Techniques for Safe Removal of Spinal Cord Stimulation Paddle Leads.

BACKGROUND: Spinal cord stimulation (SCS) is a safe neuromodulatory treatment used to treat failed back surgery syndrome, chronic neuropathic pain, and complex regional pain syndrome. Despite its efficacy, some patients fail to achieve pain relief and elect to undergo removal of SCS paddle leads. The safety and best practices of these procedures have not been defined. OBJECTIVE: In this article, we describe our technique and complication rate in a series of SCS paddle removals. METHODS: All patients who underwent SCS paddle removal at the Albany Medical Center between 2011 and 2020 were identified. Medical charts were reviewed for demographic data, operative technique, and incidence of complications within 30 days of the procedure. RESULTS: Thirty-two (91%) patients underwent a thoracic paddle removal, whereas 3 (9%) underwent a cervical paddle removal. All cases underwent preoperative imaging with computed tomography or MRI, and all cases were performed with neuromonitoring and fluoroscopy. The technique required for paddle removal depended on the extent of local scar formation and ranged from soft tissue dissection to additional laminectomy at an adjacent level. Cases took on average 2 ± 0.09 hours with 23.21 ± 4.29 cc blood loss. Two patients had superficial infections, which were cleared with 1 week of oral antibiotics. There were no other adverse events. CONCLUSION: Thirty-five patients successfully underwent paddle removal with the minor complications reported. In this article, we show that by using neuromonitoring, fluoroscopy, and the techniques described, SCS paddle removal can be performed with minimal risk.

Utility of 3-dimensionally printed models for parent education in pediatric plagiocephaly.

Objectives: Demonstrate the benefits of using 3D printed skull models when counseling families regarding disorders of the cranial vault (namely plagiocephaly and craniosynostosis), as traditional imaging review and discussion is often insufficient. Methods: 3D printed skull models of a patient with plagiocephaly were used during clinic appointments to aid in the counseling of parents. Surveys were distributed following the appointment to evaluate the utility of these models during the discussion. Results: Fifty surveys were distributed (with a 98% response rate). 3D models were both empirically and anecdotally helpful for parents in understanding their child's diagnosis. Conclusion: Advances in 3D printing technology and software have made producing models more accessible. Incorporating physical, disorder-specific models into our discussions has led to improvements in our ability to communicate with our patients and their families. Innovation: Disorders of the cranial can be challenging to describe to the parents and guardians of affected children; using 3D printed models is a useful adjunct in patient-centered discussions. The subject response to the use of these emerging technologies in this setting suggests a major role for 3D models in patient education and counseling for cranial vault disorders.

Long Segment Anterior Cervical Discectomy and Fusion, Including C2: Surgical Pearls and Review of Our Experience.

STUDY DESIGN: A retrospective study of thirteen patients undergoing 5-level anterior spinal surgery for cervical myelopathy. OBJECTIVE: While limited literature exists in reviewing the treatment of high cervical pathology extending caudally, we believe long segment surgery beginning at C2-3 can be accomplished with good success and is an option more patients may benefit from. We aim to describe the technique in accessing the C2-C3 disk space and efficacy of treating multilevel disease beginning at the C2 vertebral body. This includes an extensive technical report and surgical pearls. SUMMARY OF BACKGROUND DATA: Compression at the level of C2 can be daunting to access because of steep approach required. Few studies have described the technique in reaching the C2 level, with less information describing the efficacy of a 5-level anterior fusion starting at C2. METHODS: Patients who underwent surgery between 2000 and 2016 were identified utilizing the department billing database and ICD codes. Patients age, operative indications, levels treated, length of hospital stay, fusion outcome, and operative complications were explored. Independent analysis of fusion was performed. RESULTS: The average length of hospital stay was 3.9 days. Eight patients reported significant improvement of hand weakness, numbness, and/or gait at 6 months follow-up. The most frequent complication was dysphagia (23%). One patient experienced recurrent symptoms secondary to nonunion, and another patient suffered a postoperative neurological worsening because of anterior spinal artery syndrome. CONCLUSION: This retrospective review discusses the technique to visualize and fully decompress C2-C3 spinal segments. In addition, we explored the efficacy and perioperative risk in long segment anterior cervical discectomy and fusion.

Stabbing Injury of the Cervical Spinal Cord Resulting in Complete Loss of Bilateral Proprioception.

