Effect of Surgical Setting on Hospital-Reported Outcomes for Elective Lumbar Spinal Procedures: Tertiary Versus Community Hospitals.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: As hospital compensation becomes increasingly dependent on pay-for-performance and bundled payment compensation models, hospitals seek to reduce costs and increase quality. To our knowledge, no reported data compare these measures between hospital settings for elective lumbar procedures. The study compares hospital-reported outcomes and costs for elective lumbar procedures performed at a tertiary hospital (TH) versus community hospitals (CH) within a single health care system. METHODS: Retrospective review of a physician-maintained, prospectively collected database consisting of 1 TH and 4 CH for 3 common lumbar surgeries from 2015 to 2016. Patients undergoing primary elective microdiscectomy for disc herniation, laminectomy for spinal stenosis, and laminectomy with fusion for degenerative spondylolisthesis were included. Patients were excluded for traumatic, infectious, or malignant pathology. Comparing hospital settings, outcomes included length of stay (LOS), rates of 30-day readmissions, potentially preventable complications (PPC), and discharge to rehabilitation facility, and hospital costs. RESULTS: A total of 892 patients (n = 217 microdiscectomies, n = 302 laminectomies, and n = 373 laminectomy fusions) were included. The TH served a younger patient population with fewer comorbid conditions and a higher proportion of African Americans. The TH performed more decompressions (P < .001) per level fused; the CH performed more interbody fusions (P = .007). Cost of performing microdiscectomy (P < .001) and laminectomy (P = .014) was significantly higher at the TH, but there was no significant difference for laminectomy with fusion. In a multivariable stepwise linear regression analysis, the TH was significantly more expensive for single-level microdiscectomy (P < .001) and laminectomy with single-level fusion (P < .001), but trended toward significance for laminectomy without fusion (P = .052). No difference existed for PPC or readmissions rate. Patients undergoing laminectomy without fusion were discharged to a facility more often at the TH (P = .019). CONCLUSIONS: We provide hospital-reported outcomes between a TH and CH. Significant differences in patient characteristics and surgical practices exist between surgical settings. Despite minimal differences in hospital-reported outcomes, the TH was significantly more expensive.

Rare Systemic Response to Titanium Spinal Fusion Implant: Case Report.

Neurosurgical patients with titanium spinal implant hypersensitivity can be difficult to diagnosis due to its rarity. Suspicion for titanium allergy is generally localized to the hardware site and may initially be thought to be an infectious process. Patients who report anorexia and fatigue over a long duration after the initial post-operative period may be diagnosed with depression rather than a systemic response to spinal metallic instrumentation. To our knowledge, a systemic titanium hypersensitivity reaction to spinal fixation devices has not been reported in the literature. We offer this report to give spine surgeons additional insight into suspected systemic titanium hypersensitivity symptoms which, if remain unidentified, can severely impair patient outcomes. A 67-year-old female with an unreported nickel allergy developed severe debilitating anorexia and fatigue one month post operatively, secondary to minimally invasive thoracic spinal fixation for T11 burst fracture with disruption of posterior elements. Over a two year period, weight loss reached approximately 25 kilograms with loss of muscle mass and subcutaneous tissue surrounding the spinal implants. The screws and rods were removed to avoid skin erosion. Upon hardware removal, the patient had rapid weight gain, improved stamina and generalized sense of well-being. We recommend the removal of spinal hardware in patients with suspected systemic titanium hypersensitivity reaction.

Minimizing cortical disturbance to access ventricular subependymoma - A novel approach utilizing spinal minimally invasive tubular retractor system.

BACKGROUND: Subependymomas are rare benign tumors found primarily in the lateral and fourth ventricles. Patients become symptomatic when the tumor obstructs cerebrospinal fluid pathways. We present a novel minimally invasive technique for lateral ventricular subependymoma resection. CASE DESCRIPTION: A 57-year-old male presented after a period of progressive ataxia, right upper extremity tremor, and syncopal events. Emergent non-contrast computed tomography of the brain demonstrated a lobulated mass in the left lateral ventricle causing moderate-to-severe obstructive hydrocephalus. Emergent ventriculostomy was placed as a temporizing measure. Subsequent magnetic resonance imaging (MRI) illustrated a large benign appearing mass causing obstruction of the left foramen of Monroe. A small craniotomy was performed utilizing previous ventriculostomy twist hole. The left lateral ventricle was accessed through sequential dilation of ventriculostomy tract using a minimally invasive spine surgery tubular system. Tumor was resected en bloc under microscopic assistance. The patient had an excellent outcome with return to baseline mental status and was discharged from the hospital postoperative day 1. Follow-up MRI demonstrated gross total resection of the mass and decreasing lateral ventricle hydrocephalus with minimal cortical disturbance. CONCLUSION: A minimally invasive tubular system approach to ventricular tumors can be utilized to minimize cortical resection and brain retraction. Minimally invasive surgery also has the potential to decrease the length of stay and enhance postoperative recovery.

