are excellent in those in whom fusion is achieved. The risks in circumferential fusion-reduction procedures are acceptable.

Complications and readmission after lumbar spine surgery in elderly patients: an analysis of 2,320 patients

BACKGROUND CONTEXT

There is a paucity of literature describing risk factors for adverse outcomes after geriatric lumbar spinal surgery. As the geriatric population increases, so does the number of lumbar spinal surgeries in this cohort.

PURPOSE

The purpose of the study was to determine how safe lumbar surgery is in elderly patients. Does patient selection, type of surgery, length of surgery, and other comorbidities in the elderly patient affect complication and readmission rates after surgery?

STUDY DESIGN/SETTING

This is a retrospective cohort study.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Database was used in the study.

OUTCOME MEASURES

The outcome data that were analyzed were minor and major complications, mortality, and readmissions in geriatric patients who underwent lumbar spinal surgery from 2005 to 2015.

MATERIALS AND METHODS

A retrospective cohort study was performed using data from the ACS NSQIP database. Patients over the age of 80 years who underwent lumbar spinal surgery from 2005 to 2013 were identified using International Statistical Classification of Diseases and Related Health Problems diagnosis codes and Current Procedural Terminology codes. Outcome data were classified as either a major complication, minor complication, readmission, or mortality. Multivariate logistic regression models were used to determine risks for developing adverse outcomes in the initial 30 postoperative days.

RESULTS

A total of 2,320 patients over the age of 80 years who underwent lumbar spine surgery were identified. Overall, 379 (16.34%) patients experienced at least one complication or death. Seventy-five patients (3.23%) experienced a major complication. Three hundred thirty-eight patients (14.57%) experienced a minor complication. Eighty-six patients (6.39%) were readmitted to the hospital within 30 days. Ten deaths (0.43%) were recorded in the initial 30 postoperative days. Increased operative times were strongly associated with perioperative complications (operative time >180 minutes, odds ratio [OR]: 3.07 [95% confidence interval {CI} 2.23-4.22]; operative time 120-180 minutes, OR: 1.77 [95% CI 1.27-2.47]). Instrumentation and fusion procedures were also associated with an increased risk of developing a complication (OR: 2.56 [95% CI 1.66-3.94]). Readmission was strongly associated with patients who were considered underweight (body mass index [BMI] <18.5) and who were functionally debilitated at the time of admission (OR: 4.10 [1.08-15.48] and OR: 2.79 [1.40-5.56], respectively).

CONCLUSIONS

Elderly patients undergoing lumbar spinal surgery have high complications and readmission rates. Risk factors for complications include longer operative time and more extensive procedures involving instrumentation and fusion. Higher readmission rates are associated with low baseline patient functional status and low patient BMI.

Minimum 5-year follow-up of anterior column structural allografts in the thoracic and lumbar spine

STUDY DESIGN

An analysis of consecutive adult patients treated surgically with anterior column structural allografts for sagittal plane abnormalities.

OBJECTIVES

To evaluate the effectiveness of anterior structural allografts in maintaining long-term sagittal plane correction when combined with posterior spinal fusion and posterior segmental spinal instrumentation and to assess anterior allograft incorporation into adjacent vertebral bodies a minimum of 5 years after implantation.

SUMMARY OF BACKGROUND DATA

There is no study in the literature in which incorporation and remodeling of anterior column structural allografts with minimum 5-year follow-up are assessed. Do they collapse or resorb or sustain stress fractures between a 2-year and 5-year follow-up?

METHODS

Twenty-three consecutive adult patients (mean age, 45 years; range, 25-63 years) had a combination of anterior structural fresh-frozen allograft plus posterior autogenous grafting and posterior segmental spinal instrumentation performed from June 1988 through August 1992. All patients had sagittal plane abnormalities, and all surgeries were performed by the same surgeon. Twenty of the 23 patients returned for follow-up examinations for at least 5 years (average, 7 +/- 3 years; range, 5 +/- 4-10 +/- 3 years). Diagnoses included kyphoscoliosis (n = 8), spondylolisthesis (n = 3), degenerative disc disease (n = 3), and acute or chronic fracture (n = 6). The allografts spanned only disc spaces in 16 patients, and vertebral bodies and disc spaces in 4 patients. Forty disc spaces and four vertebral bodies were grafted, and 67 structural allografts were placed. Upright radiographs were analyzed before surgery, immediately after surgery, and at final follow-up examination to assess the degree of anterior allograft incorporation and maintenance of sagittal correction. A strict 4-point grading system was used. Two independent observers, not involved with surgical procedures, analyzed the radiographic results.

RESULTS

Of the 67 structural allografts, 66 (98.5%) showed incorporation. Both observers concluded that none of the 67 structural allografts showed evidence of collapse. In all grafted levels and in any patient, there was no difference in sagittal plane measurements obtained immediately after surgery and those obtained at follow-up examinations 2 years and 5 or more years after surgery.

CONCLUSIONS

Anterior fresh-frozen structural allograft works effectively in the long term to maintain correction of sagittal plane abnormalities if combined with posterior fusion and instrumentation. A minimum of 5 years after surgery, there is a high rate of structural allograft incorporation into the adjacent vertebral bodies.

