Outcomes and complications of surgical treatment of anterior osteophytes causing dysphagia: Single center experience.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To better understand the functional swallow outcomes, cervical balance, and surgical complications, we examined patients with anterior osteophytes and dysphagia who were treated operatively. SUMMARY OF BACKGROUND DATA: Anterior osteophytes from diffuse idiopathic skeletal hyperostosis (DISH) or degenerative etiology of the cervical spine can cause dysphagia from mechanical compression of the esophagus. Osteophytectomy is generally accepted as a safe surgical treatment, but the risk of instability is unclear. The potential for associated complications must be considered. METHODS: Patients who had anterior osteophytes and dysphagia from 2005 to 2020 were reviewed retrospectively. Demographics, radiographic parameters, functional swallow outcome, and complications were examined. RESULTS: There were 15 patients identified treated surgically. Increased osteophyte height positively correlated with severity of dysphagia with Pearson coefficient of 0.53 (p = 0.042). Functional Outcome Swallowing Scale (FOSS) scores improved after surgical treatment from median of 2 to 0 (p = 0.002). C2-7 SVA did increase by 8 mm (p = 0.007) but was generally well tolerated. There was a 27% complication rate including a case of C5 lateral mass fracture with central cord syndrome after a fall 4 days following osteophytectomy. There was one patient who was preoperatively dependent on gastrostomy tube who required a tracheostomy and had continued reliance on the gastrostomy tube. CONCLUSION: Surgical treatment of anterior osteophytes causing dysphagia with osteophytectomy can lead to overall improved FOSS scores for most patients. However, a high preoperative FOSS score may be a prognostic indicator of poor postoperative functional swallow outcome. It is important to consider the potential for instability when osteophytectomy is performed at 3 or more spinal segments.

Spondylodiscitis in end-stage renal disease: a systematic review.

OBJECTIVEDiscitis and osteomyelitis are seen in end-stage renal disease (ESRD) patients due to repeated vascular access for hemodialysis and urinary tract infections leading to recurrent bacteremia. Discitis and osteomyelitis are underdiagnosed due to the nonspecific initial presentation of back pain. In this article, we review the literature for better understanding of the problem and the importance of early diagnosis by primary care physicians and nephrologists. In addition, we discuss the decision-making, follow-up, management, and neurological outcomes.METHODSA detailed PubMed search was performed using the following terms: "end stage renal disease (ESRD)" and "chronic renal failure (CRF)," combined with "spine infections," "spondylodiscitis," "discitis," and "osteomyelitis." Search results were limited to articles written in English, case reports, and case series from 1973 to 2012. Editorials, reviews, and commentaries were excluded. Only studies involving human patients were included. The authors also included 4 patients from their own patient population.RESULTSA total of 30 articles met the inclusion criteria. Including the 4 patients from the authors' patient population, 212 patients with spine infections and maintenance dialysis were identified. The patients' ages ranged from 38 to 78 years. The duration of dialysis ranged from a few days to 16 years. The time from onset of back pain to diagnosis ranged from 3 days to 6 months. The most common causative organism was Staphylococcus aureus, followed by Staphylococcus epidermidis and gram-negative bacteria. Most of the patients were treated with antibiotics alone (76.8%), although surgery was indicated when patients presented with neurological deficits (p < 0.011). Approximately one-quarter of the patients developed neurological deficits, with devastating consequences. Fever and neurological deficits at presentation, culture positive for methicillin-resistant S. aureus, and age > 65 years were highly correlated with mortality in our analysis.CONCLUSIONSSeveral risk factors lead to failure of antibiotics and progression of disease in patients with ESRD. Challenges to diagnosis include vague presenting symptoms, co-existing destructive spondyloarthropathy, poor immune response, chronic elevations of inflammatory markers, and recurrent bacteremia. Infectious processes are more likely to cause permanent neurological deficits than transient deficits. The authors recommend close observation and serial imaging of these patients for early signs of neurological deficits. Any signs of disease progression will require aggressive surgical debridement.

Fish-Mouth Thoracic Fracture Fixation with Minimally Invasive Percutaneous Reduction: A Technical Note.

