Among patients with spondylolisthesis and lumbar spinal stenosis, laminectomy with fusion was associated with modestly greater improvement in physical health–related quality of life than laminectomy ...alone but not with significantly greater reduction in disability related to back pain.
The increased use of the lumbar spinal fusion procedure in the United States, along with the wide variation in practice, is attracting interest from multiple stakeholders, including patients, physicians, payers, and policymakers. In a report published in 2014, spinal fusion (465,000 hospital-based procedures in 2011) accounted for the highest aggregate hospital costs ($12.8 billion in 2011) of any surgical procedure performed in U.S. hospitals.
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The randomized, controlled Spine Patient Outcomes Research Trial (SPORT) showed that surgery was superior to nonoperative care for the management of lumbar degenerative spondylolisthesis.
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In SPORT, most patients in the surgical group were treated by means . . .
History and advances in spinal neurosurgery Walker, Corey T; Kakarla, U Kumar; Chang, Steve W ...
Journal of neurosurgery. Spine,
12/2019, Letnik:
31, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Insight into the historic contributions made to modern-day spine surgery provides context for understanding the monumental accomplishments comprising current techniques, technology, and clinical ...success. Only during the last century did surgical growth occur in the treatment of spinal disorders. With that growth came a renaissance of innovation, particularly with the evolution of spinal instrumentation and fixation techniques. In this article, the authors capture some of the key milestones that have led to the field of spine surgery today, with an emphasis on the historical advances related to instrumentation, navigation, minimally invasive surgery, robotics, and neurosurgical training.
Abstract
BACKGROUND
The use of bone morphogenetic proteins for fusion augmentation in spine surgery has increased dramatically in recent years. Information is continually emerging regarding the ...effectiveness and safety profile of these compounds.
OBJECTIVE
We have noted an increased incidence in sterile seroma formation and painful edema after the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for posterolateral lumbar fusion. We present a retrospective review to determine the incidence of seroma formation and to discuss its clinical implications.
METHODS
We retrospectively reviewed the operative reports of patients who underwent posterolateral lumbar fusion with the addition of rhBMP-2. We identified all patients who required surgical exploration of a postoperative sterile seroma.
RESULTS
Of the 130 patients who underwent posterolateral lumbar fusion with rhBMP-2, 6 (4.6%) were returned to the operating room for exploration of a sterile seroma. The total amount of rhBMP-2 delivered to the posterolateral space per patient was 2.1 to 14.7 mg (mean, 8.4 mg per patient). The patients were returned to the operating room 5 to 13 days (mean, 7.7 days) after their initial surgery, and infection was ruled out in all cases by intraoperative cultures.
CONCLUSION
There seems to be an increased incidence of formation of sterile seroma and painful edema in the lumbar region after posterolateral fusion with rhBMP-2. This report, along with other series highlighting the potential complications of bone morphogenetic proteins, suggests that more caution should be used when these compounds are used. Further studies are required to better define the risks and benefits of using bone morphogenetic proteins for spine surgery.
Atlas Fractures Kakarla, Udaya K; Chang, Steve W; Theodore, Nicholas ...
Neurosurgery,
03/2010, Letnik:
66, Številka:
suppl_3
Journal Article
Recenzirano
Abstract
OBJECTIVE
To provide a comprehensive review of the biomechanics, pathophysiology, and clinical management of atlas fractures.
METHODS
Selected literature review.
RESULTS
Atlas fractures ...account for 25% of craniocervical injuries, 3% to 13% of cervical spine injuries, and 1% to 3% of all spinal injuries. Motor vehicle accidents account for 80% to 85% of atlas fractures, and the mechanism of injury is axial loading. Isolated atlas fractures are more common; however, 40% to 44% of atlas fractures have concomitant axis fractures. Fractures of isolated anterior or posterior arches are more common and typically seen with concomitant spine fractures. Isolated burst fractures are the second most common type and rarely cause neurological injury. Treatment of atlas fractures is based on whether they occur in isolation or in combination with other cervical spine injuries and on the integrity of the transverse ligament, which is best assessed with high-resolution magnetic resonance imaging. Isolated atlas fractures without injury of the transverse ligament or associated with bony avulsion of the transverse ligament can be treated with halo-brace immobilization and should be followed for instability with flexion-extension radiography. Surgical fixation is recommended for nonbony avulsion of the transverse ligament or if instability is present. The type of surgical fixation is determined by the concomitant craniocervical injuries if present.
CONCLUSION
Atlas fractures can be treated with halo-brace immobilization with acceptable outcomes. The role of surgical fixation, especially for atlas burst fractures, requires further study for clarification.
Physician burnout in neurosurgery is highly prevalent and occurs most severely during residency. Although earlier assessments have identified stressors contributing to neurosurgery resident burnout, ...recovery interventions have not been studied extensively. We aimed to characterize burnout patterns and factors contributing to recovery through a single-institution assessment of neurosurgery residents across 4 decades.
We administered a 59-item questionnaire to all living current and former residents of a large neurosurgical training institution (n = 96). Respondents indicated the timeline of burnout or hardship during residency and evaluated burnout stressors and recovery factors through a 5-point Likert scale and free-text response.
