Is the Use of Intraoperative Corticosteroids Harmful in Lumbar Decompression Surgery? No abstract available

Management of Herniated Lumbar Disk Disease and Cauda Equina Syndrome in Pregnancy Lower back pain is a commonly reported symptom during pregnancy. However, herniated lumbar disk disease is an uncommon cause for such pain. Cauda equina syndrome (CES) during pregnancy is a rare clinical scenario. This review highlights the epidemiology, diagnostic and treatment strategies, and challenges encountered when managing herniated lumbar disk disease and CES in pregnancy. Magnetic resonance imaging is the diagnostic modality of choice. Nonoperative treatment strategies are successful in the vast majority of cases in patients with a herniated disk in the absence of CES. CES and progressive neurological deficits remain absolute indications for surgical intervention regardless of gestational age. For such patients or those with debilitating symptoms refractory to nonoperative treatment strategies, surgery has been demonstrated to be safe in the pregnant patient population. However, surgery should be performed with obstetric and midwifery support should complications occur to the fetus.

Mini Screws for Improving Accuracy in Navigation-assisted Spine Surgery Study Design: Presentation of a surgical technique with accompanying video (Supplemental Digital Content 1, http://links.lww.com/CLINSPINE/A67) of an illustrative case. Objective: The objective of this study was to present a helpful and easy-to-implement technique for improving initial referencing accuracy, as well as rereferencing accuracy in cases of multilevel instrumentation or in cases of dislocation of the reference array. Summary of Background Data: Navigation-assisted spine surgery has become standard of care in most hospitals performing complex spine interventions. Although short-segment instrumentations are fairly straight-forward with current hardware and software solutions, obtaining ideal accuracies and troubleshooting reference array disruptions remain challenging. Methods: A surgical technique is presented as a step-by-step guide using intraoperative videos and photographs as well as imaging data in an illustrative case of thoracic hemivertebra resection and dorsal instrumentation. Technique/Results: After skin incision is performed at the index level, posterior soft tissue preparation is performed. Before firmly attaching the reference array to a spinous process we then insert a minimum of four 5 mm mini screws at any bony structure within the exposure. Then an intraoperative navigation scan (3-dimensional computed tomography or x-ray) is obtained, and initial referencing is performed using the previously inserted mini screws as landmarks. This yields mean accuracies of 1 mm or lower and is easily verifiable by placing the navigation probe on a mini screw head. This action can be swiftly repeated at any time to prevent reduced accuracy because of insertion forces applied during pedicle screw placement. In addition, this allows for easy rereferencing in cases of disruption or complete removal of the navigation array, eliminating the need to perform additional computed tomography or x-ray scans during the procedure. Conclusions: The technique presented allows for rapid and highly accurate initial referencing and can be used in all cases of navigation-assisted spine surgery. It also allows for hassle-free rereferencing in cases of disruption or accidental removal of the reference array.

Extradural Arachnoid Cyst Excision Arachnoid cysts are an uncommon postoperative complication and can result in back pain, radiculopathy, and/or cauda equina syndrome. For symptomatic postoperative arachnoid cysts, surgical management is the accepted treatment. While excision of arachnoid cysts is the preferred surgical method, cysts with adhesions to nerve roots and/or dura can be treated with cyst fenestration to reduce morbidity of excision. Surgeons should be prepared for dural defects after cyst excision, which can require dural grafting and lumbar drains for cerebrospinal fluid diversion.

Dropped Head Syndrome: A Systematic Review Study design: This study was a systematic review. Objectives: To reveal demographic factors, etiologies, response to treatment, and to propose a novel treatment algorithm for dropped head syndrome (DHS). Summary of background data: DHS is a rare condition defined by weakness of the cervical paraspinal muscles resulting in passively correctable flexion of the cervical spine. Patients present with neck pain, difficulty eating, and impaired horizontal gaze. Because of the rarity of DHS, a paucity of information exists with regard to demographics, etiology, and relative superiority of medical and surgical treatment. Materials and Methods: We conducted a systematic literature review by searching PubMed for “dropped head syndrome,” “chin on chest,” “isolated neck extensor myopathy” (INEM), and “camptocephalia.” Inclusion criteria were English-language articles that applied a specific treatment regimen with outcome data. A binomial logistic regression analysis was then performed to determine which covariates (age, sex, and treatments) were predictive of a positive response to treatment. Results: A total of 129 patients were described in 74 studies. Mean age was 63.6 and 63% were female. More than two-thirds of all patients fell into just 4 diagnostic categories (isolated neck extensor myopathy, 31.8%; Parkinson’s, 20.2%; myasthenia gravis, 12.4%; amyotrophic lateral sclerosis, 7.0%). Overall positive response to treatment was 64.3%; primary medical treatment (73.5%), immune suppression (78.9%), and a combination of both (87.5%). Surgery was 93.8% successful. A treatment algorithm focused on appropriate diagnosis, initial medical management, with surgical evaluation only after failure of medical treatment was proposed. Conclusions: Treatment for DHS starts with accurate diagnosis of the underlying etiology and is often associated with neuromuscular disease. A treatment algorithm for appropriate management of these patients was proposed. A trial of medical management and/or immunomodulators is warranted. Failing nonoperative management, surgery is predictive of a positive outcome. Level of Evidence: Level V.