Effects of pilot hole preparation technique on pedicle screw fixation in different regions of the osteoporotic thoracic and lumbar spine

OBJECT

The authors evaluated the effects of pilot hole preparation technique on insertional torque and axial pullout resistance in osteoporotic thoracic and lumbar vertebrae.

METHODS

Using a probe technique and fluoroscopy, 102 pedicle screws were placed in 51 dual-energy x-ray absorptiometry-proven osteoporotic thoracic and lumbar levels. Screws were inserted using the same-size tapping, one-size-under tapping, or no-tapping technique. Insertional torque and axial pullout resistance were measured. Analysis of variance, Fisher exact test, and regression analysis were performed. Same-size tapping decreased pullout resistance in the lumbar spine. There was no effect on pullout resistance in the thoracic spine. Pullout resistance values were lower for all insertion techniques in the upper thoracic spine. Insertional torque and bone mineral density correlated with pullout resistance in the thoracic and lumbar spine.

CONCLUSIONS

Tapping decreased pedicle screw pullout resistance in the osteoporotic human lumbar spine, although it did not affect pullout strength in the thoracic spine. Tapping decreased insertional torque in upper thoracic levels. Surgeons should optimize overall construct rigidity when placing thoracic pedicle screws in patients with spinal segment osteoporosis.

Anterior column support in surgery for high-grade, isthmic spondylolisthesis

The literature is confusing as to the need for anterior column fusion in the surgical treatment of patients with high-grade dysplastic spondylolisthesis. The current authors present an analysis of consecutive pediatric patients treated surgically for high-grade spondylolisthesis with and without anterior column structural support with emphasis on fusion rates, segmental kyphosis correction, and functional outcomes. Thirty-seven surgical procedures were done in 31 patients for Meyerding Grade 3 or Grade 4 isthmic dysplastic spondylolisthesis. Patients were separated into two groups based on whether they had structural anterior column support (tricortical autogenous iliac crest) in addition to posterior fusion surgery. Group 1 consisted of 18 patients treated only with posterior surgery without anterior structural support (11 patients were treated with L4-sacrum posterior in situ fusion and seven patients were treated with posterior instrumented reduction with decompression and posterior fusion), and Group 2 consisted of 19 patients who had a reduction and circumferential fusion including anterior structural support. All patients had new radiographs taken at the time of followup (average, 3.1 years, range, 2 years-10 years 1 month) and completed a functional outcome questionnaire. The incidence of pseudarthrosis was 39% (seven of 18 patients) in Group 1 and 0% (0 of 19) in Group 2. All seven patients who had pseudarthrosis achieved solid fusion with a second procedure involving circumferential fusion with anterior column structural grafting. Outcomes regarding pain after treatment, function, and satisfaction were high in those patients who achieved solid fusion regardless of surgical procedure.

Rigid cervical collar treatment for geriatric type II odontoid fractures

PURPOSE

To evaluate fracture healing, functional outcomes, complications, and mortality associated with rigid cervical collars.

METHODS

Thirty-four patients with <50% odontoid displacement were treated with a rigid cervical collar for 12 weeks (Average age = 84 years). Outcome scores were compared with a group of 40 age-matched control subjects (Average age 79.3).

RESULTS

At average 14.9-month follow-up, only 6% demonstrated radiographic evidence of fracture healing and 70% had mobile odontoid nonunion. NDI scores indicated only mild disability, pain scores were low, and neither differed significantly from age-matched controls. Mobile odontoid nonunion was not associated with higher levels of disability or neck pain. Mortality rate was 11.8%. Treatment complications occurred in 6% of patients.

CONCLUSIONS

Odontoid nonunion and instability are high in geriatric patients treated with a rigid cervical collar. Fracture healing and stability did not correlate with improved outcomes. Outcomes did not differ significantly from age-matched cohorts.

Cervical spine injury severity score. Assessment of reliability

BACKGROUND

Systems for classifying cervical spine injury most commonly use mechanistic or morphologic terms and do not quantify the degree of stability. Along with neurologic function, stability is a major determinant of treatment and prognosis. The goal of our study was to investigate the reliability of a method of quantifying the stability of subaxial (C3-C7) cervical spine injuries.

METHODS

A quantitative system was developed in which an analog score of 0 to 5 points is assigned, on the basis of fracture displacement and severity of ligamentous injury, to each of four spinal columns (anterior, posterior, right pillar, and left pillar). The total possible score thus ranges from 0 to 20 points. Fifteen examiners assigned scores after reviewing the plain radiographs and computed tomography images of thirty-four consecutive patients with cervical spine injuries. The scores were then evaluated for interobserver and intraobserver reliability with use of intraclass correlation coefficients.

RESULTS

The mean intraobserver and interobserver intraclass correlation coefficients for the fifteen reviewers were 0.977 and 0.883, respectively. Association between the scores and clinical data was also excellent, as all patients who had a score of > or =7 points had surgery. Similarly, eleven of the fourteen patients with a score of > or =7 points had a neurologic deficit compared with only three of the twenty with a score of <7 points.

