Objective Long-segment fusion in adult spinal deformity (ASD) is often needed, but more focal surgeries may provide significant relief with less morbidity. The minimally invasive spinal deformity surgery (MISDEF2) algorithm guides minimally invasive ASD surgery, but it may be useful in open ASD surgery. We classified ASD patients undergoing focal decompression, limited decompression and fusion, and full correction according to MISDEF2 and correlated outcomes.
Methods A retrospective study of ASD patients treated by 2 surgeons at our hospital was performed. Inclusion criteria were: age > 50, minimum 2-year follow-up, and open ASD surgery. Tumor, trauma, and infections were excluded. Patients had open surgery including focal decompression, short segment fusion, or full scoliosis correction. All patients were categorized by MISDEF2 into 4 classes based upon spinopelvic parameters. Perioperative metrics were assessed. Radiographic correction, complications and reoperation were recorded.
Results A total of 136 patients met inclusion criteria. Mean follow-up was 46 ± 15.8 months (range, 24–118 months). Forty-seven underwent full deformity correction, 71 underwent short segment fusion, and 18 underwent decompression alone. There were 24 cases of class I, 66 cases of class II, 23 cases of class III, and 23 cases of class IV patients. Patients in class I and II had perioperative complication rates of 0% and 16.7% and revision rates of 8% and 21.2% when undergoing focal decompression or limited fusion. However, class II patients undergoing full correction had higher perioperative complications rate (p = 0.03) and revision surgery rates (p = 0.047). This difference was not seen in class III patients (p > 0.05). All class IV patients underwent full correction, but they had higher perioperative complication rates (p < 0.019), comparable revision surgery rates (p = 0.27), and better radiographic realignment (p < 0.001). In addition, full deformity correction was associated with longer length of stay, increased blood loss, and longer operative time (p < 0.001).
Conclusion The MISDEF2 algorithm may help guide ASD surgical decision making even in open surgery, with focal treatment used in class I and II patients as a viable alternative and full correction implemented in class IV patients because of severe malalignment. However, class II patients with ASD undergoing full deformity correction do have higher complication rates.
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Neurospine 2021;18(2):292-302. Published online June 30, 2021
Objective The use of telemedicine has dramatically increased due to the coronavirus disease 2019 pandemic. Many neurosurgeons are now using telemedicine technologies for preoperative evaluations and routine outpatient visits. Our goal was to standardize the telemedicine motor neurologic examination, summarize the evidence surrounding clinical use of telehealth technologies, and discuss financial and legal considerations.
Methods We identified a 12-member panel composed of spine surgeons, fellows, and senior residents at a single institution. We created an initial telehealth strength examination protocol based on published data and developed 10 agree/disagree statements summarizing the protocol. A blinded Delphi method was utilized to build consensus for each statement, defined as > 80% agreement and no significant disagreement using a 2-way binomial test (significance threshold of p < 0.05). Any statement that did not meet consensus was edited and iteratively resubmitted to the panel until consensus was achieved. In the final round, the panel was unblinded and the protocol was finalized.
Results After the first round, 4/10 statements failed to meet consensus ( < 80% agreement, and p = 0.031, p = 0.031, p = 0.003, and p = 0.031 statistical disagreement, respectively). The disagreement pertained to grading of strength of the upper (3/10 statements) and lower extremities (1/10 statement). The amended statements clarified strength grading, achieved consensus ( > 80% agreement, p > 0.05 disagreement), and were used to create the final telehealth strength examination protocol.
Conclusion The resulting protocol was used in our clinic to standardize the telehealth strength examination. This protocol, as well as our summary of telehealth clinical practice, should aid neurosurgical clinics in integrating telemedicine modalities into their practice.
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Objective The oblique lumbar interbody fusion (OLIF) can be done with either fluoroscopy or navigation. However, it is unclear how navigation affects the overall flow of the procedure. We wished to report on the accuracy of this technique using navigation and on how navigation affects surgical time and complications.