BACKGROUND: Surgical stabilization of thoracic spine fractures is recommended for unstable patterns, yet much debate exists regarding the best approach for reduction. The aim of this article was to report the outcome of a novel method for stabilization of a fish-mouth thoracic spine fracture. METHODS: A retrospective patient chart review was conducted. Data collected included blood loss, operative time, length of stay, perioperative complications, neurologic deficits, and secondary procedures. The patient underwent percutaneous reduction of a hyperextension injury to the thoracic spine. Sufficient reduction was achieved through a percutaneous approach, followed by sequential distraction of 1 rod with sequential locking of the contralateral rod to maintain deformity correction. Electrophysiologic monitoring was used during the procedure. RESULTS: Sufficient fracture reduction was achieved and evaluated on postoperative computed tomography. Operative time was 145 minutes, and estimated blood loss was 120 mL. There were no cerebrospinal fluid leaks, iatrogenic neurologic deficits, implant failures, other systemic events or revisions during the 8-month follow-up. CONCLUSIONS: This article describes the feasibility of using a novel model for reduction and stabilization of fish-mouth thoracic spine fracture with minimal soft tissue violation.

Transdural approach to resection of retro-odontoid cysts in elderly patients: report of 3 cases.

Retro-odontoid cysts that arise from the tectorial membrane are uncommon lesions that can occur in elderly patients. They arise secondary to degenerative changes, including calcium pyrophosphate deposition within the ligaments. Surgical treatment is indicated when these lesions result in intractable pain, instability, and/or myelopathy. Several surgical techniques to treat this condition exist, but the optimal approach in elderly patients with comorbidities remains controversial. Here, the authors present a case series of 3 patients who underwent successful resection of a retro-odontoid lesion performed through a transdural approach. The patients were 70, 81, and 74 years old and presented with symptoms of cervical myelopathy. In consideration of their advanced age and the location of their lesion, resection via a posterior approach was considered. A 1- to 2-cm suboccipital craniectomy and C-1 and partial C-2 laminectomy were performed. These lesions could not be accessed via an extradural posterolateral approach, and so a transdural approach was performed. In the first 2 patients, a preexisting deformity prompted an instrumented fusion. In the third patient, only a lesion resection was performed. In each case, the dural opening was made using a paramedian ipsilateral-sided incision, and the lesion was resected through an incision in the anterior dura mater. Only the posterior dura was closed primarily. MR imaging evidence of excellent spinal cord decompression was evident in follow-up examinations. Transdural resection of retro-odontoid cysts is a viable option for treating asymmetrical ventral extradural cysts. Results from this case series suggest that such an approach is safe and feasible and can provide an alternative to open or endoscopic anterior transpharyngeal approaches.

The Role of Dynamic Magnetic Resonance Imaging in Cervical Spondylotic Myelopathy.

Dynamic spinal cord compression has been investigated for several years, but until the advent of open MRI, the use of dynamic MRI (dMRI) did not gain popularity. Several publications have shown that cervical cord compression is both static and dynamic. On many occasions the evaluation of cervical spondylotic myelopathy (CSM) is straightforward, but patients are frequently encountered with a significantly worse clinical examination than would be suggested by radiological images. In this paper, we present an extensive review of the literature in order to describe the importance of dMRI in various settings and applications. A detailed literature review was performed in the Medline and Pubmed databases using the terms "cervical spondylotic myelopathy", "dynamic MRI", "kinetic MRI", and "myelomalalcia" for the period of 1980-2016. The study was limited to English language, human subjects, case series, retrospective studies, prospective reports, and clinical trials. Reviews, case reports, cadaveric studies, editorials, and commentaries were excluded. The literature search yielded 180 papers, 19 of which met inclusion criteria. However, each paper had evaluated results and outcomes in different ways. It was not possible to compile them for meta-analysis or pooled data evaluation. Instead, we evaluated individual studies and present them for discussion. We describe a number of parameters evaluated in 2661 total patients, including dynamic changes to spinal cord and canal dimensions, transient compression of the cord with changes in position, and the effects of position on the intervertebral disc. dMRI is a useful tool for understanding the development of CSM. It has found several applications in the diagnosis and preoperative evaluation of many patients, as well as certain congenital dysplasias and Hirayama disease. It is useful in correlating symptoms with the dynamic changes only noted on dMRI, and has reduced the incidence of misdiagnosis of myelopathy.

