Post-operative radiculitis following one or two level anterior lumbar surgery with or without posterior instrumentation.

The purpose of this study was to define risk factors for non-compression radiculitis following anterior lumbar surgery with or without posterior instrumentation and to define a time to resolution. In this study, we followed 58 consecutive patients who had anterior lumbar surgery with or without posterior instrumentation. We identified those with and without post-operative radiculitis. There as a 36.5% rate of postoperative radiculitis. We found that there was a moderate to strong correlation with height change and radiculitis (p = 0.044). Additionally patients treated with rh-BMP2 had a higher risk of developing symptoms. In all of the patients who developed postoperative radiculitis, symptoms resolved by 3 months. In conclusion 36.5% of patients developed post operative radiculitis. This was associated with the use of rh-BMP2, as well as increasing disc height through surgery. All symptoms resolved by 3 months posoperatively.

Innovative Technology System to Prevent Wrong Site Surgery and Capture Near Misses: A Multi-Center Review of 487 Cases.

Introduction: Wrong site surgery (WSS) is a preventable error. When these events do occur, they are often devastating to the patient, nursing staff, surgeon, and facility where the surgery was performed. Despite the implementation of protocols and checklists to reduce the occurrence of WSS, the rates are estimated to be unchanged. Materials and Methods: An innovative technology was designed to prevent WSS through a systems-based approach. The StartBox Patient Safety System was utilized at six sites by 11 surgeons. The incidence of near misses and WSS was reviewed. Results: The StartBox System was utilized for 487 orthopedic procedures including Spine, Sports Medicine, Hand, and Joint Replacement. There were no occurrences of WSS events. Over the course of these procedures, medical staff recorded 17 near misses utilizing the StartBox System. Conclusions: StartBox successfully performed all tasks without technical errors and identified 17 near miss events. The use of this system resulted in the occurrence of zero wrong site surgeries.

An Update on Wrong-Site Spine Surgery.

STUDY DESIGN: Broad narrative review of current literature and adverse event databases. OBJECTIVE: The aim of this review is to report the current state of wrong-site spine surgery (WSSS), whether the Universal Protocol has affected the rate, and the current trends regarding WSSS. METHODS: An updated review of the current literature on WSSS, the Joint Commission sentinel event statistics database, and other state adverse event statistics database were performed. RESULTS: WSSS is an adverse event that remains a potentially devastating problem, and although the incidence is difficult to determine, the rate is low. However, given the potential consequences for the patient as well as the surgeon, WSSS remains an event that continues to be reported alarmingly as often as before the implementation of the Universal Protocol. CONCLUSIONS: A systems-based approach like the Universal Protocol should be effective in preventing wrong-patient, wrong-procedure, and wrong-sided surgeries if the established protocol is implemented and followed consistently within a given institution. However, wrong-level surgery can still occur after successful completion of the Universal Protocol. The surgeon is the sole provider who can establish the correct vertebral level during the operation, and therefore, it is imperative that the surgeon design and implement a patient-specific protocol to ensure that the appropriate level is identified during the operation.

Defining the Normal Trends of Serum Creatine Kinase Levels Following Spinal Surgery.

STUDY DESIGN: Prospective, prognostic study, level II evidence. PURPOSE: To define the normal change in the creatine kinase (CK) levels in patients undergoing prone or supine lumbar or cervical spine surgery and to determine if positioning influences the postoperative changes in the CK levels. OVERVIEW OF LITERATURE: Spine surgery is one of the most commonly performed and fastest growing areas of surgery in the United States. Thus, the various possible complications need to be understood, and risk factors for these complications need to be mitigated. One of the rare complications, reported in the literature as small case series and case reports, is rhabdomyolysis, diagnosed by high CK levels. Thus far, very few studies have examined the rise in CK levels following spine surgery, and to our knowledge, none has assessed the potential association of surgical positioning and the rise in CK levels. METHODS: We retrospectively analyzed 94 patients. We obtained their preoperative CK levels, and re-assessed their CK levels at postoperative day (POD) 1, 2, and 3, as well as at their 2-week follow-up. The data were analyzed with respect to the spine level and positioning to determine if positioning had any effect on the postoperative rise in the CK level. RESULTS: Total 94 consecutive patients were enrolled in this study. The average preoperative CK level was 179.64, and the average CK level was 847.04 on POD 1. Prone positioning showed a greater rise in the CK levels following surgery than the supine positioning. In a similar manner, lumbar procedures led to a larger rise in the CK levels than cervical surgery. Prone/lumbar surgery showed the largest increase among all groups. Finally, revision surgery and instrumentation both increased the postoperative CK levels. CONCLUSIONS: This study demonstrated that positioning can affect the postoperative CK level rise, with patients undergoing prone/ lumbar surgery showing the greatest rise in the postoperative CK levels. This rise, however, may be related to paraspinal muscle damage, rather than the positioning itself.