The survey response rate was 67% (64 of 96). The overall self-reported burnout rate was 30% (19 of 64). Recent trainees were significantly more likely to report burnout (P < 0.05). Postgraduate year 2 was cited by 66% of respondents as the onset of burnout or hardship. The most common stressors included work-life imbalance (55%) and imbalance of resident duties (33%). The highest-impact recovery factors were end of a rotation or postgraduate year (80%), increased sleep (48%), and meaningful relationships with colleagues (42%). Institution-specific factors, such as outdoor activities (52%) and intraprogram social events (34%), were also influential in recovery. In free-text responses, respondents identified a strong sense of mission in neurosurgical training as a central driver of recovery to wellness.
Institutional support structures promoting mentorship and camaraderie are actionable methods to encourage resident burnout recovery. This study serves as a model for other programs to identify their “critical periods” of burnout and effective wellness interventions.
Abstract
During the 1930s, white matter tracts began to assume relevance for neurosurgery, especially after Cajal's work. In many reviews of white matter neurobiology, the seminal contributions of ...Josef Klingler (1888-1963) and their neurological applications have been overlooked. In 1934 at the University of Basel under Eugen Ludwig, Klingler developed a new method of dissection based on a freezing technique for brain tissue that eloquently revealed the white matter tracts. Klingler worked with anatomists, surgeons, and other scientists, and his models and dissections of white matter tracts remain arguably the most elegant ever created. He stressed 3-dimensional anatomic relationships and laid the foundation for defining mesial temporal, limbic, insular, and thalamic fiber and functional relationships and contributed to the potential of stereotactic neurosurgery. Around 1947, Klingler was part of a Swiss-German group that independently performed the first stereotactic thalamotomies, basing their targeting and logic on Klingler's white matter studies, describing various applications of stereotaxy and showing Klingler's work integrated into a craniocerebral topographic system for targeting with external localization of eloquent brain structures and stimulation of deep thalamic nuclei. Klingler's work has received renewed interest because it is applicable for correlating the results of the fiber-mapping paradigms from diffusion tensor imaging to actual anatomic evidence. Although others have described white matter tracts, none have had as much practical impact on neuroscience as Klinger's work. More importantly, Josef Klingler was an encouraging mentor, influencing neurosurgeons, neuroscientists, and brain imaging for more than three quarters of a century.
Objective To evaluate risk factors for the development of dysphagia after anterior cervical surgery. Methods The records of 249 patients who underwent anterior cervical surgery were reviewed. The ...presence and severity of dysphagia were assessed with the Dysphagia Disability Index 6 weeks and 3, 6, and 12 months after surgery. Age; sex; ethnicity; cigarette smoking; previous cervical surgeries; reoperation for same pathology; type of procedure, incision, and instrumentation; number and levels involved; side of procedure, length of surgery; and use of postoperative bracing were analyzed. Results During the first 6 months after surgery, 27 (10.8%) patients developed dysphagia. From these patients the presence of dysphagia at 6 weeks and at 3 and 6 months was 88.8%, 29.6%, and 7.4%, respectively. By 12 months, dysphagia had resolved in all cases. The mean age of patients with dysphagia was 55 years (SD 12.98) and 50 years (SD 12.07) in patients without dysphagia ( P = 0.05). Dysphagic patients had an average of 2.2 (SD 1.15) levels operated compared with 1.84 (SD 0.950) in nondysphagic patients ( P = 0.05). Patients who developed dysphagia were most often treated at C4-5 (67%) and C5-6 (81%: P < 0.001). Although mean operative time was slightly longer in patients with dysphagia (186 minutes) compared with those without (169 minutes), the difference was not significant. Conclusions In our patients, the incidence of dysphagia was low, and it had completely resolved at 12 months in all cases. Risk factors for dysphagia were multilevel procedures, involvement of C4-5 and C5-6, and age.
Anterior cervical discectomy and fusion with plating is a common procedure performed for cervical spondylosis by spine surgeons. However, data on procedures involving 4 disc spaces are lacking. We ...report the outcomes of patients who underwent 4-level anterior cervical discectomy and fusion with plating at a single institution.
Between 1997 and 2006, 34 patients (19 females, 15 males; mean age, 58 years; age range, 38-83 years) underwent 4-level anterior cervical discectomy and fusion with plating based on a surgical database search. Only patients undergoing surgery at 4 contiguous disc levels were included. Data were collected in a retrospective fashion. Patients' demographics, symptoms, neurologic findings, and radiographic findings at admission were recorded. Long-term clinical and radiographic outcomes at last follow-up were analyzed.
Twenty-nine patients (85%) underwent anterior cervical discectomy and fusion with plating at C3-C7. Sixteen patients presented with neurologic deficits, of which 14 (88%) improved. None worsened after surgery. Minor complications occurred in 26 patients, including transient dysphagia in 18 (53%) and hoarseness in 3 (9%). Radiographic outcomes were available in 27 patients (median follow-up, 15 months; range, 4-71 months). The overall fusion rate was 92.6%. Stable fibrous nonunions were present in 2 patients; the chance of nonunion was 1.9% per level and 7% per patient. Adjacent-level disease occurred in 2 patients.
In carefully selected patients, 4-level anterior cervical discectomy and fusion with plating can be associated with high rates of fusion. The technique is safe and effective for managing multilevel cervical spondylotic myelopathy and may obviate the need for circumferential procedures.
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