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Pancreatic adenocarcinoma is an extremely aggressive cancer with a low survival rate. Common sites for metastases include the liver and lungs, while brain metastases are considered extremely rare, especially in elderly patients. We present an elderly female patient who developed brain metastases 51 months after the initial diagnosis of pancreatic cancer and was treated with gross tumor resection, chemotherapy, and stereotactic radiosurgery. The treatment completely resolved her neurological symptoms but did not result in improved survival for this patient. The patient developed generalized tonic-clonic seizures, was diagnosed with leptomeningeal carcinomatosis, and died 5.5 months after tumor resection. The literature on pancreatic cancer with brain metastases is scarce, with limited guidelines for treatment strategies in this patient population. Adding this case report to the existing literature may provide additional guidance to clinicians managing patients with similar presentations.

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PURPOSE: In an effort to control postoperative pain more effectively in spinal fusion patients, intraoperative intrathecal morphine (ITM) administration is gaining popularity and acceptance with clinicians. This study seeks to determine the impact of intraoperative intrathecal opioid (ITO) administration following lumbar fusion surgery on postoperative pain and length of hospitalization as primary outcomes. Secondary outcomes will investigate postoperative opioid intake and side effects. METHODS: The retrospective analysis of collected data was performed. The study compared patients undergoing one- or two-level transforaminal interbody fusions between 2019 and 2021 who intraoperatively received two different ITO doses (n = 89) vs. the reference group (n = 48) that did not receive ITO. The patients in the ITO group received either 0.2 mg (n = 44) of duramorph or 0.2 mg duramorph + 50 mcg fentanyl (n = 45). The effect of ITO was evaluated for the first four postoperative days (POD) on pain scores (visual analog scale), length of stay (LOS, hours) and opioid requirement (MED, morphine equivalent dose). RESULTS: In the ITO group, a significant reduction of postoperative pain scores (t(99) = 4.3, p < 0.001) and opioid intake (t(70) = 2.49, p = 0.015) was noted on POD1. Cohen's d effect sizes were 0.76 and 0.50, meaning that postoperative pain and MED intake were reduced by about ¾ to ½ standard deviations (SD) in the ITO group. Further, multivariate regression models revealed that ITO administration predicted lower postoperative pain scores for the two PODs (ß = - 0.83, p < 0.001; ß = - 0.63, p = 0.022) and MED intake for the first two PODs (ß = - 20.8, p = 0.047; ß = - 16.4, p = 0.030). Mean LOS was 15.4 h less in the ITO group (mean ± SD, 63.4 ± 37.1 vs. 78.8 ± 39.6, p = 0.10). CONCLUSIONS: In conclusion, our study provides results in a large sample of patients undergoing transforaminal lumbar fusions. The results demonstrated that ITO administration is effective in reducing POD1 pain scores and POD1-2 opioid requirement while not increasing the risk of any opioid-related side effects.

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Analgésicos Opioides , Fusión Vertebral , Humanos , Analgésicos Opioides/uso terapéutico , Analgésicos Opioides/efectos adversos , Morfina/efectos adversos , Estudios Retrospectivos , Tiempo de Internación , Inyecciones Espinales , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Fusión Vertebral/métodos

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STUDY DESIGN: Prospective, randomized, blinded clinical trial. OBJECTIVE: To examine clinical and radiological outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF) surgeries randomized to receive either polyether-ether-ketone (PEEK) or structural bone allografts. SUMMARY OF BACKGROUND DATA: The biomechanical qualities as well as osteoconductive, osteogenic, and osteoinductive properties of various graft materials have been previously evaluated. There remain questions, however, as to whether there are any clinical and/or radiographic outcome differences in the selection of interbody graft types for ACDF. METHODS: Patients undergoing one- to three-level ACDF with single anterior plate fixation were randomized (1:1 ratio) to receive either cortical allograft or PEEK interbody spacers. Radiographic and clinical outcomes were assessed at 3, 6, 12, and 24 months with an additional postoperative radiographic assessment. RESULTS: A total of 120 patients were enrolled and randomized. Comparing clinical outcomes, no differences in arm or neck pain scores were noted; however, there was a statistically significant (≤0.041) improvement in SF-36 PCS scores for the allograft group at all follow-up time points and a tendency toward lower disability scores. Overall, evidence of radiographic fusion was achieved in 87 (91.6%) patients: five (10.2%) and three (6.5%) patients had pseudoarthrosis (P = 0.72) in the PEEK and allograft groups, respectively. At 24 months' follow-up time, any cervical or segmental alignment restoration achieved with surgery was lost and no statistically significant changes were detected when all levels of surgery were included. Likewise, there were no statistically significant differences between the groups for anterior or posterior body height measurements at the 24 months' follow-up. Approximately 20% of patients had anterior and posterior subsidence, all grade 0 regardless of the group assignment. CONCLUSION: Comparable radiographic outcomes were observed for patients undergoing one- to three-level PEEK versus allograft-assisted ACDF surgeries. Although MCID comparisons suggest that allograft and PEEK-treated patients have similar clinical outcomes, testing that incorporates the magnitude of the change suggests that there may be a statistically significant greater magnitude of improvement for the allograft group patients, but further studies with a larger sample size would be helpful to determine if a true effect exists.