Minimally-Invasive versus Conventional Repair of Spondylolysis in Athletes: A Review of Outcomes and Return to Play.

Spondylolysis from pars fracture is a common injury among young athletes, which can limit activity and cause chronic back pain. While current literature has examined the relative benefits of surgical and conservative management of these injuries, no study has yet compared outcomes between conventional direct repair of pars defects and modern minimally invasive procedures. The goals of surgery are pain resolution, return to play at previous levels of activity, and a shorter course of recovery. In this review, the authors have attempted to quantify any differences in outcome between patients treated with conventional or minimally invasive techniques. A literature search was performed of the PubMed database for relevant articles, excluding articles describing conservative management, traumatic injury, or high-grade spondylolisthesis. Articles included for review involved young athletes treated for symptomatic spondylolysis with either conventional or minimally invasive surgery. Two independent reviewers conducted the literature search and judged articles for inclusion. All studies were classified according to the North American Spine Society standards. Of the 116 results of our initial search, 16 articles were included with a total of 150 patients. Due to a paucity of operative details in older studies and inconsistencies in both clinical methods and reporting among most articles, little quantitative analysis was possible. However, patients in the minimally invasive group did have significantly higher rates of pain resolution (p<0.001). Short recovery times were also noted in this group. Both groups experienced low complication rates, and the majority of patients returned to previous levels of activity. Surgical repair of spondylolysis in young athletes is a safe and practical therapy. Current literature suggests that while conventional repair remains effective, minimally invasive procedures better clinical outcomes. We await further data to conduct a more thorough quantitative analysis of these techniques.

Indeterminate Dendritic Cell Tumor in Thoracic Spine: A Case Report.

BACKGROUND: Indeterminate dendritic cell tumor (IDCT) is an extremely rare hematologic disorder with poorly understood pathogenesis. Occasionally encountered by hematologists, unusual presentations of IDCT have not been reported in the spine literature. METHODS: We report a 51-year-old man who presented with a 3-month history of progressively worsening axial thoracic back pain radiating to his sides. Magnetic resonance imaging revealed a 3-cm enhancing mass at the T9 vertebral body with an exophytic component causing significant canal stenosis. Initial percutaneous biopsy revealed histiocytic sarcoma. RESULTS: The patient underwent exploratory thoracotomy and en bloc resection of the lesion with T8-10 fusion. Final pathology results revealed IDCT with fibrosis. IDCT immunostaining was partially positive for Langerhans cell marker (positive for S100 and CD1a, but lacked Birbeck granules and Langerin stain) and partially positive for blastic plasmacytoid dendritic cell neoplasm. Additionally, it was positive for CD45, CD68, and CD163. Lymphadenopathy was absent in this patient. CONCLUSIONS: Although first reported in the 1980s, IDCT has been omitted from most classifications owing to its rarity. Hematologists have debated the cell of origin; it is believed to comprise pre-Langerhans cells, as Birbeck granules are acquired after migration to the epidermis. IDCT remains of indeterminate origin. We report the first case of spinal IDCT. Familiarity with the histologic features is warranted to ensure accurate diagnosis and appropriate treatment.

Endoscope-Assisted Abscess Drainage Secondary to Endoscope-Assisted Transforaminal Lumbar Interbody Fusion: 1-Year Follow-Up.