Patient Perceptions of Iliac Crest Bone Grafting in Minimally Invasive Transforaminal Lumbar Interbody Fusion Study Design: Retrospective cohort. Objective: The objective of this study was to determine patients’ perception of iliac crest bone graft (ICBG) harvesting and donor site pain following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Summary of Background Data: The incidence of donor site pain has been debated in the literature because of the varying techniques associated with its harvest. Methods: Patients undergoing primary, single-level MIS TLIF with ICBG were retrospectively identified. ICBG harvesting was performed using a percutaneous technique with a tubular retractor. A survey was administered to assess if patients could accurately describe which side of their iliac crest they believed was harvested, and if they were experiencing any pain perceived to be originating from the donor site. Patient characteristics were compared using χ2 analysis and independent t test. Results: In total, 82 patients were included. The majority of patients had the ICBG harvested from the left iliac crest (97.5%). Approximately half of the patients correctly identified the side of harvest (50.6%). 48.1% of patients reported they were not confident or had guessed on their response. Patients that reported pain from the ICBG were more likely to feel confident or somewhat confident in their harvest site identification (57.9% vs. 46.3%) but less likely to be correct (36.8% vs. 63.4%) than patients without pain. 22 patients (27.8%) correctly identified the side of harvest without guessing. Of these, 11 (13.9%) reported pain. Conclusions: Approximately half of patients undergoing MIS TLIF with ICBG are able to correctly identify which side of their iliac crest was harvested. However, the majority of patients reporting pain were unable to correctly identify the side of harvest. This suggests that most patients are likely attributing other sources of pain to their ICBG. Therefore, rates of donor site pain may be over-reported in the current literature with contemporary harvesting techniques.

30-Day Postoperative Morbidity and Readmission Following Revision Anterior Cervical Discectomy and Fusion (ACDF) Study Design: This was a retrospective cohort study. Objective: To analyze risk factors associated with 30-day adverse outcomes and readmissions after revision anterior cervical discectomy and fusion (ACDF). Summary of Background Data: No current literature has evaluated the risk factors associated with adverse outcomes after revision ACDF. Methods: The 2012–2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using Current Procedural Terminology codes for ACDF (22551, 22554, and 63075) combined with Current Procedural Terminology codes 22830 (exploration of spinal fusion) or 22855 (removal of anterior instrumentation) to identify revision cases. Patients undergoing concurrent posterior cervical spine surgery and/or corpectomies were excluded from the analysis. A total of 1140 patients were retrieved for analysis. Results: Out of a total of 1140 patients, 51 (4.5%) experienced at least 1 any adverse event, with 40 (3.5%) experiencing a severe adverse event, and 17 (1.5%) experiencing a minor adverse event. A 30-day readmission rate was 3.4% (N=39) after a revision ACDF. On multivariate analysis, any adverse events were significantly associated with male sex [odds ratio (OR), 1.98], 2-level versus 1-level fusion (OR, 2.05), and a length of stay (LOS)>1 day (OR, 7.70). Severe adverse events were independently associated with male sex (OR, 2.85), smoking (OR, 0.33), 2-level versus 1-level fusion (OR, 2.03), and LOS>1 day (OR, 7.28). LOS>1 day was the only significant factor associated with an minor adverse event (OR, 14.65) and readmission within 30 days (OR, 2.67). Conclusions: Using a national surgical database, the study is the first of its kind to report rates and risk factors associated with adverse outcomes after ACDFs. Providers should understand the need of preoperative risk stratification in these patients to reduce the risk of experiencing adverse outcomes. Level of Evidence: Level III—retrospective.