CONCLUSIONS

The Cervical Spine Injury Severity Score had excellent intraobserver and interobserver reliability. We believe that quantifying stability on the basis of fracture morphology will allow surgeons to better characterize these injuries and ultimately lead to the development of treatment algorithms that can be tested in clinical trials.

Functional outcomes, morbidity, mortality, and fracture healing in 58 consecutive patients with geriatric odontoid fracture treated with cervical collar or posterior fusion

Controversy exists as to the most effective management option for elderly patients with type II odontoid fractures. The purpose of this study is to evaluate outcomes associated with rigid cervical collar and posterior fusion surgery. Patients with ≥ 50% odontoid displacement were treated with posterior fusion surgery including C1-2 (PSF group, n = 25, average age = 80 years). Patients with < 50% odontoid displacement were treated with a rigid cervical collar for 12 weeks (collar group, n = 33, average age = 83 years). These inhomogeneous groups were followed for an average of 14 months. Fracture healing rates were higher in the operative group (28% versus 6%). Neck Disability Index scores were slightly lower in the nonoperative group (13 versus 18.3, p = 0.23). Analogue pain scores were also slightly lower in the nonoperative group (1.3 versus 1.9, p = 0.26). The mortality rate was 12.5% in the collar group and 20% in the operative group. Complications were higher in the operative group (24% versus 6%). Rates of type II odontoid facture healing and stability appear to be higher in geriatric patients treated with posterior fusion surgery. Fracture healing and stability did not correlate with improved outcomes with respect to levels of pain, function, and satisfaction. Mortality and complication rates are lower in those patients with lesser-displaced fractures who are treated with a cervical collar and early mobilization.

Functional outcomes of instrumented posterior lumbar interbody fusion in active-duty US servicemen: a comparison with nonoperative management

BACKGROUND CONTEXT

The existing literature lacks a functional outcome study addressing instrumented posterior lumbar fusion surgery in physically active patients. Furthermore, results of operative versus nonoperative treatment in these patients are not clear.

PURPOSE

To evaluate patient-assessed function, pain, and satisfaction and military job performance between servicemen treated operatively and nonoperatively.

STUDY DESIGN/SETTING

This is a nonrandomized analysis of consecutive active-duty military servicemen treated either operatively or nonoperatively for chronic back pain and single-level lumbar disc degeneration with emphasis on functional outcomes.

PATIENT SAMPLE

Active-duty US servicemen with chronic low back pain. OUTCOME MEASURES/METHODS: Twenty-nine consecutive active-duty US servicemen were treated for chronic back pain and single-level lumbar disc degeneration by the same surgeon at a military spine facility. Fifteen were treated with instrumented posterior lumbar interbody fusion (PLIF), and 14 refused surgery and chose to be treated nonoperatively with spinal extensor muscle-strengthening exercise, medications, and restricted duty. The average follow-up time was 14 months (range, 6 to 24 months). All servicemen completed a functional outcome questionnaire American Academy of Orthopedic Surgeons/Scoliosis Research Society (AAOS/SRS) with emphasis on pre- and posttreatment function, pain, and satisfaction. The two groups were also compared using military job performance parameters.

RESULTS

Four of 14 (28%) of the servicemen treated nonoperatively ultimately received a disability discharge from the military for back pain, another 5 of 14 (36%) remained on permanent duty-restriction profiles, and only 5 of 14 (36%) returned to full, unrestricted military duty. In the PLIF group, 12 of 15 soldiers (80%) were able to return to full duty, only 3 of 15 (20%) remained on permanent restrictive duty-limitation profiles, and 0 of 15 (0%) received a disability discharge from the military for back pain. Twelve of 15 (80%) of the PLIF group and 8 of 14 (57%) of the group treated nonoperatively were physically able to complete the posttreatment physical fitness test. No difference was observed between premorbid and posttreatment physical training (PT) test scores in either group. However, scores for patient-assessed posttreatment pain, function, and satisfaction were significantly higher in the PLIF group. Soldiers who were able to return to full military duty did so at an average of 2 months for the group treated nonoperatively (n = 5) and 4 months for the PLIF group (n = 12). Complications in the PLIF group included dural tear (n = 2), unilateral transient lower extremity paresthesia (n = 1), and wound seroma requiring reoperation (n = 1).

CONCLUSIONS

In this nonrandomized study of 29 active-duty US servicemen with chronic low back pain and single-level lumbar disc degeneration, instrumented PLIF surgery was associated with a high rate of return to full military duty. Servicemen treated with this technique were less likely to receive a back pain disability discharge or a permanent physical limitation profile when compared with servicemen who chose to be treated nonoperatively. Outcomes with respect to postreatment pain, function, and satisfaction were higher in patients treated with instrumented PLIF and were excellent in servicemen who were able to return to full duty regardless of treatment.

Epidural abscess and discitis complicating instrumented posterior lumbar interbody fusion: a case report

STUDY DESIGN

A case of epidural abscess and discitis following instrumented PLIF using a single carbon fiber interbody cage is presented.