Methods A retrospective review was undertaken to evaluate patients who underwent OLIF using spinal navigation at University of California San Francisco. Data collected were demographic variables, perioperative variables, and radiographic images. Postoperative lateral radiographs were analyzed for accuracy of cage placement. The disc space was divided into 4 quadrants from anterior to posterior, zone 1 being anterior, and zone 4 being posterior. The accuracy of cage placement was assessed by placement.
Results There were 214 patients who met the inclusion criteria. A total of 350 levels were instrumented from L1 to L5 using navigation. The mean follow-up time was 17.42 months. The mean surgical time was 211 minutes, and the average surgical time per level was 129.01 minutes. After radiographic analysis, 94.86% of cages were placed within quartiles 1 to 3. One patient (0.47%) underwent revision surgery because of suboptimal cage placement. For approach-related complications, transient neurological symptoms were 10.28%, there was no vascular injury.
Conclusion The use of navigation to perform OLIF from L1 to L5 resulted in a cage placement accuracy rate of 94.86% in 214 patients.
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Objective Lean management strategies aim to increase efficiency by eliminating waste or by improving processes to optimize value. The operating room (OR) is an arena where these strategies can be implemented. We assessed changes in OR efficiency after the application of lean methodology on perioperative anesthesia associated with posterior cervical spine surgeries.
Methods We utilized pre- and post-lean study design to identify inefficiencies during the perioperative anesthesia process and implemented strategies to improve the process. Patient characteristics were recorded to assess for differences between the 2 groups (group 1, prelean; group 2, post-lean). In the pre-lean period, key steps in the perioperative anesthesia process were identified that were amenable to lean implementation. The time required for each identified key step was recorded by an independent study coordinator. The times for each step were then compared between the groups utilizing univariate analyses.
Results After lean implementation, there was a significant decrease in overall perioperative anesthesia process time (88.4 ± 4.7 minutes vs. 76.2 ± 3.2 minutes, p = 0.04). This was driven by significant decreases in the steps: transport and setup (10.4 ± 0.8 minutes vs. 8.0 ± 0.7 minutes, p = 0.03) and positioning (20.8 ± 2.1 minutes vs. 15.7 ± 1.3 minutes, p = 0.046). Of note, the total time spent in the OR was lower for group 2 (270.1 ± 14.6 minutes vs. 252.8 ± 14.1 minutes) but the result was not statistically significant, even when adjusting for number of operated levels.
Conclusion Lean methodology may be successfully applied to posterior cervical spine surgery whereby improvements in the perioperative anesthetic process are associated with significantly increased OR efficiency.
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Objective This retrospective cohort study seeks to identify risk factors associated with complications following posterior cervical laminectomy and fusion (PCLF) surgery.
Methods Adults undergoing PCLF from 2012 through 2018 at a single center were identified. Demographic and radiographic data, surgical characteristics, and complication rates were compared. Multivariate logistic regression models identified independent predictors of complications following surgery.
Results A total of 196 patients met the inclusion criteria and were included in the study. The medical, surgical, and overall complication rates were 10.2%, 23.0%, and 29.1% respectively. Risk factors associated with medical complications in multivariate analysis included impaired ambulation status (odds ratio [OR], 2.27; p=0.02) and estimated blood loss over 500 mL (OR, 3.67; p=0.02). Multivariate analysis revealed preoperative narcotic use (OR, 2.43; p=0.02) and operative time (OR, 1.005; p=0.03) as risk factors for surgical complication, whereas antidepressant use was a protective factor (OR, 0.21; p=0.01). Overall complication was associated with preoperative narcotic use (OR, 1.97; p=0.04) and higher intraoperative blood loss (OR, 1.0007; p=0.03).
Conclusion Preoperative narcotic use and estimated blood loss predicted the incidence of complications following PCLF for CSM. Ambulation status was a significant predictor of the development of a medical complication specifically. These results may help surgeons in counseling patients who may be at increased risk of complication following surgery.