INTRODUCTION: Endoscopic discectomy and fusions have been gaining popularity in the recent past and are noted to be safe for their application in elderly population. The procedure involves ultra-small incision for discectomy followed by placement of percutaneous screws in awake patients. Treatment of advanced spinal pathology with endoscope-assisted techniques is challenging. Although not common with the endoscopic approach, postoperative infection can be problematic, as there are no established guidelines on its management. METHODS: A 76-year-old female patient underwent lumbar 4-5 endoscopic-assisted transforaminal lumbar interbody fusion for severe degenerative changes leading to back and radicular leg pain. She did well postoperatively and was discharged home the following day. She presented to the outside hospital with new onset of severe back pain, sepsis, and positive methicillin-susceptible Staphylococcus aureus with blood culture and demonstrated no improvement while on antibiotics. RESULTS: Initial magnetic resonance imaging revealed postoperative changes only. With positive blood culture and localized pain, she was then offered to undergo a percutaneous drainage of the abscess. Under local anesthesia and intravenous sedation, a small pocket of collection was found along the endoscopic trajectory from previous surgery. After evacuation of the collection, the interbody device was irrigated with vancomycin through endoscope. Postoperatively, immediate symptomatic improvement was noted in back pain. She was discharged home on oxacillin and continues to do well at 12 months' follow-up with excellent fusion. CONCLUSIONS: The present case illustrates the successful treatment of a surgical-site infection after endoscope-assisted transforaminal lumbar interbody fusion via a repeat percutaneous endoscopic approach.

Trends in Open and Endoscopic Cubital Tunnel Release in the Medicare Patient Population.

BACKGROUND: Cubital tunnel syndrome (CUT) is the second most common peripheral neuropathy with an annual incidence of 24.7 per 100 000, affecting nearly twice as many men as women. With increasing focus on cost-effectiveness and cost-containment in medicine, a critical understanding of utilization of health care resources for open and endoscopic approaches for cubital tunnel release is of value. The purpose of this study was to evaluate the costs and utilization trends of open and endoscopic cubital tunnel release. METHODS: We performed a retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, Indiana) for procedures performed from 2005 to 2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate were evaluated. RESULTS: Our query returned 262 104 patients with CUT, of which 69 378 (26.5%) and 4636 (1.8%) were surgically managed with open and endoscopic release respectively. Average charges were higher in endoscopic release ($3798) than open release ($3197) while reimbursements were higher in open releases ($1041) than endoscopic release, ($866). Both were performed most commonly in the <65 years age range. CONCLUSIONS: Despite the unexpectedly lower reimbursement rate with endoscopic release, endoscopy utilization is growing faster than open releases in the Medicare population. Lower reimbursement is likely related to lack of a dedicated current procedural terminology code for endoscopic cubital tunnel release.

Trends in open and endoscopic carpal tunnel release utilization in the Medicare patient population.

BACKGROUND: Surgical management of carpal tunnel syndrome (CTS) is performed with an open or endoscopic approach. Current literature suggests that the endoscopic approach is associated with higher costs and a steeper learning curve. This study evaluated the billing and utilization trends of both approaches. METHODS: A retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, IN) was performed for patients undergoing open carpal tunnel release (OCTR) or endoscopic carpal tunnel release (ECTR) from 2005-2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate (CAGR) were evaluated. RESULTS: Our query returned 1,500,603 carpal tunnel syndrome patients, of which 507,924 (33.8%) and 68,768 (4.6%) were surgically managed with OCTR and ECTR respectively (remainder treated conservatively). Compound annual growth rate was significantly higher in ECTR (5%) than OCTR (0.9%; P < 0.001). Average charges were higher in OCTR ($3820) than ECTR ($2952), whereas reimbursements were higher in ECTR (mean $1643) than OCTR (mean $1312). Both were performed most commonly in the age range of 65-69 y, females, and southern geographic region. CONCLUSIONS: ECTR is growing faster than OCTR in the Medicare population. Contrary to previous literature, our study shows that ECTR had lower charges and reimbursed at a higher rate than OCTR.

Augmented-reality integrated robotics in neurosurgery: are we there yet?