OBJECTIVE

To describe a previously unreported complication of epidural abscess and discitis following posterior lumbar interbody fusion using a single carbon fiber cage.

SUMMARY OF BACKGROUND DATA

Various complications have been reported with PLIF. These include graft migration, pseudarthrosis, implant subsidence, epidural hemorrhage, incidental durotomy, arachnoiditis, transient or permanent neurologic deficits, persistence of pain, and wound infections. There are no reported cases of epidural abscess or refractory discitis associated with PLIF.

METHODS

A 35-year-old infantryman on active duty with chronic low back pain and single-level lumbar disc degeneration underwent instrumented PLIF after reporting no improvement with 3 years of extension-based physical therapy and nonsteroidal pain medications. His back pain was reported improved at 6 weeks after surgery. At 12 weeks after surgery, he presented to the emergency department with intense back pain and fevers. Laboratory data were remarkable for elevated erythrocyte sedimentation rate (118) and C-reactive protein (38). Initial imaging studies, including a lumbar MRI, did not demonstrate any abnormalities. The patient continued to spike fevers, and a repeat lumbar MRI 1 week later clearly demonstrated the presence of an epidural abscess at the level of the PLIF surgery. The patient was treated with surgical debridement and epidural abscess drainage. The interbody cage was left in place. Surgical cultures identified Staphylococcus aureus as the pathogen, and the patient was placed on intravenous vancomycin. During the ensuing 3 weeks, his clinical symptoms worsened and his radiographs demonstrated lucency in the region of his interbody cage. Repeat debridement was performed, and his interbody cage and pedicle screw instrumentation were removed 4 months after initial surgery.

RESULTS

The disc space infection resolved following removal of the implants. Radiographs at 6 months after instrumentation removal demonstrated solid bilateral posterolateral arthrodesis. The patient returned to active duty 1 year after his initial surgery, reporting that his back pain was reduced compared with his preoperative level.

CONCLUSIONS

There is a paucity of literature on epidural abscess and discitis as complications associated with PLIF. In this case, the infection persisted despite surgical debridement and intravenous antibiotics. The patient ultimately required removal of the interbody implant and posterior instrumentation. The patient developed solid posterolateral arthrodesis despite the presence of deep infection, which led to early implant removal 4 months after the initial surgery. This case underscores the potential importance of concomitant posterolateral fusion, particularly following wide laminectomy and facetectomy required for PLIF.

Anterior cervical discectomy and fusion with structural allograft and plates for the treatment of unstable posterior cervical spine injuries

Object

The purpose of this study was to evaluate complications and radiographic and functional outcomes of isolated anterior stabilization surgery in which structural allograft and plates were used for posterior unstable subaxial cervical spine lateral mass, facet, and ligamentous injuries.

Methods

Between August 2003 and January 2008, 19 consecutive patients with unstable lateral mass, facet, and/or posterior ligamentous injuries of the subaxial cervical spine were treated by a single surgeon via an anterior approach. This was performed using structural allograft and plate fixation. Patients with any associated anterior vertebral fractures were excluded from the study. Autogenous bone grafts or bone graft substitutes were not used in any patient. The average age of the patients was 43 years (range 17–87 years) and the mean follow-up period was 20.4 months (range 6–48 months). Seventeen of the 19 patients participated in the study; the other 2 were lost to follow-up. Operative times, estimated blood loss, length of hospital stay (LOS), and perioperative complications were recorded for each patient. Radiographic outcomes included fusion scores and sagittal alignment measurements. Outcome scores with respect to neck pain, satisfaction with surgery, and function were recorded for each patient according to analog pain and satisfaction scales and the Neck Disability Index (NDI). Additionally, NDI and pain scores at final follow-up were compared with a group of healthy, age-matched controls.

Results

The average surgical time was 60 minutes (range 28–108 minutes), and the estimated blood loss averaged 48.9 ml per surgical procedure (range 20–150 ml). The LOS for the 13 patients who had no other associated injuries averaged 2.2 days (range 2–3 days). Fifteen of 17 patients achieved solid radiographic fusion, and no patient demonstrated instability. Only 1 patient had significant loss of the initial sagittal alignment correction at final follow-up. The average NDI score for the 17 patients was 6.5 (range 0–11), indicating mild disability and comparing favorably to a group of healthy age-matched controls. There was no statistical difference in pain scores for the trauma patients and control group at ultimate follow-up (1.5 vs 0.3, respectively). Satisfaction scores for the 17 trauma patients were high, averaging 94% (range 80–100%). Ten of the 11 patients with preoperative radiculopathy demonstrated complete resolution of this condition. Complications occurred in 1 patient with transient hoarseness and 1 with transient swallowing difficulty. There were no wound complications. Screw breakage occurred in 1 patient, and an additional patient required revision surgery for pseudarthrosis.

Conclusions

Anterior cervical discectomy and fusion performed using interbody structural allograft and plate fixation is highly effective in the treatment of unstable posterior cervical lateral mass, facet, and ligamentous injuries. This treatment option results in low intraoperative blood loss, short operating times, and a brief LOS. Radiographic outcomes with respect to segmental stability are excellent, and fusion rates with the use of structural allograft alone are high. Outcomes with respect to pain, function, and patient satisfaction are high, and complications are acceptably low.