Impact of Sickle Cell Anemia on Inpatient Morbidity After Spinal Fusion Study Design: A retrospective study. Objective: To determine the impact of sickle cell anemia on perioperative outcomes and resource utilization in elective spinal fusion surgery. Summary of Background Data: Sickle cell anemia has been identified as an important surgical risk factor in otolaryngology, cardiothoracic surgery, general surgery, and total joint arthroplasty. However, the impact of sickle cell anemia on elective spine surgery is unknown. Methods: Hospitalizations for elective spinal fusion surgery between the years of 2001–2014 from the US National Inpatient Sample were identified using ICD-9-CM codes and patients were grouped into those with and without sickle cell anemia. The main outcome measures were in-hospital neurological, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, and wound-related complications and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing elective spinal fusion with or without sickle cell anemia. Results: From a total of 4,542,719 patients undergoing elective spinal fusions from 2001 to 2014, 456 sickle cell disease patients were identified. Sickle cell anemia is a significant independent predictor for pulmonary embolism [odds ratio (OR)=7.37; confidence interval (CI), 4.27–12.71; P<0.001], respiratory complications (OR=2.36; CI, 1.63–3.42; P<0.001), wound complications (OR=3.84; CI, 2.72–5.44; P<0.001), and overall inpatient complications (OR=2.58; CI, 2.05–3.25; P<0.001). Sickle cell anemia patients also have significantly longer length of stay (7.0 vs. 3.8 d; P<0.001) and higher inpatient costs ($20,794 vs. $17,608 P<0.05). Conclusions: Sickle cell anemia is associated with increased risk of perioperative complications and greater health care resource utilization. Sickle cell anemia patients undergoing spinal fusion surgeries should be counseled on these increased risks. Moreover, current strategies for perioperative management of sickle cell anemia patients undergoing spinal fusion surgery need to be improved.

PHQ-9 Score Predicts Postoperative Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion Study Design: This was a retrospective cohort study. Objective: This study evaluates if an association exists between preoperative depression and postoperative outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Summary of Background Data: Few studies have quantified preoperative depression symptoms using Patient Health Questionnaire-9 (PHQ-9) to predict postoperative outcomes after lumbar fusion, especially MIS TLIF. Methods: A surgical database of patients undergoing primary, single-level MIS TLIF was retrospectively reviewed. Patients were stratified by predefined preoperative PHQ-9 scores: no depression (<5), mild depression (5–9), and moderate to severe depression (≥10). Inpatient pain scores and narcotics use were recorded. Oswestry Disability Index, Veterans RAND-12 Mental Component Score and Physical Component Score, and Visual Analog Scale (VAS) back and leg pain scores were collected preoperatively and at 6-week, 12-week, and 6-month follow-up. One-way analysis of variance and χ2 analysis determined if an association existed between PHQ-9 subgroups and baseline characteristics or perioperative outcomes. Multivariate linear regression assessed for an association between PHQ-9 and postoperative patient-reported outcomes. Results: In total, 94 patients were included. Patients with higher PHQ-9 scores were younger, obese, and carried workers’ compensation insurance. Higher PHQ-9 scores were associated with worse preoperative Oswestry Disability Index, Veterans RAND-12 Mental Component Score and Physical Component Score, and VAS back and leg pain scores. Patients with higher PHQ-9 reported greater inpatient VAS pain scores on postoperative day 0 and 1 and demonstrated greater hourly narcotics consumption on postoperative day 0. Furthermore, higher PHQ-9 scores exhibited less improvement in all patient-reported outcomes. Conclusions: Patients with severe depression symptoms reported greater pain, increased narcotics consumption, and less clinical improvement after MIS TLIF. Therefore, patients with greater PHQ-9 scores should be monitored more closely and may benefit from additional counseling with regard to postoperative outcomes to better manage pain control and expectations of recovery.

Evaluating the Concurrent Validity of PROMIS Physical Function in Anterior Cervical Discectomy and Fusion Study Design: This study was a retrospective cohort analysis. Objectives: This study aims to evaluate the concurrent validity of Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) domain as compared with legacy measures of patient-reported outcomes (PROs) among patients undergoing anterior cervical discectomy and fusion (ACDF). Summary of Background Data: As PROMIS becomes increasingly utilized, it is important to assess its validity among procedure-specific populations. Methods: Patients undergoing a primary, 1–3 level ACDF were retrospectively identified from a prospectively maintained surgical registry. PROMIS PF and legacy PRO scores were obtained at preoperative, 6-week, 12-week, and 6-month postoperative visits. Legacy PROs included Neck Disability Index (NDI), Short Form-12 (SF-12) physical composite, Visual Analog Scale (VAS) neck pain, and VAS arm pain. Postoperative improvements in PROs were assessed using paired t tests. Correlations between PROMIS and legacy PROs were tested using Pearson correlation coefficient. Results: A total of 57 ACDF patients were analyzed. The mean preoperative PROMIS PF was 40.0±6.4. PROMIS PF significantly improved at 12-week and 6-month follow-up. NDI, VAS neck pain, and VAS arm pain scores demonstrated significant improvement at all postoperative time points. SF-12 scores only exhibited significant improvement at the 6-month follow-up visit. Significant correlations between PROMIS PF, NDI, and SF-12 were identified at all preoperative and postoperative time points. PROMIS PF exhibited strong correlations with VAS neck pain at postoperative time points, and a moderate correlation preoperatively. Conclusions: Patients undergoing a primary 1–3 level ACDF experience significant improvements in PROMIS PF scores at 12-week and 6-month follow-up. Furthermore, PROMIS PF exhibits strong correlations to NDI and SF-12 at all preoperative and postoperative time points. These results suggest that PROMIS PF accurately measures PF and may be used in lieu of legacy PF instruments for patients undergoing ACDF.