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Vértebras Cervicales , Fusión Vertebral , Aloinjertos , Benzofenonas , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugía , Discectomía , Humanos , Cetonas/uso terapéutico , Polietilenglicoles/uso terapéutico , Polímeros , Estudios Prospectivos , Resultado del Tratamiento

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BACKGROUND CONTEXT: Allograft and polyether-ether-ketone (PEEK) radiographic, biomechanical, histological properties have been extensively studied and both spacers have their advantages and shortcomings. There are no comparative randomized or double-blinded spinal fusion clinical trials reported to date. PURPOSE: The study's primary objective was to prospectively investigate clinical and radiological outcomes in patients undergoing lumbar interbody fusions and randomized to receive either PEEK or structural bone allografts. STUDY DESIGN/ SETTING: A prospective, randomized, double-blinded clinical trial was initiated at a single center. PATIENT SAMPLE: A total of 138 patients were enrolled, randomized and 121 patients completed the study. OUTCOME MEASURES: The primary clinical outcome parameters were scored from standardized patient-reported questionnaires. The severity of lower back and leg pain was evaluated using the 11-point Visual Analog Scale (VAS). The Oswestry Disability Questionnaire was used to evaluate chronic disability and activities of daily living. Health-related quality of life and functional outcomes were assessed using Health-related Quality of Life Questionnaire (SF-36 v2). Two scores within the scoring algorithm were analyzed: Physical Component (PCS) and Mental Component Summary (MCS). The primary radiological outcomes included restoration and maintenance of vertebral body height, lumbar sagittal and segmental alignment, and fusion status. METHODS: All patients were followed for 2 years ± 2 months; radiographic and clinical outcomes were assessed at 3, 6, 12 and 24 months with an additional follow-up at 3 weeks for radiographic assessment. RESULTS: A total of 138 patients undergoing transforaminal lumbar interbody fusions (TLIF) were randomized (1:1) to receive either cortical allograft or PEEK interbody lordotic spacers. Although no differences were detected between the allograft and PEEK patient groups at any of the follow-up time points, there was a highly significant (p<.0001) improvement in all clinical outcome measures. Overall, evidence of radiographic fusion was achieved in 118 (97.5%) patients at the 24 months follow-up. Three patients, all in the allograft group, had pseudoarthrosis and underwent revision surgeries. Postoperative improvement of sagittal alignment, anterior (ABH) or posterior body height (PBH) was initially achieved, but it was mainly lost or reduced at the final follow-up and there were no statistically significant differences between the groups. At the end of the study, improvement and maintenance of lumbar lordosis were achieved in 43.3% and 49.2% patients and segmental alignment in 38.3% and 36.1% for the allograft and PEEK patient groups, respectively. Similarly, ABH was improved and maintained in 28.3% and 36.1% patients and PBH in 28.3% and 44.3% for the allograft and PEEK groups, respectively. CONCLUSIONS: Although allograft-assisted surgeries may have reduced fusion rates, the study findings demonstrated that TLIF surgery with two different types of cages and in conjunction with rhBMP-2 resulted in similar radiological or clinical outcomes and a highly statistically significant improvement in all clinical outcome measures at the end of the study regardless of the randomization group.

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Lordosis , Fusión Vertebral , Actividades Cotidianas , Aloinjertos , Benzofenonas , Humanos , Cetonas/efectos adversos , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/cirugía , Polímeros , Estudios Prospectivos , Calidad de Vida , Fusión Vertebral/efectos adversos , Resultado del Tratamiento

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OBJECTIVE: The main objective of this study was to analyze the ability of local anesthetic instillation into the retropharyngeal space to reduce dysphagia symptoms and occurrence rates in patients undergoing anterior cervical discectomy and fusion (ACDF) procedures. METHODS: A single-center, prospective, randomized, double-blinded, and placebo-controlled clinical study was performed. We enrolled patients undergoing one- or two-level ACDF procedures for cervical degenerative disc disease with disc herniation, radiculopathy and/or myelopathy symptoms. The patients were randomly assigned (1:1 ratio) to receive either 0.5% bupivacaine hydrochloride or 0.9% NaCl solution. RESULTS: Forty-three (74%) and 41 (77%) of patients reported dysphagia symptoms at the time of discharge in the investigational and control groups, respectively. There were no statistically significant differences in duration of dysphagia symptoms, Swallowing-Quality of Life (SWAL-QOL) survey or pain scores between the investigational and control patient groups at any of the follow-up time points. Controlling for independent variables, only younger age significantly predicted dysphagia symptoms at discharge, 2-week, and 3-month follow-ups (P ≤ 0.03; R ≥ -0.038; OR 0.96, 95% CI 0.93-0.99. Female sex was associated with lower SWAL-QOL scores at discharge (P = 0.046; R = 0.87; OR 2.38, 95% CI 1.02-5.56). A total of 8 (13.8%) and 6 (11.3%) patients in the investigational and control groups, respectively, were referred to a specialist or underwent speech therapy for their dysphagia symptoms. There were no adverse reactions to the study drug observed. CONCLUSIONS: Local retropharyngeal space anesthetic instillation did not reduce dysphagia symptoms or occurrence rates in patients undergoing anterior discectomy and fusion surgeries.