Low-Grade Isthmic Spondylolisthesis Treated with Instrumented Posterior Lumbar Interbody Fusion in U.S. Servicemen

PURPOSE

The existing literature lacks a functional outcomes study addressing instrumented posterior lumbar fusion surgery for isthmic spondylolisthesis in physically active patients. Presently, spinal surgeons can provide only anecdotal advice when discussing operative outcomes with these patients. This is a nonrandomized analysis of consecutive military servicemen treated operatively for chronic back pain and low-grade isthmic spondylolisthesis with single-level lumbar disc degeneration with emphasis on functional outcomes. The purpose was to evaluate patient-assessed function/pain/satisfaction and military job performance in U.S. servicemen treated with posterior lumbar interbody fusion (PLIF).

METHODS

Thirty consecutive U.S. military servicemen with chronic low back pain and low-grade lumbar isthmic spondylolisthesis were referred to the same surgeon at a military treatment facility. All servicemen were treated operatively with instrumented PLIF using autogenous iliac crest bone graft, one or two nonthreaded interbody cages (Brantigan or Harms), and a four-pedicle screw/rod construct. A concomitant bilateral posterolateral fusion was performed in all 30 cases. The average follow-up time was 15 months (range 12-48 months). Twenty-five of the 30 servicemen completed a functional outcomes questionnaire (American Academy of Orthopaedic Surgeons/Scoliosis Research Society) with emphasis on pre- and posttreatment function, pain, and satisfaction. The servicemen were also evaluated using standard military job performance parameters.

RESULTS

Three of the 30 servicemen (10%) requested and received a disability discharge from the military for back pain that continued throughout the postoperative period and prevented return to military duty. An additional 8 of the original 30 soldiers (27%) required some form of permanent physical activity limitation (situps/pushups/running/lifting) to permit their return to military duty, and 19 of 30 (63%) soldiers were able to return to full and unrestricted military duty after surgery. Those soldiers who were able to return to unrestricted military duty (n = 19) did so at an average of 6 months post treatment (range 2-16 months). Of the soldiers who were able to return to military duty, 21 of 30 (70%) were able to complete the posttreatment military physical fitness test at an average of 8 months postoperatively (range 2-32 months). No significant differences were observed between premorbid and postsurgical physical fitness test scores. There was a trend toward lower postsurgical scores. Complications included dural tear (n = 4), unilateral transient lower extremity paresthesia (n = 1), and wound seroma requiring reoperation (n = 1).

CONCLUSIONS

In this nonrandomized study of 30 U.S. servicemen with chronic low back pain, low-grade isthmic spondylolisthesis, and single-level lumbar disc degeneration, instrumented PLIF surgery was associated with a high rate of return to functional military duty. Outcomes with respect to posttreatment pain, function, and satisfaction were high in patients treated with instrumented PLIF.

Comparison of adult spinal deformity patients with and without rheumatoid arthritis undergoing primary non-cervical spinal fusion surgery: a nationwide analysis of 52,818 patients

BACKGROUND CONTEXT

Numerous studies have analyzed the impact of rheumatoid arthritis (RA) on the cervical spine and its related surgical interventions. However, there is a paucity of literature available conducting the same analyses in patients with non-cervical spine involvement.

PURPOSE

The objective of this study was to compare patient characteristics, comorbidities, and complications in patients with and without RA undergoing primary non-cervical spinal fusions.

STUDY DESIGN/SETTING

This is a retrospective national database review.

PATIENT SAMPLE

A total of 52,818 patients with adult spinal deformity undergoing non-cervical spinal fusions (1,814 patients with RA and 51,004 patients without RA).

OUTCOME MEASURES

The outcome measures in the study include patient characteristics, as well as complication and mortality rates.

MATERIALS AND METHODS

Using the Nationwide Inpatient Sample from 2003 to 2014, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes were used to identify patients aged ≥18 years old with and without RA undergoing primary non-cervical spinal fusions. Univariate analysis was used to determine patient characteristics, comorbidities, and complication values for each group. Bivariate analysis was used to compare the two groups. Significance was set at p<.05.

RESULTS

Patients with RA were older (p<.001), were more likely to be women (p<.001), had increased rates of osteoporosis (p<.001), had a greater percentage of their surgeries reimbursed by Medicare (p<.001), and more often had weekend admissions (p=.014). There was no difference in all the other characteristics. Patients with RA had higher rates of iron deficiency anemia, congestive heart failure, chronic pulmonary disease, depression, and fluid and electrolyte disorders (all, p<.001). Patients without RA had higher rates of alcohol abuse (p=.027). There was no difference in all the other complications. There was no difference in mortality rate (p=.99). Total complications were greater in patients with RA (p<.001). Patients with RA had higher rates of infection (p=.032), implant-related complications (p=.010), incidental durotomies (p=.001), and urinary tract infections (p<.001). No difference existed among the other complications.

CONCLUSIONS

Patients with RA have an increased number of comorbidities and complication rates compared with patients without RA. Such knowledge can help surgeons and patients with RA have beneficial preoperative discussions regarding outcomes.