Surgical robots have captured the interest-if not the widespread acceptance-of spinal neurosurgeons. But successful innovation, scientific or commercial, requires the majority to adopt a new practice. "Faster, better, cheaper" products should in theory conquer the market, but often fail. The psychology of change is complex, and the "follow the leader" mentality, common in the field today, lends little trust to the process of disseminating new technology. Beyond product quality, timing has proven to be a key factor in the inception, design, and execution of new technologies. Although the first robotic surgery was performed in 1985, scant progress was seen until the era of minimally invasive surgery. This movement increased neurosurgeons' dependence on navigation and fluoroscopy, intensifying the drive for enhanced precision. Outside the field of medicine, various technology companies have made great progress in popularizing co-robots ("cobots"), augmented reality, and processor chips. This has helped to ease practicing surgeons into familiarity with and acceptance of these technologies. The adoption among neurosurgeons in training is a "follow the leader" phenomenon, wherein new surgeons tend to adopt the technology used during residency. In neurosurgery today, robots are limited to computers functioning between the surgeon and patient. Their functions are confined to establishing a trajectory for navigation, with task execution solely in the surgeon's hands. In this review, the authors discuss significant untapped technologies waiting to be used for more meaningful applications. They explore the history and current manifestations of various modern technologies, and project what innovations may lie ahead.

Metals in Spine.

The treatment of spinal disorders requires the consideration of a number of factors and understanding the type of material we are implanting is important. Alloys have different mechanical properties and behave differently under different physiologic conditions. Spinal implants need to have good performance in the characteristics of biofunctionality and biocompatibility. In this review, the alloys titanium, cobalt-chrome, nitinol, and tantalum will be examined closely. Several of the important properties that are considered when selecting an alloy for use in spinal instrumentation are explored and detailed for each. This allows for an assessment and comparison of each alloy and a possible determination of which is the best alloy for specific surgery or the best alloy for use in specific situations.

The Use of Intraoperative Electromyogram During Spinal Cord Stimulator Placement Surgery: A Case Series.

BACKGROUND: Spinal cord stimulation (SCS) is an efficacious treatment for various chronic pain syndromes culminating predominantly into spinal nerves. To improve intraoperative electrode placement, several groups have advocated the use of intraoperative neuromonitoring for localization of the spinal cord midline. In our study we present the case series of patients undergoing stimulator placement with consistent electromyographic intraoperative testing, with an emphasis on examining reoperation rates and complications. METHODS: After approval from the institutional review board, we retrospectively collected data on standard demographics, preoperative diagnoses, prior spine surgeries, electrode manufacturer, blood loss, complications, and patient outcome. RESULTS: The study included 103 patients with an average age of 60.7 years. Of these, 72 (69.9%) had prior spine surgery, which was associated with higher rate of reoperation (P = 0.019). The mean latency between initial SCS implantation and revision surgery ± SD was 14.6 ± 17.2 months, with a median time of 280 days. There was a 13.6% complication rate. Common complications that lead to reoperation included migrated electrode or failed generator. CONCLUSIONS: Our retrospective chart review of 103 patients indicates that patients receiving SCS implantation in conjunction with electromyographic monitoring have low complication rates and rarely return to the operating room for electrode repositioning or removal.

Surgical outcomes of elderly patients with cervical spondylotic myelopathy: a meta-analysis of studies reporting on 2868 patients.