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Anestésicos Locales/uso terapéutico , Vértebras Cervicales/cirugía , Trastornos de Deglución/prevención & control , Discectomía/métodos , Degeneración del Disco Intervertebral/cirugía , Desplazamiento del Disco Intervertebral/cirugía , Faringe , Complicaciones Posoperatorias/prevención & control , Fusión Vertebral/métodos , Adulto , Anciano , Bupivacaína/uso terapéutico , Trastornos de Deglución/epidemiología , Trastornos de Deglución/fisiopatología , Método Doble Ciego , Femenino , Humanos , Degeneración del Disco Intervertebral/complicaciones , Desplazamiento del Disco Intervertebral/complicaciones , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Calidad de Vida , Radiculopatía/etiología , Radiculopatía/cirugía , Compresión de la Médula Espinal/etiología , Compresión de la Médula Espinal/cirugía

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Introduction  Many clinical, social, and even economic factors have been extensively analyzed in the literature and shown to influence the length of stay (LOS) after spinal procedures. However, surgeon's experience was mostly examined relative to a learning curve and not regarding the time in practice. The primary objective of this study was to determine the effect of one surgeon's experience on the LOS in patients undergoing one- to two-level transforaminal lumbar interbody fusions (TLIFs). Materials and Methods  The study design was a retrospective cohort study of hospital discharge data. The cohort was comprised of 240 consecutive patients who had undergone open one- or two-level elective TLIF procedures for lumbar degenerative disc disease. The primary predictor was the surgeon's experience based upon the years of practice. The primary outcome was LOS, which was controlled by the discharge criteria that remained consistent throughout the study. Results  Based on the Poisson regression model, it can be inferred that the LOS is not significantly associated with a surgeon's experience (Pr(>|t|) = 0.8985, CI: -0.5825 to 0.5114) while controlling for all other variables. Other independent factors did seem to significantly influence patients' LOS, including the admission type (Pr(>|t|) = 9.637-08, CI: -0.8186 to -0.3786), the number of TLIF levels (Pr(>|t|) = 1.721-06, CI: 0.0606 to 0.1446), the Clavien-Dindo ( Pr(>|t|) = 0, CI: 0.1489 to 0.1494), the American Society of Anesthesiologists (ASA) physical status classification scores (Pr(>|t|) = 4.878-3, CI: 0.0336 to 0.1880), and being discharged to skilled nursing facility (Pr(>|t|) = 3.44-2, CI: 0.0127 to 0.3339). Conclusions Based upon the years in practice, surgeon experience was not associated with length of hospitalization and estimated blood loss during surgery in patients undergoing one- and two-level TLIF surgeries. However, while controlling for all other variables, the surgeon's experience and surgical time had a highly significant correlation. The study results clearly demonstrated efficiency, but we did not identify a clear correlation between LOS and surgeon experience overtime suggesting that other factors are likely contributing to such outcome. The average LOS is a complex measure of healthcare resource use and hospital discharge policy or other variables are likely having more effect on LOS than individual surgeons' preferences.

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Capillary hemangiomas are hamartomatous congenital vascular malformations that are particularly uncommon in the spinal epidural space, and those with intrathoracic extensions are extremely rare. Although considered benign, capillary hemangiomas can cause rare hemorrhagic complications and risk of spinal cord compression or extension into the neural foramen. Therefore, surgery should be considered even in the absence of neurological symptoms. The literature reports three patients either underwent a partial resection or a complete tumor removal was achieved by accessing the lesion through a posterolateral approach and removing the costotransverse joint. The patient underwent a same-day, two-staged gross total resection of the tumor via combined posterior right-sided T7-T8 complete facetectomy and extradural mass resection with T7 nerve transection, followed by a posterolateral fusion of the T7-T8 vertebra. Stage 2 consisted of a video-assisted intrathoracic approach for the removal of the remaining tumor. The two-stage surgical procedure described in our case report allows for complete removal of intrathoracic and intraspinal portions of the mass with less morbidity.