Harvesting Autogenous Cancellous Bone Graft from the Anterior Iliac Crest.

Autograft bone graft harvest is an important surgical technique in the armamentarium of the orthopaedic surgeon. The iliac crest can provide a robust amount of bone graft, but using it carries a risk of complications including neurologic injury, gait disturbance, sensory dysesthesia, and ilium fracture. We present a surgical technical involving harvest of cancellous bone graft from the anterior iliac crest that minimizes the complication profile associated with tricortical bone graft harvest. It should be noted that there are differences between the outcomes of anterior and posterior crest harvests. Anterior autograft harvest is associated with a higher complication rate, with more iliac wing fractures, postoperative hematomas, and sensory disturbances. The posterior approach, however, is associated with more postoperative pain than the anterior approach, with the patient often experiencing more pain from the harvest than from the procedure itself. The all-cancellous iliac crest bone graft harvest provides the benefit of a large quantity of autogenous bone for various procedures, ranging from spinal fusion to osseous reconstruction. The major steps of this procedure are (1) offset of the surgical incision, (2) exposure of the iliac crest while avoiding neurologic structures, (3) identifying the location of and performing a corticotomy of the iliac crest, (4) harvesting the cancellous bone graft using curets, (5) obtaining hemostasis, and (6) performing a layered closure. The postoperative course entails immediate weight-bearing as tolerated. There is a potential for complications, which are discussed at the individual points of concern during this video.

Anterior Fixation of Floating Facet Fractures in the Cervical Spine: A Prospective Case Series and Biomechanical Analysis.

BACKGROUND: Unilateral fractures involving complete separation of the lateral mass from the vertebra and lamina (floating lateral mass fractures) are a unique subset of cervical spine fractures. These injuries are at significant risk for displacement without operative fixation. Posterior fixation has proven to facilitate adequate fusion. However, there are few data supporting the clinical success of single-level anterior fixation. METHODS: Biomechanical evaluation of floating lateral mass fractures and a consecutive case series of patients with rotationally unstable floating lateral mass fractures treated with anterior fixation using an integrated cage-screw device with anterior plating (ICSD) was performed. The study comprised 7 fresh human cadaver cervical spines (C2-C7), and 11 patients with floating lateral mass fractures. Segmental flexibility testing evaluating axial rotation, flexion/extension, and lateral bending was performed in a cadaveric model after 2 types of single-level anterior fixation and 1 type of 2-level posterior fixation. Eleven patients with a floating lateral mass fracture of the cervical spine underwent anterior fixation with an ICSD. Radiographs and clinical outcomes were retrospectively reviewed. RESULTS: Compared with the intact condition, posterior instrumentation significantly (P < .05) reduced range of motion (ROM) in all 3 planes; anterior fixation with cervical plate and interbody spacer significantly reduced ROM in lateral bending only; and the ICSD significantly reduced ROM in flexion/extension and lateral bending. In the clinical arm, there were no long-term complications, subsidence >2 mm, failure of fixation, reoperation, pseudoarthrosis, or listhesis at final follow-up. CONCLUSIONS: The addition of 2 screws placed through a cervical cage can improve anterior fixation in a human cadaveric model of floating lateral mass fractures. Early clinical results demonstrate a low complication rate and a high rate of healing with single-level anterior fixation using this technique.

The Science and Clinical Applications of Placental Tissues in Spine Surgery.

STUDY DESIGN: Narrative literature review. OBJECTIVES: Placental tissue, amniotic/chorionic membrane, and umbilical cord have seen a recent expansion in their clinical application in various fields of surgery. It is important for practicing surgeons to know the underlying science, especially as it relates to spine surgery, to understand the rationale and clinical indication, if any, for their usage. METHODS: A literature search was performed using PubMed and MEDLINE databases to identify studies reporting the application of placental tissues as it relates to the practicing spine surgeon. Four areas of interest were identified and a comprehensive review was performed of available literature. RESULTS: Clinical application of placental tissue holds promise with regard to treatment of intervertebral disc pathology, preventing epidural fibrosis, spinal dysraphism closure, and spinal cord injury; however, there is an overall paucity of high-quality evidence. As such, evidence-based guidelines for its clinical application are currently unavailable. CONCLUSIONS: There is no high-level clinical evidence to support the application of placental tissue for spinal surgery, although it does hold promise for several areas of interest for the practicing spine surgeon. High-quality research is needed to define the clinical effectiveness and indications of placental tissue as it relates to spine surgery.

Preventing Construct Subsidence Following Cervical Corpectomy: The Bump-stop Technique.