A simple technique for thoracoscopic assisted placement of the distal limb of syringopleural shunts.

BACKGROUND: Syringomyelia is an unusual accumulation of fluid within the spinal cord that may be associated with significant neurologic symptoms. Surgical drainage using various techniques is often required to reduce the intraparenchymal pressure and to alleviate symptoms. Syringopleural shunting seems to produce best results. PATIENTS AND METHODS: A simple technique to insert the distal limb of the syringopleural shunt into the pleural space is described in detail. The patient is placed in prone position. The syrinx is accessed from a dorsal incision and the proximal limb is inserted into the fluid cavity. The tube is tunneled through the subcutaneous space laterally and caudally. A 5mm blunt port is inserted lateral to the scapula and advanced under visual control using a 5mm 30° camera through the subcutaneous tissue and muscle and at the upper border of the 5th rib through the intercostals. With ventilation paused, the pleura is penetrated and CO2 is insufflated with a pressure of 8mm mercury. Under visual control the distal limb of the shunt is inserted at the pleural recessus and the tube is directed cranially. Positive airway pressure is applied re-expanding the lung. The trocar is removed from the pleural cavity and the skin is closed with subcuticular sutures. RESULTS: The shunt was successfully placed in three consecutive cases including one redo case (1 male, 1 female aged 50 and 51 years with post traumatic syrinx). Postoperative chest x-ray excluded pneumothorax and no chest tube was required. Neurologic improvement was achieved in both patients. CONCLUSIONS: General surgeons should be familiar with this simple technique similar to laparoscopic assisted placement of distal ventriculoperitoneal shunt catheters into the abdominal cavity.

Modified Minimally Invasive Transforaminal Lumbar Interbody Fusion Technique Can Potentially Improve Safety of Interbody Graft Placement.

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MITLIF) is a well-described procedure with excellent reported outcomes. A modification of interbody graft placement can potentially improve the ease and safety of this procedure. OBJECTIVE: To describe a modification of the MITLIF graft placement and retrospectively review our experience including intraoperative and postoperative complications. METHODS: Single surgeon, single institution, retrospective analysis of consecutive patients who underwent a modified MITLIF technique between November 2011 and December 2013. Hospital records including operative notes and discharge summaries were reviewed for patient demographics, surgical parameters including operative time and estimated blood loss, intraoperative complications including durotomy/cerebrospinal fluid leak, and postoperative outcomes including time before ambulation and length of stay were all reviewed and analyzed. RESULTS: Eighty-three consecutive MITLIF patients; 71 underwent 1-level fusion and 12 had multilevel fusions. Average operative time for single level was 181 min; multilevel was 323 min. Average estimated blood loss was 140 mL. Time before ambulation was <1 d, average length of stay was 1.6 d. There were a total of 4 complications in this series (4.8%). There was zero incidence of durotomy or cerebrospinal fluid leak. CONCLUSION: This modified MITLIF technique of maintaining the medial facet prior to discectomy and interbody graft placement can offer the minimally invasive spine surgeons increased assurance while placing the graft and potentially enhance the overall safety and efficacy of this approach. Surgeons utilizing this approach will have little difficulty utilizing this slight modification.

Stand-alone LLIF Lateral Cage Migration: A Case Report.

Lateral approaches to the lumbar disc space have become popular in recent years with very few reported complications. We report on a rare case of a stand-alone cage migration. A 77-year-old female presented with a right L2-3 radiculopathy that was refractory to maximum medical management. This was secondary to foraminal compression at L2-3 and L3-4 due to degenerative disc disease and levoscoliosis, as well as Grade 1 spondylolisthesis at both levels. A left-sided approach lateral lumbar interbody fusion was performed at L2-3 and L3-4 using a lordotic polyetheretherketone (PEEK) graft (50 mm length x 18 mm width x 9 mm height) packed with demineralized bone matrix (DBM). A contralateral release of the annulus fibrosis was performed during the decompression prior to graft insertion. Postoperative anteroposterior and lateral x-ray imaging confirmed good position of interbody grafts, correction of scoliosis as well as spondylolisthesis, and restoration of disc height achieving foraminal indirect decompression. A routine postoperative x-ray at three months demonstrated asymptomatic ipsilateral cage migration at the L2-3 level with evidence of arthrodesis in the disc space. This was managed conservatively without further surgical intervention. Placement of a lateral plate or interbody intradiscal plating system in patients with scoliosis and significant coronal deformity is an option that can be considered to prevent this rare LLIF complication. Moreover, asymptomatic cage migration may be conservatively managed without reoperation.