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Cervical disc arthroplasty (CDA), or total disc replacement, has emerged as an option in the past two decades for the management of 1- and 2-level cervical disc herniation and spondylosis causing radiculopathy, myelopathy, or both. Multiple prospective randomized controlled trials have demonstrated CDA to be as safe and effective as anterior cervical discectomy and fusion, which has been the standard of care for decades. Moreover, CDA successfully preserved segmental mobility in the majority of surgical levels for 5–10 years. Although CDA has been suggested to have long-term efficacy for the reduction of adjacent segment disease in some studies, more data are needed on this topic. Surgery for CDA is more demanding for decompression, because indirect decompression by placement of a tall bone graft is not possible in CDA. The artificial discs should be properly sized, centered, and installed to allow movement of the vertebrae, and are commonly 6 mm high or less in most patients. The key to successful CDA surgery includes strict patient selection, generous decompression of the neural elements, accurate sizing of the device, and appropriately centered implant placement.
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Outcomes of cervical disc replacement in patients with neck pain greater than arm pain Pratyush Shahi, Avani S. Vaishnav, Ryan Lee, Eric Mai, Michael E. Steinhaus, Russel Huang, Todd Albert, Sravisht Iyer, Evan D. Sheha, James E. Dowdell, Sheeraz A. Qureshi The Spine Journal.2022; 22(9): 1481. CrossRef
Outcomes of cervical arthroplasty versus anterior cervical arthrodesis: a systematic review and meta-analysis of randomized clinical trials with a minimum follow-up of 7-year Jorge H. Núñez, Berta Escudero, Irene Omiste, Judith Martínez-Peñas, Maria Surroca, Francisco Alonzo-González, David Bosch-García European Journal of Orthopaedic Surgery & Traumatology.2022; 33(5): 1875. CrossRef
Letter to the Editor Regarding “Anterior Bone Loss in Cervical Disk Arthroplasty Correlates with Increased Cervical Lordosis” Ioannis Siasios, Kalliopi Tsoleka, Ethymia Samara, Theodosis Birbilis World Neurosurgery.2022; 166: 288. CrossRef
Safety and Validity of Anterior Cervical Disc Replacement for Single-level Cervical Disc Disease: Initial Two-year Follow-up of the Prospective Observational Post-marketing Surveillance Study for Japanese Patients Toshihiro TAKAMI, Takeshi HARA, Masahito HARA, Toshihiko INUI, Kiyoshi ITO, Izumi KOYANAGI, Junichi MIZUNO, Masaki MIZUNO, Hiroyuki NAKASE, Nobuyuki SHIMOKAWA, Taku SUGAWARA, Shinsuke SUZUKI, Toshiyuki TAKAHASHI, Masakazu TAKAYASU, Satoshi TANI, Kazutoshi Neurologia medico-chirurgica.2022; 62(11): 489. CrossRef
Does the sizing of current cervical disc arthroplasty systems match Chinese cervical anatomic dimensions? Lu Wang, Meng Bai, Xing-Bin Li, Zhao-Rui Wang, Bang Wang, Ai-Bing Huang Frontiers in Bioengineering and Biotechnology.2022;[Epub] CrossRef
Multilevel cervical disc arthroplasty: a review of optimal surgical management and future directions Tsung-Hsi Tu, Ching-Ying Wang, Yu-Chun Chen, Jau-Ching Wu Journal of Neurosurgery: Spine.2022; : 1. CrossRef
Cervical disc arthroplasty for Klippel-Feil syndrome Chu-Yi Lee, Ching-Lan Wu, Hsuan-Kan Chang, Jau-Ching Wu, Wen-Cheng Huang, Henrich Cheng, Tsung-Hsi Tu Clinical Neurology and Neurosurgery.2021; 209: 106934. CrossRef