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Enfermedades de la Columna Vertebral , Fusión Vertebral , Humanos , Prótesis e Implantes , Articulación Sacroiliaca

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OBJECTIVE: Unplanned readmissions after spinal surgery adversely affect not only healthcare costs but also the quality of delivered care. The primary objective of this study was to identify the rates and predicting factors of unplanned 30-day readmissions at a community-based hospital. PATIENTS AND METHODS: This study is a retrospective review of a single-center community-based hospital administrative and clinical records identifying unplanned readmissions. Risk factors for readmissions due to surgical site infections, pain, medical vs. procedure-related complications, and the number of readmissions were studied using multiple logistic regression analysis. RESULTS: A total overall readmission rate was 7.3 % (79 readmissions for 1077 patients). The readmission rates for thoracolumbar and cervical surgeries were 5.5 % and 1.8 %, respectively. The mean duration to primary readmission was 11.4 + 8.5 days. The most common procedure-related complication diagnosed at readmittance was wound-related complications (26 readmissions, 32.9 %). The most common non-surgical complication was a drug reaction or overdose (10.1 %). Multivariate logistic regression analyses revealed that longer hospitalization was a highly significant predictor of wound-related complications, followed by discharge to home or home care, and lower ASA scores (all <0.048). A younger age predicted readmissions due to pain (p = 0.014) and longer OR time did not reach statistical significance (p = 0.079). Higher ASA scores predicted readmissions due to medical vs. surgical complications (p = 0.028). There were no statistically significant predictors identified for more than one readmission during the 30-day post-discharge period. CONCLUSIONS: The overall rate of 30-day unplanned readmissions at a community-based hospital was 7.3 % for patients undergoing spinal surgeries and was similar to the rates reported by larger academic tertiary care institutions and registry-based studies. The study suggests that surgical site infections was the most common reason for readmissions, which was predictive by longer hospitalization, discharge disposition, and lower ASA scores.

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Descompresión Quirúrgica , Hospitales Comunitarios , Degeneración del Disco Intervertebral/cirugía , Dolor Postoperatorio/epidemiología , Readmisión del Paciente/estadística & datos numéricos , Fusión Vertebral , Infección de la Herida Quirúrgica/epidemiología , Anciano , Pérdida de Sangre Quirúrgica , Vértebras Cervicales/cirugía , Sobredosis de Droga/epidemiología , Femenino , Fracturas por Compresión/cirugía , Humanos , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Análisis Multivariante , Tempo Operativo , Estudios Retrospectivos , Factores de Riesgo , Seroma/epidemiología , Fracturas de la Columna Vertebral/cirugía , Traumatismos Vertebrales/cirugía , Neoplasias de la Columna Vertebral/cirugía , Dehiscencia de la Herida Operatoria/epidemiología , Vértebras Torácicas/cirugía , Factores de Tiempo

RESUMEN

STUDY DESIGN: A prospective observational study with a historical reference group. OBJECTIVES: The main objectives of this study were to determine the impact of preventative multimodal analgesia (PMA) on postoperative opioid requirements and analgesic effectiveness in patients undergoing lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: PMA addresses the multiple pathways of acute and chronic pain by interfering with peripheral and central sensitization and should provide a way to achieve safer and more effective pain management with reduced opioid medication use. MATERIALS AND METHODS: This study compared postoperative opioid requirement and analgesic effect in a total of 101 patients undergoing elective, 1-level or 2-level transforaminal lumbar interbody fusion surgeries for symptomatic lumbar degenerative disk disease. The PMA patient group included 51 consecutive patients who received 1000 mg of acetaminophen, 300-900 mg of gabapentin, and 200-400 mg of celecoxib 1 hour before their index procedure. The reference group included 50 patients who received 15 mg of morphine-equivalent dose (MED) preoperatively.Multiple linear regression was used to evaluate the effect of PMA on postoperative pain and MED over 4 postoperative days, while controlling for all variables likely to influence these outcomes, including age, sex, baseline opioid use, duration of surgery, postoperative intrathecal morphine use and the administration of muscle relaxants and anticonvulsants. RESULTS: The differences in opioid requirement and postoperative pain scores were statistically significant on all 4 postoperative days. The effect size varied from -0.54 to -0.99 (34.8%-54.2% MED reduction) for the postoperative opioid requirement and from -0.59 to -1.16 (28.9%-37.3% visual analog scale reduction) for postoperative pain indicating that these measures were reduced by about ½ to 1 SD in the PMA patient group. CONCLUSIONS: PMA is a highly effective and safe method for postoperative pain management in patients undergoing elective lumbar fusion surgeries by improving pain control and reducing opioid requirement. LEVEL OF EVIDENCE: Level III.