OBJECTIVE Cervical spondylotic myelopathy usually presents in the 5th decade of life or later but can also present earlier in patients with congenital spinal stenosis. As life expectancy continues to increase in the United States, the preconceived reluctance toward operating on the elderly population based on older publications must be rethought. It is a known fact that outcomes in the elderly cannot be as robust as those in the younger population. There are no publications with detailed meta-analyses to determine an acceptable level of outcome in this population. In this review, the authors compare elderly patients older than 75 years to a nonelderly population, and they discuss some of the relevant strategies to minimize complications. METHODS In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the authors performed a PubMed database search to identify English-language literature published between 1995 and 2015. Combinations of the following phrases that describe the age group ("elderly," "non-elderly," "old," "age") and the disease of interest as well as management ("surgical outcome," "surgery," "cervical spondylotic myelopathy," "cervical degenerative myelopathy") were constructed when searching for relevant articles. Two reviewers independently assessed the outcomes, and any disagreement was discussed with the first author until it was resolved. A random-effects model was applied to assess pooled data due to high heterogeneity between studies. The mean difference (MD) and odds ratio were calculated for continuous and dichromatic parameters, respectively. RESULTS Eighteen studies comprising elderly (n = 1169) and nonelderly (n = 1699) patients who received surgical treatment for cervical spondylotic myelopathy were included in this meta-analysis. Of these studies, 5 were prospective and 13 were retrospective. Intraoperatively, both groups required a similar amount of operation time (p = 0.35). The elderly group had lower Japanese Orthopaedic Association (JOA) scores (MD -1.36, 95% CI -1.62 to -1.09; p < 0.00001) to begin with compared with the nonelderly group. The nonelderly group also had a higher postoperative JOA score (MD -1.11, 95% CI -1.44 to -0.79; p < 0.00001), therefore demonstrating a higher recovery rate from surgeries (MD -11.98, 95% CI -16.16 to -7.79; p < 0.00001). The length of stay (MD 4.14, 95% CI 3.54-4.73; p < 0.00001) was slightly longer in the elderly group. In terms of radiological outcomes, the elderly group had a smaller postoperative Cobb angle but a greater increase in spinal canal diameter compared with the nonelderly group. The complication rates were not significant. CONCLUSIONS Cervical myelopathy is a disease of the elderly, and age is an independent factor for recovery from surgery. Postoperative and long-term outcomes have been remarkable in terms of improvement in mobility and independence requiring reduced nursing care. There is definitely a higher potential risk while operating on the elderly population, but no significant difference in the incidence of postoperative complications was noted. Withholding surgery from the elderly population can lead to increased morbidity due to rapid progression of symptoms in addition to deconditioning from lack of mobility and independence. Reduction in operative time under anesthesia, lower blood loss, and perioperative fluid management have been shown to minimize the complication rate. The authors request that neurosurgeons weigh the potential benefit against the risks for every patient before withholding surgery from elderly patients.

Early experience with endoscopic revision of lumbar spinal fusions.

Approximately half a million spinal fusion procedures are performed annually in the US. It is estimated that up to one-third of arthrodesis constructs require revision surgeries. In this study the authors present endoscopic treatment strategies targeting 3 types of complications following arthrodesis surgery: 1) adjacent-level foraminal stenosis; 2) foraminal stenosis at an arthrodesis segment; and 3) stenosis caused by a displaced interbody cage. A retrospective chart review of 11 patients with a mean age of 68 ± 15 years was performed (continuous variables are shown as the mean ± SEM). All patients had a history of lumbar arthrodesis surgery and suffered from unilateral radiculopathy. Endoscopic revision surgeries were done as outpatient procedures, and there were no intraoperative or perioperative complications. The cohort included 3 patients with foraminal stenosis at the level of previous arthrodesis. They presented with unilateral radicular leg pain (visual analog scale [VAS] score: 7.3 ± 2.1) and were severely disabled, as evidenced by an Oswestry Disability Index (ODI) of 46 ± 4.9. Transforaminal endoscopic foraminotomies were performed, and at a mean follow-up time of 9.0 ± 2.5 months VAS was reduced by an average of 6.3. The cohort also includes 7 patients suffering unilateral radiculopathy due to adjacent-level foraminal stenosis. Preoperative VAS for leg pain of the symptomatic side was 6.0 ± 1.6, VAS for back pain was 5.2 ± 1.7, and ODI was 40 ± 6.33. Endoscopic decompression led to reduction of the ipsilateral leg VAS score by an average of 5, resulting in leg pain of 1 ± 0.5 at an average of 8 months of follow-up. The severity of back pain remained stable (VAS 4.2 ± 1.4). Two of these patients required revision surgery for recurrent symptoms. Finally, this study includes 1 patient who presented with weakness and pain due to retropulsion of an L5/S1 interbody spacer. The patient underwent an endoscopic interlaminar approach with partial resection of the interbody cage, which resulted in complete resolution of her radicular symptoms. Endoscopic surgery may be a useful adjunct for management of certain arthrodesis-related complications. Endoscopic foraminal decompression of previously fused segments and resection of displaced interbody cages appears to have excellent outcomes, whereas decompression of adjacent segments remains challenging and requires further investigation.

Transforaminal endoscopic discectomy to relieve sciatica and delay fusion in a 31-year-old man with pars defects and low-grade spondylolisthesis.