BACKGROUND: Direct penetrating trauma to the spinal cord as a result of stabbing is rare. The vertebral column is strongly suited to protecting the vital neural structures underneath, especially in the midline. CASE DESCRIPTION: A 25-year-old woman experienced a direct stabbing injury to her spinal cord, through the midline structures, resulting in bilateral dorsal column injury. She remained intact with regard to motor function despite bilateral sensory and proprioception loss. CONCLUSIONS: Owing to the strength of the protective elements of the osseous structures surrounding the spinal cord, direct stabbing injuries usually result in incomplete neurologic deficits. This is generally manifested as a Brown-Sequard syndrome because of the midline ligamentous structures and spinous processes deflecting injuries laterally. Our patient experienced a direct midline puncture, resulting in a unique case of bilateral dorsal column injury. These injuries are generally treated conservatively, in the absence of a retained foreign body. Spinal cord stabbing injuries are a rare entity with interesting clinical and anatomic correlations.

The effect of length of follow-up on substantial clinical benefit thresholds in patients undergoing surgery for cervical degenerative myelopathy.

Patient-reported outcome measures are increasingly used to access pain, disability, physical function, and mental status to quantify effectiveness of surgical intervention in cervical myelopathy, yet each score has little meaning without established thresholds linked to clinical benefit. We set out to develop thresholds for substantial clinical benefit (SCB) in patients undergoing surgery for cervical myelopathy and to evaluate the effect of length of follow-up on SCB thresholds. Thirty-five patients undergoing spinal surgery for progressive cervical myelopathy were tracked from 2005 to 2015. Observations were categorized into three groups: short-term, intermediate, and long-term, corresponding to average follow-up intervals of 3.8, 9.2, and 29.0 months. SCB thresholds were calculated for neck visual analog score (VAS), Neck Disability Index (NDI), Short Form-12 physical (PCS), SF-12 mental component scores (MCS), and modified Japanese Orthopedic Association score (mJOA) using receiver operating curve analysis with a 5-level patient satisfaction index as the anchor. SCB thresholds for each outcome measure were obtained with a range of areas under the curve indicating varying degrees of discriminatory ability, reported with increasing length of follow-up. NDI and PCS were most discriminatory of SCB at any time period. Stratification of thresholds by length of time revealed a significant effect of follow-up time with NDI but not PCS. NDI and PCS thresholds have significantly strong discriminatory value in identifying patients receiving substantial clinical benefit with regard to cervical myelopathy. When NDI is used to predict outcome, choosing thresholds calibrated for follow-up time is recommended to maximize predictive power.

A comparison of minimally invasive posterior cervical decompression and open anterior cervical decompression and instrumented fusion in the surgical management of degenerative cervical myelopathy.

OBJECTIVE Minimally invasive posterior cervical decompression (miPCD) has been described in several case series with promising preliminary results. The object of the current study was to compare the clinical outcomes between patients undergoing miPCD with anterior cervical discectomy and instrumented fusion (ACDFi). METHODS A retrospective study of 74 patients undergoing surgery (45 using miPCD and 29 using ACDFi) for myelopathy was performed. Outcomes were categorized into short-term, intermediate, and long-term follow-up, corresponding to averages of 1.7, 7.7, and 30.9 months, respectively. Mean scores for the Neck Disability Index (NDI), neck visual analog scale (VAS) score, SF-12 Physical Component Summary (PCS), and SF-12 Mental Component Summary (MCS) were compared for each follow-up period. The percentage of patients meeting substantial clinical benefit (SCB) was also compared for each outcome measure. RESULTS Baseline patient characteristics were well-matched, with the exception that patients undergoing miPCD were older (mean age 57.6 ± 10.0 years [miPCD] vs 51.1 ± 9.2 years [ACDFi]; p = 0.006) and underwent surgery at more levels (mean 2.8 ± 0.9 levels [miPCD] vs 1.5 ± 0.7 levels [ACDFi]; p < 0.0001) while the ACDFi patients reported higher preoperative neck VAS scores (mean 3.8 ± 3.0 [miPCD] vs 5.4 ± 2.6 [ACDFi]; p = 0.047). The mean PCS, NDI, neck VAS, and MCS scores were not significantly different with the exception of the MCS score at the short-term follow-up period (mean 46.8 ± 10.6 [miPCD] vs 41.3 ± 10.7 [ACDFi]; p = 0.033). The percentage of patients reporting SCB based on thresholds derived for PCS, NDI, neck VAS, and MCS scores were not significantly different, with the exception of the PCS score at the intermediate follow-up period (52% [miPCD] vs 80% [ACDFi]; p = 0.011). CONCLUSIONS The current report suggests that the optimal surgical strategy in patients requiring dorsal surgery may be enhanced by the adoption of a minimally invasive surgical approach that appears to result in similar clinical outcomes when compared with a well-accepted strategy of ventral decompression and instrumented fusion. The current results suggest that future comparative effectiveness studies are warranted as the miPCD technique avoids instrumented fusion.