Cervical corpectomy is a viable technique for the treatment of multilevel cervical spine pathology. Despite multiple advances in both surgical technique and implant technology, the rate of construct subsidence can range from 6% for single-level procedures to 71% for multilevel procedures. In this technical note, we describe a novel technique, the bump-stop technique, for cervical corpectomy. The technique positions the superior and inferior screw holes such that the vertebral bodies bisect them. This allows for fixation in the dense cortical bone of the endplate while providing a buttress to corpectomy cage subsidence. We then discuss a retrospective case review of 24 consecutive patients, who were treated using this approach, demonstrating a lower than previously reported cage subsidence rate.

The Wiese Knot: A Sliding-Locking Arthroscopic Knot.

Despite recent advances in knotless suture devices for arthroscopic surgical procedures, arthroscopic knot tying remains a necessary skill for the arthroscopic surgeon. Successful completion of arthroscopic knot tying relies on a thorough understanding of the chosen technique, proper suture management, adequate knot tensioning and securement, and the ability to reproducibly create the knot. We introduce a technique that serves as both a sliding and locking knot while being simple to master and reproducible to perform.

Hemodialysis-Associated Spondylodiscitis of the Cervical Spine: A Case Report.

CASE: A fifty-seven-year-old, hemodialysis-dependent man presented with a one-month history of progressive neck pain and paresthesias of the upper extremities. Radiographic examination demonstrated collapse of the C5 and C6 vertebrae with resultant kyphosis and spinal cord compression. CONCLUSION: The patient underwent a staged anterior debridement with C5 and C6 corpectomies, cage placement, and plate fixation of C4 to C7, followed by a posterior arthrodesis from C4 to C7. He completed a six-week course of intravenous antibiotics for the treatment of Staphylococcus epidermidis spondylodiscitis, followed by suppressive oral antibiotics. At one year of follow-up, he had no residual neck pain or neurological signs or symptoms.

A novel alternative for removal of the AxiaLif (TranS1) in the setting of pseudarthrosis of L5-S1.

BACKGROUND: Minimally invasive spine surgery continues to be a growing trend for orthopedic and neurosurgical spinal interventions. Technological advances have allowed surgeons to perform L5-S1 fusions via posterolateral or anterior approaches through less invasive techniques. The development of the AxiaLIF system (TranS1, Inc., Wilmington, NC) is predicated on the application of minimally invasive techniques to attain fusion at L5-S1 and L4-S1 levels with a novel corridor of approach, described as the presacral "safe zone." PURPOSE: The authors describe an alternative approach for removing a L5-S1 transsacral implant that was placed through a percutaneous paracoccygeal approach using the presacral safe zone. The purpose of this technical note is to demonstrate that use of the previous percutaneous presacral tract, as recommended by the manufacturer, is not mandatory. In cases of anterior pseudarthrosis following this device, a paramedian retroperitoneal approach to L5-S1 not only allows for adequate visualization for revision but also provides adequate and safe caudal exposure over the sacral promontory to remove the implant through its previous osseous path. STUDY DESIGN/SETTING: This technical note highlights the concerns for revision of the AxiaLif (TranS1) screw through the presacral scarred tract. METHODS: The AxiaLif (TranS1), used in this case is an alternative method to anterior, posterior, or transforaminal lumbar interbody fusion. Removal of this implant for pseudarthrosis was performed through a paramedian retroperitoneal approach with caudal extension. After anterior discectomy, the AxiaLif screw was removed via manipulation through the disc space and delivered through the sacrum. This was followed by complete discectomy and bone grafting of the voids left in the L5 and sacral vertebral bodies. Standard anterior lumbar interbody reconstruction was then performed using a polyetheretherketone implant followed by revision of the pedicle screw construct posteriorly. RESULTS: Preoperative symptoms were resolved in the immediate postoperative period secondary to the immediate stability afforded by the revision of the loose implants. Fusion was achieved within 6 months and confirmed with fine-cut computed tomography images. CONCLUSION: This novel technique of avoiding a scarred down presacral corridor in the hands of surgeons unfamiliar with the technique allows for safe removal of the AxiaLif (TranS1) implant coupled with revision to anterior lumbar interbody fusion through the same incision.

Distal biceps tendon insertion: an anatomic study.

Knowledge of the exact location of the distal biceps brachii insertion is crucial when performing tendon reconstruction or repair. To quantitatively describe the morphology of the distal biceps brachii insertion, 20 cadaveric arms were examined. Linear and angular measurements, including the footprint dimensions and shape, radial tuberosity dimensions and irregularities, and the rotational position of the tuberosity and footprint, were obtained. The axial and transverse dimensions of the radial tuberosity and distal biceps tendon footprint measured 24.2 x 12 mm and 18.7 x 3.7 mm, respectively. The insertion footprint is on the posterior/ulnar aspect of the radial tuberosity centered at approximately 30 degrees anterior to the lateral/coronal plane with the forearm fully supinated. This explains why any preoperative limitation in supination may make an anatomic repair difficult through a single anterior incision. To our knowledge, this is the first study to quantitatively describe the angular location of the radial tuberosity and the relationship of the distal biceps tendon on the tuberosity.