Unilateral versus Bilateral Instrumentation in Spinal Surgery: A Systematic Review

Study Design Systematic review. Clinical Questions (1) What is the comparative efficacy of unilateral instrumentation compared with bilateral instrumentation in spine surgery? (2) What is the safety of unilateral instrumentation compared with bilateral instrumentation in spine surgery? Methods Electronic databases and reference lists of key articles were searched up to September 30, 2014, to identify studies reporting the comparative efficacy and safety of unilateral versus bilateral instrumentation in spine surgery. Studies including recombinant human bone morphogenetic protein 2 as adjunct therapy and those with follow-up of less than 2 years were excluded. Results Ten randomized controlled trials met the inclusion criteria: five compared unilateral with bilateral instrumentation using open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF), one used open posterolateral fusion, and four used minimally invasive TLIF/PLIF. There were no significant differences between unilateral and bilateral screw instrumentation with respect to nonunion, low back or leg pain scores, Oswestry Disability Index, reoperation, or complications. Conclusions The existing literature does not identify significant differences in clinical outcomes, union rates, and complications when unilateral instrumentation is used for degenerative pathologic conditions in the lumbar spine. The majority of published reports involve single-level lumbar unilateral instrumentation.

Vertebral Artery Injury during Routine Posterior Cervical Exposure: Case Reports and Review of Literature

Study Design Case series. Objective We report the unusual occurrence of vertebral artery injury (VAI) during routine posterior exposure of the cervical spine. The importance of preoperative planning to identify the course of the bilateral vertebral arteries during routine posterior cervical spine surgery is emphasized. Methods VAI is a rare but potentially devastating complication of cervical spinal surgery. Most reports of VAI are related to anterior surgical exposure or screw placement in the posterior cervical spine. VAI incurred during posterior cervical spinal exposure surgery is not adequately addressed in the existing literature. Two cases of VAI that occurred during routine posterior exposure of the cervical spine in the region of C2 are described. Results VAI was incurred unexpectedly in the region of the midportion of the posterior C1-C2 interval during the initial surgical exposure phase of the operation. An aberrant vertebral artery course in the V2 anatomical section in the region between C1 and C2 intervals was identified postoperatively in both patients. A literature review demonstrates a relatively high incidence of vertebral artery anomalies in the upper cervical spine; however, the literature is deficient in reporting vertebral artery injury in this region. Recommendations for preoperative vertebral artery imaging also remain unclear at this time. Conclusions Successful management of this unexpected complication was achieved in both cases. This case report and review of the literature highlights the importance of preoperative vertebral artery imaging and knowledge of the course of the vertebral arteries prior to planned routine posterior exposure of the upper cervical spine. In both cases, aberrancy of the vertebral artery was present and not investigated or detected preoperatively.

Nonoperative Management of Craniocervical Ligamentous Distraction Injury: Literature Review

Study Design Literature review and case report. Objective Review the existing literature and report the successful nonoperative management of a two-level craniocervical ligamentous distraction injury. Methods A PubMed and Medline review revealed only three limited reports involving the nonoperative management of patients with craniocervical distraction injury. This article reviews the existing literature and reports the case of a 27-year-old man who was involved in a motorcycle accident and sustained multiple systemic injuries and ligamentous distraction injuries to both occipitocervical joints and both C1-C2 joints. The patient's traumatic brain injury and bilateral pulmonary contusions precluded safe operative management of the two-level craniocervical distraction injury. Therefore, the patient was placed in a halo immobilization device. Results The literature remains unclear as to the specific indications for nonoperative management of ligamentous craniocervical injuries. Nonoperative management was associated with poor outcomes in the majority of reported patients. We report a patient who was managed for 6 months in a halo device. Posttreatment computed tomography and flexion-extension radiographs demonstrated stable occipitocervical and C1-C2 joints bilaterally. The patient reported minimal neck pain and had excellent functional outcome with a Neck Disability Index score of 2 points at 41 months postoperatively. He returned to preinjury level of employment without restriction. Conclusions Further study is needed to determine which craniocervical injuries may be managed successfully with nonoperative measures.

Large Compressive Pseudomeningocele Causing Early Major Neurologic Deficit After Spinal Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVES

Large compressive pseudomeningocele causing a major neurologic deficit is a very rare complication that is not well described in the existing literature.

METHODS

Institutional review board consent was obtained to study 2552 consecutive extradural spinal surgical cases performed by a single senior spinal surgeon during a 10-year period. The surgeon's database for the decade was retrospectively reviewed and 3 cases involving postoperative major neurologic deficits caused by large compressive pseudomeningocele were identified.

RESULTS

The incidence of postoperative compressive pseudomeningocele causing major neurologic deficit was 0.12% (3/2552) per decade of spinal surgery with approximately 1.3% of cases incurring incidental durotomy. Average age of the patients was 57 years (range 45-78). One patient had posterior cervical spine surgery, and 2 patients had posterior lumbar surgery. All 3 patients had intraoperative incidental durotomy repaired during their index procedure. Large compressive pseudomeningocele causing major neurologic deficit occurred in the early 2-week postoperative period in all patients and was clearly identified on postoperative magnetic resonance imaging. All 3 patients were treated with emergent decompression and repair of the dural defect. All patients recovered neurologic function after revision surgery.