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Analgésicos/administración & dosificación , Vértebras Lumbares , Dolor Postoperatorio/prevención & control , Fusión Vertebral , Anciano , Esquema de Medicación , Femenino , Humanos , Degeneración del Disco Intervertebral/cirugía , Masculino , Morfina/administración & dosificación , Estudios Prospectivos , Resultado del Tratamiento

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OBJECTIVE: Obesity affects not only the health of an individual but society as a whole and especially the healthcare system. Healthcare providers are faced with challenges to deliver adequate care in this resource-limited environment, assure safety, and accommodate the increasing population of overweight patients. The effects of increased body mass index (BMI) on clinical outcomes, complications, health care resource utilization, effectiveness of minimally invasive approaches, and perioperative parameters in spine surgeries have all been previously studied, but the majority of these findings are conflicting rather than conclusive. The main objective of this study was to analyze the impact of BMI on perioperative outcomes in patients undergoing one- to two-level elective TLIF procedures for degenerative spine conditions and to identify the need to modify internal hospital operational planning, team organization, and patient flow processes to accommodate patients who are overweight. PATIENTS AND METHODS: A single-center retrospective case-review study was completed. The study included 172 consecutive patients who underwent elective one- or two-level transforaminal lumbar interbody fusions (TLIF). The patients were categorized as obese if they had BMI value that was equal to or greater than 30 kg/m2. Outcome measures included surgical and non-operative operating room (OR) time, length of stay (LOS), and estimated blood loss (EBL). Multiple regression analyses were performed to determine if BMI had an effect on perioperative parameters while controlling for independent variables. RESULTS: BMI did not have a statistically significant effect on surgical (p = 0.13) and non-operative OR time (p = 0.82). Obese patients remained hospitalized on average 0.45 ± 0.25 days longer (p = 0.037) and lost 71.8 ± 26.3 mL more blood (p = 0.007). CONCLUSIONS: Obesity is associated with longer hospitalization and more intraoperative blood loss, but may have no impact on surgical and non-operative OR times in patients undergoing one- and two-level TLIFs.

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Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Índice de Masa Corporal , Tiempo de Internación , Tempo Operativo , Fusión Vertebral , Adulto , Anciano , Femenino , Humanos , Degeneración del Disco Intervertebral/cirugía , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Obesidad/complicaciones , Quirófanos , Estudios Retrospectivos , Resultado del Tratamiento

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BACKGROUND: Significant progress in hardware and surgical techniques for sacroiliac joint (SIJ) fusion surgeries has facilitated safer and more efficacious procedures for patients. Triangular-shaped implants for SIJ fusions are the most-studied devices and have demonstrated good short-term and long-term clinical outcomes. Reports on cylindrical threaded implants are very limited. Owing to biomechanical differences in the implants and the surgical techniques required for their placement, previously reported results may not be applicable to cylindrical threaded implants. The aim of this study was to report preliminary clinical experience with minimally invasive SIJ fusion using intraoperative stereotactic navigation and the Rialto SI Fusion System. METHODS: We retrospectively reviewed 24 patients who underwent SIJ fusions between May 2015 and October 2017 performed by a single surgeon. RESULTS: Mean total satisfaction score was 89.0% ± 27.6%. A statistically significant reduction (P = 0.0028) in low back pain scores was noted from an average baseline score of 6.6 ± 2.4 to 3.7 ± 3.3 postoperatively. Leg pain scores decreased from 4.8 ± 3.8 to 1.5 ± 2.9 (P = 0.0034). Mean surgical time was 53.0 ± 13.9 minutes. It took significantly longer (P = 0.0089) to perform the initial 13 cases (59.9 ± 15.2 minutes) compared with subsequent cases (45.4 ± 7.3 minutes). Estimated blood loss was minimal (10.4 ± 5.2 mL). CONCLUSIONS: Minimally invasive SI joint fusion using cylindrical threaded implants can be safely performed with minimal morbidity and good clinical outcomes.

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Fijadores Internos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Articulación Sacroiliaca/cirugía , Fusión Vertebral/métodos , Técnicas Estereotáxicas , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Datos Preliminares , Estudios Retrospectivos , Fusión Vertebral/instrumentación , Resultado del Tratamiento

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BACKGROUND: Various diagnostic characteristics associated with neurocysticercosis have been well studied; however, their potential to be implicated in other differential diagnoses has not been well demonstrated. CASE DESCRIPTION: We report the case of a 55-year-old Hispanic man who underwent a Chiari decompression surgery, which was complicated with hydrocephalus. Despite a ventriculoperitoneal shunt placement, he continued to have headaches and was soon found to have several skull base subarachnoid lesions, which were later diagnosed as the sequelae of an active neurocysticercosis infection. CONCLUSION: This case report highlights the importance of overlapping symptoms between diseases in a short temporal context.