Isthmic spondylolisthesis due to pars defects resulting from trauma or spondylolysis is not uncommon. Symptomatic patients with such pars defects are traditionally treated with a variety of fusion surgeries. The authors present a unique case in which such a patient was successfully treated with endoscopic discectomy without iatrogenic destabilization. A 31-year-old man presented with a history of left radicular leg pain along the distribution of the sciatic nerve. He had a disc herniation at L5/S1 and bilateral pars defects with a Grade I spondylolisthesis. Dynamic radiographic studies did not show significant movement of L-5 over S-1. The patient did not desire to have a fusion. After induction of local anesthesia, the patient underwent an awake transforaminal endoscopic discectomy via the extraforaminal approach, with decompression of the L-5 and S-1 nerve roots. His preoperative pain resolved immediately, and he was discharged home the same day. His preoperative Oswestry Disability Index score was 74, and postoperatively it was noted to be 8. At 2-year follow-up he continued to be symptom free, and no radiographic progression of the listhesis was noted. In this case preservation of stabilizing structures, including the supraspinous and interspinous ligaments and the facet capsule, may have reduced the likelihood of iatrogenic instability while at the same time achieving symptom control. This may be a reasonable option for select patient symptoms confined to lumbosacral radiculopathy.

Early experience with endoscopic foraminotomy in patients with moderate degenerative deformity.

OBJECTIVE Asymmetrical degeneration of the disc is one of the most common causes of primary degenerative scoliosis in adults. Coronal deformity is usually less symptomatic than a sagittal deformity because there is less expenditure of energy and hence less effort to maintain upright posture. However, nerve root compression at the fractional curve or at the concave side of the main curve can give rise to debilitating radiculopathy. METHODS This study was a retrospective analysis of 16 patients with coronal deformity of between 10° and 20°. All patients underwent endoscopic foraminal decompression surgery. The pre- and postoperative Cobb angle, visual analog scale (VAS), 36-Item Short Form Health Survey (SF-36), and Oswestry Disability Index scores were measured. RESULTS The average age of the patients was 70.0 ± 15.5 years (mean ± SD, range 61-86 years), with a mean followup of 7.5 ± 5.3 months (range 2-14 months). The average coronal deformity was 16.8° ± 4.7° (range 10°-41°). In 8 patients the symptomatic foraminal stenosis was at the level of the fractional curve, and in the remaining patients it was at the concave side of the main curve. One of the patients included in the current cohort had to undergo a repeat operation within 1 week for another disc herniation at the adjacent level. One patient had CSF leakage, which was repaired intraoperatively, and no further complications were noted. On average, preoperative VAS and SF-36 scores showed a tendency for improvement, whereas a dramatic reduction of VAS, by 65% (p = 0.003), was observed in radicular leg pain. CONCLUSIONS Patients with mild to moderate spinal deformity are often compensated and have tolerable levels of back pain. However, unilateral radicular pain resulting from foraminal stenosis can be debilitating. In select cases, an endoscopic discectomy or foraminotomy enables the surgeon to decompress the symptomatic foramen with preservation of essential biomechanical structures, delaying the need for a major deformity correction surgery.

Reconstruction of open wounds as a complication of spinal surgery with flaps: a systematic review.

OBJECT A systematic review of the available evidence on the prophylactic and therapeutic use of flaps for the coverage of complex spinal soft-tissue defects was performed to determine if the use of flaps reduces postoperative complications and improves patient outcomes. METHODS A PubMed database search was performed to identify English-language articles published between 1990 and 2014 that contained the following phrases to describe postoperative wounds ("wound," "complex back wound," "postoperative wound," "spine surgery") and intervention ("flap closure," "flap coverage," "soft tissue reconstruction," "muscle flap"). RESULTS In total, 532 articles were reviewed with 17 articles meeting the inclusion criteria of this study. The risk factors from the pooled analysis of 262 patients for the development of postoperative complex back wounds that necessitated muscle flap coverage included the involvement of instrumentation (77.6%), a previous history of radiotherapy (33.2%), smoking (20.6%), and diabetes mellitus (17.2%). In patients with instrumentation, prophylactic coverage of the wound with a well-vascularized flap was shown to result in a lower incidence of wound complications. One study showed a statistically significant decrease in complications compared with patients where prophylactic coverage was not performed (20% vs 45%). The indications for flap coverage after onset of wound complications included hardware exposure, wound infection, dehiscence, seroma, and hematoma. Flap coverage was shown to decrease the number of surgical debridements needed and also salvage hardware, with the rate of hardware removal after flap coverage ranging from 0% to 41.9% in 4 studies. CONCLUSIONS Prophylactic coverage with flaps in high-risk patients undergoing spine surgery reduces complications, while therapeutic coverage following wound complications allows the salvage of hardware in the majority of patients.