CONCLUSIONS

Incidental durotomy and repair causing a large compressive pseudomeningocele after spine surgery is a rare and potentially devastating event. Early postoperative magnetic resonance imaging assists in the diagnosis. Emergent decompression combined with revision dural repair surgery may result in improved outcomes. Surgeons should be cognizant of this rare cause of early postoperative major neurologic deficit in patients who had previous dural repair.

Symptomatic Triple-Region Spinal Stenosis Treated with Simultaneous Surgery: Case Report and Review of the Literature

Study Design Case report. Objectives Symptomatic triple-region spinal stenosis (TRSS), defined as spinal stenosis in three different regions of the spine, is extremely rare. To our knowledge, treatment with simultaneous decompressive surgery is not described in the literature. We report a case of a patient with TRSS who was treated successfully with simultaneous decompressive surgery in three separate regions of the spine. Methods A 50-year-old man presented with combined progressive cervical and thoracic myelopathy along with severe lumbar spinal claudication and radiculopathy. He underwent simultaneous decompressive surgery in all three regions of his spine and concomitant instrumented fusion in the cervical and thoracic regions. Results Estimated blood loss for the procedure was 600 mL total (250 mL cervical, 250 mL thoracic, 100 mL lumbar) and operative time was ∼3.5 hours. No changes were noted on intraoperative monitoring. The postoperative course was uncomplicated. The patient was discharged to inpatient rehabilitation on postoperative day (POD) 7 and discharged home on POD 11. At 6-month follow-up, his gait and motor function was improved and returned to normal in all extremities. He remains partially disabled due to chronic back pain. Conclusions This report is the first of symptomatic TRSS treated with simultaneous surgery in three different regions of the spine. Simultaneous triple region stenosis surgery appears to be an effective treatment option for this rare condition, but may be associated with prolonged hospital stay after surgery.

Return to Play in Athletes Receiving Cervical Surgery: A Systematic Review

Study Design Systematic review. Clinical Questions Among athletes who undergo surgery of the cervical spine, (1) What proportion return to play (RTP) after their cervical surgery? (2) Does the proportion of those cleared for RTP depend on the type of surgical procedure (artificial disk replacement, fusion, nonfusion foraminotomies/laminoplasties), number of levels (1, 2, or more levels), or type of sport? (3) Among those who return to their presurgery sport, how long do they continue to play? (4) Among those who return to their presurgery sport, how does their postoperative performance compare with their preoperative performance? Objectives To evaluate the extent and quality of published literature on the topic of return to competitive athletic completion after cervical spinal surgery. Methods Electronic databases and reference lists of key articles published up to August 19, 2015, were searched to identify studies reporting the proportion of athletes who RTP after cervical spine surgery. Results Nine observational, retrospective series consisting of 175 patients were included. Seven reported on professional athletes and two on recreational athletes. Seventy-five percent (76/102) of professional athletes returned to their respective sport following surgery for mostly cervical herniated disks. Seventy-six percent of recreational athletes (51/67) age 10 to 42 years RTP in a variety of sports following surgery for mostly herniated disks. No snowboarder returned to snowboarding (0/6) following surgery for cervical fractures. Most professional football players and baseball pitchers returned to their respective sport at their presurgery performance level. Conclusions RTP decisions after cervical spine surgery remain controversial, and there is a paucity of existing literature on this topic. Successful return to competitive sports is well described after single-level anterior cervical diskectomy and fusion surgery for herniated disk. RTP outcomes involving other cervical spine diagnoses and surgical procedures remain unclear. Additional quality research is needed on this topic.

Unstable subaxial cervical spine injury with normal computed tomography and magnetic resonance initial imaging studies: a report of four cases and review of the literature

STUDY DESIGN

Case series.

OBJECTIVE

To describe 4 cases of unstable subaxial cervical spine injury not demonstrated with initial radiograph, computed tomography (CT), and magnetic resonance (MR) imaging.

SUMMARY OF BACKGROUND DATA

When evaluating the cervical spine for ligamentous or osseous injuries in the blunt trauma patient population, negative predictive value measurements of 100% for CT and MR imaging have been published. Unstable subaxial cervical spine injury has rarely been reported in the spine literature in conjunction with initial radiograph, CT, and MR imaging demonstrating no osseous or ligamentous injury. Historically, reports of subacute cervical spine instability following trauma exist and were presented before the availability of MR and multidetector CT imaging.

METHODS AND RESULTS

We report 4 examples of unstable subaxial cervical spine injury each with initial imaging interpreted as negative. All 4 cases presented at a level-one tertiary care facility. Follow-up radiographs demonstrated unstable cervical spine injuries requiring surgical stabilization.