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Malformación de Arnold-Chiari/diagnóstico por imagen , Malformación de Arnold-Chiari/cirugía , Hidrocefalia/diagnóstico por imagen , Hidrocefalia/cirugía , Neurocisticercosis/diagnóstico por imagen , Neurocisticercosis/cirugía , Malformación de Arnold-Chiari/complicaciones , Diagnóstico Diferencial , Humanos , Hidrocefalia/complicaciones , Masculino , Persona de Mediana Edad , Neurocisticercosis/complicaciones

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BACKGROUND: The consequences of suffering postoperative complications in elderly undergoing spinal surgeries may be different compared to younger patients. The primary objective of this study was to identify the types and frequency of medical complications and mortality rates in patients 80 years of age or older undergoing elective spinal fusion surgeries for degenerative spinal disease. METHODS: A prospective observational study with a retrospective chart review was performed, which included all consecutive patients ≥80 years old undergoing elective spinal fusion surgeries from May 2012 to August 2015. We identified a total of 95 patients, of which 39 cervical and 56 lumbar surgeries were performed. There were 41 female and 54 male patients with the mean age of 82.8 years (range, 80-91). The perioperative complications were allocated into the following categories: infection, pulmonary, cardiac, gastrointestinal, hematologic, urologic, neurovascular, thromboembolic, and other. Baseline and postoperative clinical outcome scores were compared to evaluate efficacy. RESULTS: The mean follow-up time was 14.8 months (range, 5 days to 37 months) with an overall mortality rate of 8.4%. The 30-day, 90-day, and 1-year mortality rates were 2.1, 2.1, and 4.2%, respectively. There were 53.9 and 71.4% patients with complications in the cervical and lumbar patient groups, respectively. The presence of general comorbidities and the number of intervertebral levels predicted the occurrence of perioperative complications. Also, longer OR times were associated with a higher number of complications per patient and the occurrence of a UTI. Dysphagia was a significant predictor in developing pneumonia and atelectasis. CONCLUSIONS: The incidence of perioperative medical complications and mortality rates in octogenarians undergoing elective spinal surgeries are quite high. The benefits of having surgery must be weighed against the risks of not only surgical but also adverse medical events. An informed decision-making process should include discussion of potential postoperative morbidity specific to this patient population in order to guide patient's acceptance of higher risks and expectations postoperatively. It is also important to identify potential complications and adapt preventive measures in order to help minimize them in this patient population.

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Complicaciones Posoperatorias/epidemiología , Fusión Vertebral/efectos adversos , Anciano de 80 o más Años , Procedimientos Quirúrgicos Electivos/efectos adversos , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/clasificación , Complicaciones Posoperatorias/mortalidad

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OBJECTIVE: Success rates of surgical interventions for lumbar disorders vary significantly depending on multiple factors and, among them, the duration of symptoms. It is not clear whether there is a "cutoff" time when decompression and fusion surgery becomes less effective in the conditions with chronic nerve root compression symptomatology. The main objective of this study was to analyze whether duration of symptoms has any effect on clinical outcomes and primarily resolution of radicular pain symptoms due to degenerative disk disease and stenosis with spondylolisthesis in patients undergoing transforaminal lumbar interbody fusion (TLIF). METHODS: The prospective observational study was performed. Eighty-four patients with radicular symptoms due to degenerative disk disease and stenosis with spondylolisthesis with no previous fusion surgeries and undergoing 1- to 3-level TLIF surgery were enrolled. Fifteen patients (18%) were lost to follow-up and were excluded from this analysis leaving a total of 69 patients. Standardized questionnaires were used to analyze clinical outcomes and were administered preoperatively within 3 months of scheduled surgery, and postoperatively at 3, 6, 12, and 24 months. To emphasize the change in clinical outcome scores, the relevant scores were calculated as the ratio of minimal clinically important difference values and change scores. The change scores were calculated by subtracting the postoperative scores from the baseline scores. Multiple regression analyses were conducted to examine the relationship of the duration of symptoms and relevant minimal clinically important difference ratio values while controlling for independent variables. Further, a comparison between 2 groups of patients was performed to analyze the changes of clinical outcomes for the patients who underwent fusion within <24 months versus ≥24 months. RESULTS: It was determined that the duration of symptoms was a significant predictor of better leg pain resolution (P=0.018), but not back pain resolution (P=0.27), or improvement in ODI (P=0.10) and SF-36 PCS scores (P=0.19). The patients with shorter duration of symptoms had significantly better radicular symptom resolution (P=0.032) compared with patients who waited at least 24 months or longer to undergo fusion. CONCLUSIONS: A shorter duration of symptoms was found to be a statistically significant predictor for better resolution of radicular symptoms in patients undergoing TLIF for painful degenerative disk disease and stenosis with spondylolisthesis.

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Foramen Magno/cirugía , Degeneración del Disco Intervertebral/cirugía , Vértebras Lumbares/cirugía , Radiculopatía/cirugía , Fusión Vertebral , Adulto , Anciano , Demografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Factores de Tiempo

