MIS lateral spine surgery: a systematic literature review of complications, outcomes, and economics.

BACKGROUND: Over the past decade, the minimally disruptive lateral transpsoas approach for lumbar interbody fusion (MI-LIF) is increasingly being used as an alternative to conventional surgical approaches. The purpose of this review was to evaluate four primary questions as they relate to MI-LIF: (1) Is there an anatomical justification for MI-LIF at L4-5? (2) What are the complication and outcome profiles of MI-LIF and are they acceptable with respect to conventional approaches? (3) Given technical and neuromonitoring differences between various MI-LIF procedures, are there any published clinical differences? And, (4) are modern minimally disruptive procedures (e.g., MI-LIF) economically viable? METHODS: Through a MEDLINE and Google Scholar search, a total of 237 articles that discussed MI-LIF were identified. Of those, topical areas included anatomy (22), biomechanics/testing (17), technical descriptions (11), case reports (40), complications (30), clinical and radiographic outcomes (43), deformity (23), trauma or thoracic applications (10), and review articles (41). RESULTS: In answer to the questions posed, (1) there is a high strength of evidence showing MI-LIF to be anatomically justified at all levels of the lumbar spine from L1-2 to L4-5. The evidence also supports the use of advanced neuromonitoring modalities. (2) There is moderate strength evidence in support of reproducible and reasonable complication, side effect, and outcome profiles following MI-LIF which may be technique dependent. (3) There is low-strength evidence that shows elevated neural complication rates in non-traditional (e.g., shallow-docking approaches and/or those without specialized neuromonitoring) MI-LIF, and (4) there is low- to moderate-strength evidence that modern minimally disruptive surgical approaches are cost-effective. CONCLUSIONS: There is considerable published evidence to support MI-LIF in spinal fusion and advanced applications, though the results of some reports, especially concerning complications, vary greatly depending on technique and instrumentation used. Additional cost-effectiveness analyses would assist in fully understanding the long-term implications of MI-LIF.

Inconsistencies between abstracts and manuscripts in published studies about lumbar spine surgery.

STUDY DESIGN: Systematic review. OBJECTIVE: To perform a comparison of randomized controlled trial (RCT) abstracts and manuscripts published in recent spinal literature. SUMMARY OF BACKGROUND DATA: RCTs represent the "gold standard" upon which evidence-based treatment decisions are made. Inconsistencies between an abstract and manuscript can mislead readers' interpretation of findings and conclusions. Abstract findings are often cited without reference to the manuscript itself. In other fields of medicine, studies have shown discrepancies between RCT abstracts and manuscripts. METHODS: A literature search of RCTs published in Spine, The Spine Journal, and Journal of Spinal Disorders and Techniques during a 10-year period (2001-2010) was performed. All manuscripts described as randomized trials concerning lumbar spinal surgery were selected. Manuscripts were analyzed using a standardized 21-item questionnaire to collect data regarding inconsistencies or bias in the abstract compared with the manuscript. Abstracts were considered deficient if they contained data that were either inconsistent with the manuscript or if they failed to include important findings from the manuscript. Four reviewers reported on the 40 manuscripts that met the inclusion criteria. Each manuscript was reviewed by 2 reviewers. In the event of conflicts in analysis, resolution was achieved through discussion between the reviewers. RESULTS: At least 1 inconsistency was found in 75% of studies. Despite the word "randomized" appearing in 75% of titles and 92.5% of abstracts, the method of randomization was not described in 37.5% of manuscripts and (if described) was considered unacceptable in 28%. The primary outcome of the study was clearly stated in only 22.5% of abstracts and 47.5% of manuscripts. Pertinent negatives were not reported in 40% of the abstracts. Relevant statistically significant results were reported in only 60% of abstracts. CONCLUSION: Abstracts are discrepant with full manuscripts in a surprisingly high proportion of manuscripts. Authors, editors, and peer reviewers should strive to ensure that abstracts accurately represent the data in RCT manuscripts.

Paraganglioma presenting as metastatic lesion in a cervical vertebra: a case report and review of the literature.

STUDY DESIGN: Case report. OBJECTIVE: To discuss the spinal presentation and treatment of paraganglioma, a rare tumor of the extra-adrenal paraganglia, derived from neural crest cells in sympathetic ganglions. SUMMARY OF BACKGROUND DATA: Malignant paragangliomas are a very rare entity. The diagnosis of malignant paraganglioma is made by local recurrence after total resection of the primary mass, or findings of distant metastases. Roughly half of distant metastases are located in the cervical lymph nodes, and the remainder is evenly distributed among bone, lung, and liver. Vertebral metastases are exceedingly rare, and only isolated case reports have described them. METHODS: A 71-year-old man reported increasing neck pain and upper extremity weakness. The patient had a previous carotid body tumor resection in the past and a contralateral carotid body tumor left intact. Our imaging workup, including plain radiograph, computerized tomography scan and MRI, revealed an intraosseous lesion at C6 with vertebral body destruction. The patient underwent decompressive surgery through an anterior Smith-Robinson approach for myelopathy, followed by adjuvant external beam radiation. The histologic and immunohistochemical assays revealed a malignant paraganglioma. RESULTS: Paragangliomas are often highly vascular tumors. Intraoperative blood loss was significant and may have been mitigated by preoperative embolization. The patient showed clinical improvement almost immediately after surgery. CONCLUSION: We report a rare case of malignant paraganglioma and discussed adjuvant treatments to consider for distant metastases, such as I-MIBG, conventional radiotherapy, and chemotherapy.