CONCLUSION

Notwithstanding high sensitivities, specificities, and negative predictive values for cervical spine imaging and "clearance" mechanisms, 4 cases that illustrate the potential for undetected unstable cervical spine injuries are presented. Tremendous advancements in medical imaging have been made. However, radiograph, CT, and MR imaging may still fail to accurately translate the anatomic and dynamic complexity of the cervical spine into digital images that accurately guide clinical practice. A full understanding of and keen appreciation for the fact that no imaging technique, classification method, or clearance protocol can produce 100% sensitivity at all times is essential. These case reports cumulatively demonstrate a 0.04% to 0.2% incidence of undetected cervical injury requiring surgical stabilization. Removing cervical collar immobilization as quickly as possible based on negative interpretation of imaging data may prove harmful in a measurable percentage of patients and must be undertaken with caution only after clinical correlation and strict follow-up is established.

The Use of Bone Morphogenetic Protein in Pediatric Cervical Spine Fusion Surgery: Case Reports and Review of the Literature

Study Design Case report. Objective There is a paucity of literature describing the use of bone graft substitutes to achieve fusion in the pediatric cervical spine. The outcomes and complications involving the off-label use of bone morphogenetic protein (BMP)-2 in the pediatric cervical spine are not clearly defined. The purpose of this article is to report successful fusion without complications in two pediatric patients who had instrumented occipitocervical fusion using low-dose BMP-2. Methods A retrospective review of the medical records was performed, and the patients were followed for 5 years. Two patients under 10 years of age with upper cervical instability were treated with occipitocervical instrumented fusion using rigid occipitocervical fixation techniques along with conventionally available low-dose BMP-2. A Medline and PubMed literature search was conducted using the terms "bone morphogenetic protein," "BMP," "rh-BMP2," "bone graft substitutes," and "pediatric cervical spine." Results Solid occipitocervical fusion was achieved in both pediatric patients. There were no reported perioperative or follow-up complications. At 5-year follow-up, radiographs in both patients showed successful occipital cervical fusion without evidence of instrumentation failure or changes in the occipitocervical alignment. To date, there are few published reports on this topic. Complications and the appropriate dosage application in the pediatric posterior cervical spine remain unknown. Conclusions We describe two pediatric patients with upper cervical instability who achieved successful occipital cervical fusion without complication using off-label BMP-2. This report underscores the potential for BMP-2 to achieve successful arthrodesis of the posterior occipitocervical junction in pediatric patients. Use should be judicious as complications and long-term outcomes of pediatric BMP-2 use remain undefined in the existing literature.

Unilateral cervical facet dislocation in a 9-year-old boy

Facet dislocations in children are rare. This article presents the youngest case of a unilateral facet dislocation described in the pediatric population. A 9-year-old boy sustained a flexion/axial loading injury to his cervical spine while wrestling with his friends, causing a unilateral facet dislocation at C4/5. Prereduction magnetic resonance imaging (MRI) demonstrated the absence of a diskal herniation or cord impingement and an intact posterior ligamentous complex. Due to the patient's young age, the decision was made to forgo a supervised awake closed reduction. Closed reduction was performed under general anesthesia with somatosensory-evoked potential and motor-evoked potential monitoring. Closed reduction was successfully achieved after Gardner-Wells tongs were applied and used to manually direct slow, steady in-line traction, along with slight flexion and posterior rotation of the dislocated side under direct fluoroscopy. The patient was immediately awakened from anesthesia and was found to have an intact sensory examination. He was immobilized in a cervical collar for 12 weeks. At 2-year follow-up, he remained asymptomatic without recurrence and had painless full range of motion of the cervical spine. Radiographs revealed a normally aligned cervical spine. Unilateral cervical facet dislocations and subluxations are the result of a distractionflexion force applied to the spine along with a rotational component. These are not uncommon injuries in the adult spine; however, in the young pediatric population, cervical facet dislocations are rare.

An Analysis of Patient and Fracture Characteristics and Clinical Outcomes in Patients With Hyperostotic Spine Fractures

STUDY DESIGN

Retrospective study.

OBJECTIVE

To evaluate outcomes and complications following operative and nonoperative management of hyperostotic spine fractures.

METHODS

Patients presenting between 2008 and 2017 to a single level 1 trauma center with hyperostotic spine fractures had their information and fracture characteristics reviewed. Bivariate analyses were conducted to compare patients across a number of characteristics and outcomes. Multivariate logistic regression models for complication and mortality were done in a stepwise fashion.

RESULTS

Sixty-five ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH) patients with a spine fracture met our inclusion criteria. DISH was slightly more prevalent (55% vs 45%). Overall delayed diagnosis, reoperation, mortality (at 1 year), and complication rates were high at 32%, 13%, 23%, and 57%, respectively. In multivariate logistic regression models, patients undergoing operative management had significantly increased odds of having a complication (odds ratio [OR] = 23.03, 95% confidence interval [CI] = 2.24-236.45, P = .008), while increasing age was associated with increased odds of death (OR = 1.18, 95% CI = 1.06-1.31, P = .003).

CONCLUSIONS

Patients with AS or DISH who fracture their spine are at high risk of complication and death. However, neither operative nor nonoperative treatment increases the odds of mortality. This study helps add to a growing, but still limited, body of literature on the characteristics of patients with spine fractures in the setting of AS or DISH.