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BACKGROUND: According to the published reports, revision surgery is sometimes recommended even in patients with asymptomatic anterior lumbar intervertebral graft migrations. The main purpose of this chart review study was to report on the clinical course and outcomes of patients who had anterior intervertebral graft extrusions after transforaminal lumbar interbody fusion (TLIF). METHODS: From July 2002 to July 2014, 1259 consecutive TLIF surgeries were performed. These were reviewed, and patients who had anterior intervertebral graft extrusions were identified. RESULTS: The incidence of graft extrusion was 0.6% (7 of 1259 patients). There were 6 female patients and 1 male patient with an average age of 65.7 years (range, 44-80 years). All patients underwent TLIF with bilateral pedicle screw fixation, and 6 received recombinant human bone morphogenetic protein-2. Graft migrations were diagnosed between 5 days and 8 months postoperatively except for 2 cases in which migration occurred intraoperatively. The patients were closely followed for an average of 27.4 months (range, 12-43 months). All patients remained asymptomatic during the follow-up period and had solid fusion despite extrusions with an average time to fusion of 13 months (range, 10-18 months). No other adverse events occurred during the follow-up period. CONCLUSIONS: The risks of additional and highly invasive revision surgery should be weighed against the potential short-term and long-term complications associated with graft extrusions or migrations. It was demonstrated that fusion may take longer but can be achieved, and close observation may be adequate for asymptomatic patients.

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Trasplante Óseo , Migración de Cuerpo Extraño/etiología , Complicaciones Posoperatorias/etiología , Fusión Vertebral/métodos , Adulto , Anciano , Anciano de 80 o más Años , Síndrome de Fracaso de la Cirugía Espinal Lumbar/cirugía , Femenino , Estudios de Seguimiento , Humanos , Laminectomía , Masculino , Persona de Mediana Edad , Reoperación , Espondilolistesis/cirugía

RESUMEN

The purpose of this study was to evaluate potential technical advantages of the CO2 laser technology in mini-open transforaminal lumbar interbody fusion (TLIF) surgeries and report our preliminary clinical data on the safety and clinical outcomes. There is currently no literature discussing the recently redeveloped CO2 laser technology application for lumbar fusion. Safety and clinical outcomes were compared between two groups: 24 patients that underwent CO2 laser-assisted one-level TLIF surgeries and 30 patients that underwent standard one-level TLIF surgeries without the laser. There were no neural thermal injuries or other intraoperative laser-related complications encountered in this cohort of patients. At a mean follow-up of 17.4 months, significantly reduced lower back pain scores (P=0.013) were reported in the laser-assisted patient group compared to a standard fusion patient group. Lower extremity radicular pain intensity scores were similar in both groups. Laser-assisted TLIF surgeries showed a tendency (P = 0.07) of shorter operative times that was not statistically significant. Based on this preliminary clinical report, the safety of the CO2 laser device for lumbar fusion surgeries was assessed. There were no neural thermal injuries or other intraoperative laser-related complications encountered in this cohort of patients. Further investigation of CO2 laser-assisted lumbar fusion procedures is warranted in order to evaluate its effect on clinical outcomes.

RESUMEN

BACKGROUND CONTEXT: There have been controversial reports published in the literature on the duration of symptoms (DOS) and clinical outcome correlation in patients undergoing anterior cervical discectomy and fusion (ACDF) for painful degenerative disc disease and radiculopathy. PURPOSE: The primary purpose of this study was to analyze if the DOS has any effect on clinical outcomes. STUDY DESIGN/SETTING: A post hoc analysis was performed on an original prospective clinical study analyzing clinical outcomes and cervical sagittal alignment correlations. PATIENTS SAMPLE: Fifty-eight patients undergoing one- or two-level ACDF surgeries for cervical degenerative radiculopathy were analyzed. OUTCOME MEASURES: Standardized questionnaires were used to evaluate clinical outcomes. Neck and arm pain was evaluated using (Visual Analog Scale [VAS]). Two scales of Health-Related Quality-of-Life Questionnaire (Short-Form 36 Health Survey [SF-36]) were used for this study: the physical component summary (PCS) and mental component summary (MCS). Neck disability index (NDI) was used to evaluate chronic disability in activities of daily living. The patients completed a self-reported Patient Satisfaction with Results Survey. METHODS: Patients who had previous or redo surgeries, were diagnosed with myelopathy or had more than two-level ACDF surgeries were excluded, leaving a total of 58 patients. The mean follow-up was 37.2 months (range 12-54). Patients were divided into two groups for clinical outcome analyses according to the DOS: patients who had surgery within 6 months (n=29) or more than 6 months (n=29) after becoming symptomatic. RESULTS: There were no statistically significant differences in any demographic or clinical parameters among the patient groups. Controlling for preoperative scores, the patients who had surgery within 6 months reported significantly higher reduction (p=.04) in arm pain scores compared with the patients who waited more than 6 months. No significant differences were detected in postoperative neck pain VAS (p=.3), NDI (p=.06), SF-36 PCS (p=.08), and MCS (p=.8) scores. CONCLUSIONS: Neck and upper extremity pain can be successfully treated conservatively. In those cases, when surgical intervention is pursued, patients with shorter DOS have better improvement in radiculopathy symptoms that is statistically significant.