Deep brain stimulation as a treatment for Parkinson's disease related camptocormia.

In this systematic review, we aimed to profile the various reported interventions for camptocormia in Parkinson's disease (PD) and give an overview of the benefits of deep brain stimulation (DBS). Currently, there is no consensus in the literature regarding this. PD manifests in several ways and camptocormia is one of the commonly encountered problems for both spine and functional neurosurgeons. It is a significant forward flexion of the thoracolumbar spine which resolves in the recumbent position. DBS was introduced in 2002 in the USA, and since then its efficacy and applications have tremendously increased. We reviewed the PubMed and Medical Subject Headings database using the phrases "Parkinson's disease" or "Parkinson" in combination with "spinal deformity" or "camptocormia" or "bent spine syndrome" and "deep brain stimulation". Our review was limited to English language literature and we excluded camptocormia of non-PD origin. Our search yielded 361 articles with 131 patients in the pooled data. The majority (59%) of patients were women and the age range was 48-76 years. While half the patients on levodopa (n=42) saw no improvement of their camptocormia, 71% of the lidocaine group (n=27) and 68% of the DBS group (n=32) showed significant improvement. For mean flexion angle, the spinal surgery and DBS group demonstrated profound improvement in the bending angle, 89.9% and 78.2%, respectively. However, major complications following spinal surgery were noted. Although the results are from a small group of patients, DBS has achieved sustained improvement in camptocormia with low postoperative morbidity, and appears to be a promising treatment option. A larger, long term study is necessary to establish comprehensive outcome data.

Pooled data analysis on anterior versus posterior approach for rheumatoid arthritis at the craniovertebral junction.

OBJECT: Rheumatoid arthritis (RA) is one of the most debilitating autoimmune diseases affecting the craniovertebral junction (CVJ). Patients predominantly present with myelopathic symptoms and intractable neck pain. The surgical approach traditionally has been either a combined anterior and posterior approach or a posterior-only approach. In this article, the authors review pooled data from the literature and discuss the benefits of the two types of approaches. METHODS: A search of the PubMed database was conducted using key words that describe spine deformities in RA and specific spinal interventions. The authors evaluated the neurological outcomes based on the Ranawat scale in both the groups through chi-square analysis. Multiple logistic regression was carried out to further examine for potential confounders. Any adverse sequalae resulting from either approach were also documented. Because all the procedures performed via a transoral approach in the analyzed articles also involved posterior fixation, for convenience of comparison, the combined procedures are referred to as "anterior approach" or "anterior-posterior" in the present study. RESULTS: The search yielded 233 articles, of which 11 described anterior approaches and 14 evaluated posterior approaches. The statistical analysis showed that patients treated with a posterior approach fared better than those treated with an anterior (combined) approach. It was noted that those patients in whom the cervical subluxations were reducible on traction predominantly underwent posterior approaches. CONCLUSIONS: CVJ instability is a serious complication of RA that requires surgical intervention. Although the anterior-posterior combined approach can provide direct decompression, it is associated with morbidity, and the analysis showed no statistically significant benefit to patients. In contrast, the posterior approach has been shown to provide statistically significant superiority with respect to stabilization and subsequent pannus reduction. Surgical approaches are undertaken based on the reducibility of subluxations with traction and the vector of compressive force. However, the choice of surgical approach should be based on the individual patient's pathology.