ABSTRACT
BACKGROUND: Minimally invasive tubular access for posterior cervical foraminotomy can be an effective and safe technique for decompression of the nerve root utilizing minimally invasive muscle splitting with routine outpatient discharge. This technique has come under scrutiny calling into question the associated learning curve, a subjective limited exposure provided, and an argument that the risks and complications are largely unknown. In response to previously published critiques, this study aims to describe the outcomes and complications associated with this technique in a large patient series. METHODS: A retrospective chart review was performed from 1999 to 2013 capturing a single surgeon's experience with the minimally invasive tubular access for posterior cervical foraminotomy technique from a single institution, encompassing 463 patients. Surgical outcome documented at follow-up and complications were obtained from this patient series. Additional variables analyzed include: Hospital length of stay, number of levels operated, targeted root for decompression, side operated, length of surgery, and estimated blood loss. RESULTS: Outpatient discharge was achieved in 91.6% of cases. There were 10 complications (2.2%) among the 463 patients undergoing this technique from 1999 to 2013. Patients were followed for an average of 1 year and 2 months postoperatively. Improvement from the preoperative condition was observed in 98.2% of patients and excellent outcomes with patients reporting complete relief of symptoms with no or mild residual discomfort was seen in 92.2%. CONCLUSIONS: Compared with open techniques, minimally invasive tubular access for posterior cervical foraminotomy demonstrates comparable, if not superior, complication rates, and patient outcomes.
ABSTRACT
The American Association of Neurological Surgeons (AANS), 11 years ago converted its Internal Revenue Code (IRC) tax status from a 501 (c) (3) to a 501 (c) (6) entity. By doing so, the professional medical association, now a trade association, was able to more aggressively lobby, support political campaigns, and pursue business opportunities for its members. In the following decade, major changes were seen in the practice of neurosurgery, especially as it relates to spine surgery. With the majority of neurosurgeons limiting themselves to a spine practice, an increased number of spinal procedures, most noted in the Medicare population, was recorded. For example, a 15-fold increase in complex spinal fusions for spinal stenosis was seen between 2002 and 2007. While the basis for this increase was not readily apparent, it was associated with a reduction in reimbursement per case of about 50%, fueling the belief that the increase in complexity of surgery permitted recovery of fees in complex cases to off-set the loss of reimbursement for simpler cases. Considering the growth of spinal surgery within neurosurgery, and decrease funding for spine surgery, in the future there may be too many surgeons chasing too few dollars. There appears to be within neurosurgery a crisis developing where future manpower projections do not realistically match future anticipated specialty funding.
ABSTRACT
UNLABELLED: Physicians may use approved drugs and devices in ways not approved by the US Food and Drug Administration, a process termed off-label use. Often, because there is not suitable data defining safety and efficacy, the results of such use may become problematic, as occurred with the off-label use by spine surgeons of bone morphogenetic proteins in anterior cervical fusions. Using this undesirable history of bone morphogenetic proteins, and the historical record of the introduction of another drug, chymopapain, a method is developed and presented whereby such drugs or devices in the future may be studied by the professional medical specialties themselves outside the New Drug Application process, but with appropriate input from government and industry. ABBREVIATIONS: : AANS, American Association of Neurological SurgeonsACDF, anterior cervical discectomy and fusionACF, anterior cervical fusionBMP, bone morphogenetic proteinCNS, Congress of Neurological SurgeonsDJDD, degenerative joint and disc diseaseFDA, US Food and Drug Administration.