Cervical disc arthroplasty: What we know in 2020 and a literature review Jun Jae Shin, Kwang-Ryeol Kim, Dong Wuk Son, Dong Ah Shin, Seong Yi, Keung-Nyun Kim, Do-Heum Yoon, Yoon Ha, K Daniel Riew Journal of Orthopaedic Surgery.2021;[Epub] CrossRef
Late complication of cervical disc arthroplasty: heterotopic ossification causing myelopathy after 10 years. Illustrative case Che-Han Hsu, Yi-Hsuan Kuo, Chao-Hung Kuo, Chin-Chu Ko, Jau-Ching Wu, Wen-Cheng Huang Journal of Neurosurgery: Case Lessons.2021;[Epub] CrossRef
Cervical disc arthroplasty at C2–3: illustrative case Jason Ku, Johnson Ku, Hsuan-Kan Chang, Jau-Ching Wu Journal of Neurosurgery: Case Lessons.2021;[Epub] CrossRef
Cervical Disc Replacement Jeremy Steinberger, Sheeraz Qureshi Neurosurgery Clinics of North America.2020; 31(1): 73. CrossRef
Comparison of cervical disc arthroplasty and anterior cervical discectomy and fusion for the treatment of cervical disc degenerative diseases on the basis of more than 60 months of follow-up: a systematic review and meta-analysis Yijian Zhang, Nanning Lv, Fan He, Bin Pi, Hao Liu, Angela Carley Chen, Huilin Yang, Mingming Liu, Xuesong Zhu BMC Neurology.2020;[Epub] CrossRef
Letter to the Editor. Indolent clinical and radiological effects of cervical disc arthroplasty Wen-Cheng Huang, Yu-Chun Chen, Tsung-Hsi Tu, Hsuan-Kan Chang, Chao-Hung Kuo Journal of Neurosurgery: Spine.2020; 32(6): 984. CrossRef
Letter to the Editor. Cervical spondylotic myelopathy Atul Goel Journal of Neurosurgery: Spine.2020; 32(4): 631. CrossRef
Letter to the Editor. The need for research prioritization in cervical myelopathy Oliver Daniel Mowforth, Michelle Louise Starkey, Mark Reinhard Kotter, Benjamin Marshall Davies Journal of Neurosurgery: Spine.2020; 32(5): 777. CrossRef
Segmental Motion of the Cervical Spine After Total Disc Replacement Using ActivC Versus Discectomy and Fusion Using Stand-alone Cage Bum-Joon Kim, Se-Hoon Kim, Seung-Hwan Lee, Sung-Kon Ha, Sang-Dae Kim, Dong-Jun Lim World Neurosurgery.2019; 126: e1228. CrossRef
Cervical disc arthroplasty for less-mobile discs Tsung-Hsi Tu, Chu-Yi Lee, Chao-Hung Kuo, Jau-Ching Wu, Hsuan-Kan Chang, Li-Yu Fay, Wen-Cheng Huang, Henrich Cheng Journal of Neurosurgery: Spine.2019; 31(3): 310. CrossRef
Recent advances in the management of cervical spondylotic myelopathy: bibliometric analysis and surgical perspectives Yu-Chun Chen, Chao-Hung Kuo, Chieh-Ming Cheng, Jau-Ching Wu Journal of Neurosurgery: Spine.2019; 31(3): 299. CrossRef
Anterior Cervical Disc Replacement : Current Status and Future Perspective in Japan Toshihiro Takami, Kentaro Naito, Kenji Ohata Spinal Surgery.2019; 33(2): 144. CrossRef
Effect of Myelopathy on Early Clinical Improvement After Cervical Disc Replacement: A Study of a Local Patient Cohort and a Large National Cohort Andre M. Samuel, Harold G. Moore, Avani S. Vaishnav, Steven McAnany, Todd Albert, Sravisht Iyer, Yoshihiro Katsuura, Catherine Himo Gang, Sheeraz A. Qureshi Neurospine.2019; 16(3): 563. CrossRef
Preservation Versus Elimination of Segmental Motion in Anterior Cervical Spine Surgery Wen-Cheng Huang, Jau-Ching Wu Neurospine.2019; 16(3): 576. CrossRef
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