Asunto(s)

Vértebras Cervicales/cirugía , Discectomía/métodos , Degeneración del Disco Intervertebral/cirugía , Dolor/cirugía , Radiculopatía/cirugía , Fusión Vertebral/métodos , Actividades Cotidianas , Adulto , Anciano , Anciano de 80 o más Años , Evaluación de la Discapacidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Estudios Prospectivos , Calidad de Vida , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

BACKGROUND: Transforaminal lumbar interbody fusion with bilateral segmental pedicle screw (PS) fixation is a widely used and well-recognized technique that provides fixation and load-bearing capacity, while restoring morphometric spine parameters and relieving symptoms in patients with degenerative disc disease. A supplemental interspinous process fixation plate (ISFP) as an adjunct to unilateral PS fixation allows for reduced invasiveness of this technique compared with bilateral PS placement. The biomechanical comparison results have been previously reported, but the significance of these findings has not been studied in clinical settings. METHODS: A prospective cohort study with a supplemental retrospective chart review and radiographic analysis was performed. Patients were divided into 2 groups: bilateral PS fixation (n = 75) or unilateral PS fixation + ISFP (n = 96). Lateral lumbar standing radiographs were obtained for preoperative and postoperative foraminal height (FH), disc height, segmental sagittal alignment, and lumbar sagittal alignment measurements. Standardized questionnaires were used to compare postoperative clinical outcomes. RESULTS: The estimated blood loss, duration of procedure, and length of hospital stay were significantly lower for 1-level and 2-level procedures in the unilateral PS + ISFP group. A statistically significant mean disc height increase was observed in both groups. Regardless of the disc height increase, a statistically significant FH loss was detected in the bilateral PS group (from 17.1 mm to 16.3 mm; 4.7% loss; P = 0.04) compared with FH height loss in the unilateral PS + ISFP group that was not statistically significant (from 19.0 mm to 18.4 mm; 3.2% loss; P = 0.1). The analysis of segmental sagittal alignment, lumbar sagittal alignment, clinical outcomes, and fusion rates did not demonstrate any statistically significant differences. CONCLUSIONS: Significantly reduced surgical invasiveness was associated with unilateral PS + ISFP fixation, which represents the major advantage of this technique. Unilateral fixation was also associated with a slightly lower reduction in FH and was equally effective as bilateral PS fixation in regard to fusion rates, clinical outcomes, and other radiographic outcomes studied.

Asunto(s)

Tornillos Óseos , Fijación Interna de Fracturas/métodos , Vértebras Lumbares/cirugía , Fusión Vertebral/métodos , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Lateralidad Funcional , Humanos , Degeneración del Disco Intervertebral/diagnóstico por imagen , Degeneración del Disco Intervertebral/cirugía , Vértebras Lumbares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Estudios Prospectivos , Radiografía , Resultado del Tratamiento , Adulto Joven

RESUMEN

OBJECT: Several retrospective studies have demonstrated higher accuracy rates and increased safety for navigated pedicle screw placement than for free-hand techniques; however, the accuracy differences between navigation systems has not been extensively studied. In some instances, 3D fluoroscopic navigation methods have been reported to not be more accurate than 2D navigation methods for pedicle screw placement. The authors of this study endeavored to identify if 3D fluoroscopic navigation methods resulted in a higher placement accuracy of pedicle screws. METHODS: A systematic analysis was conducted to examine pedicle screw insertion accuracy based on the use of 2D, 3D, and conventional fluoroscopic image guidance systems. A PubMed and MEDLINE database search was conducted to review the published literature that focused on the accuracy of pedicle screw placement using intraoperative, real-time fluoroscopic image guidance in spine fusion surgeries. The pedicle screw accuracy rates were segregated according to spinal level because each spinal region has individual anatomical and morphological variations. Descriptive statistics were used to compare the pedicle screw insertion accuracy rate differences among the navigation methods. RESULTS: A total of 30 studies were included in the analysis. The data were abstracted and analyzed for the following groups: 12 data sets that used conventional fluoroscopy, 8 data sets that used 2D fluoroscopic navigation, and 20 data sets that used 3D fluoroscopic navigation. These studies included 1973 patients in whom 9310 pedicle screws were inserted. With conventional fluoroscopy, 2532 of 3719 screws were inserted accurately (68.1% accuracy); with 2D fluoroscopic navigation, 1031 of 1223 screws were inserted accurately (84.3% accuracy); and with 3D fluoroscopic navigation, 4170 of 4368 screws were inserted accurately (95.5% accuracy). The accuracy rates when 3D was compared with 2D fluoroscopic navigation were also consistently higher throughout all individual spinal levels. CONCLUSIONS: Three-dimensional fluoroscopic image guidance systems demonstrated a significantly higher pedicle screw placement accuracy than conventional fluoroscopy or 2D fluoroscopic image guidance methods.

Asunto(s)

Imagenología Tridimensional/métodos , Monitoreo Intraoperatorio/métodos , Fusión Vertebral/métodos , Columna Vertebral/cirugía , Cirugía Asistida por Computador/métodos , Tornillos Óseos , Humanos