Publications by authors named "Neel Anand"

91 Publications

High Prevalence of Biofilms on Retrieved Implants from Aseptic Pseudarthrosis Cases.

Spine Surg Relat Res 2021 23;5(2):104-108. Epub 2020 Sep 23.

Department of Bioengineering and Orthopaedics Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, USA.

Introduction: Recent literature has associated pseudarthrosis and pedicle screw loosening with subchronic infection at the pedicle of the vertebra. The positive culture results of a previous retrieval analysis show that such patients have a high frequency of bacterial contamination. The objective of this study is to visually capture the architecture of these undiagnosed infections, which have been described in other studies as biofilms on supposedly "aseptic" screw loosening.

Methods: Explants from 10 consecutive patients undergoing revision spine surgery for pseudarthrosis were collected and fixed in glutaraldehyde solution. Each of these implants was imaged thoroughly by using scanning electron microscopy and x-ray spectroscopy to evaluate the architecture of the biofilm. Additionally, eight patient swabs from tissues around the implants were sent for cultures to assess bacterial infiltration in tissues beyond the biofilm. The implants were also analyzed using energy dispersive x-ray spectroscopy. The exclusion criteria included clinically diagnosed infection (current or previous) and/or mechanical failure of the implant due to falls/accidents.

Results: The study was successful in capturing the visual architecture of the biofilm on retrieved implants. A total of 77% of pseudarthrosis cases presented with loose pedicle screws, which were diagnosed by a preoperative computed tomography scan showing radiolucency along the screw track and were confirmed intraoperatively, and 72% of the cases showed biofilm on explants.

Conclusions: In the absence of the clinical presentation of infection, impregnated bacteria could form a biofilm around an implant, and this biofilm can remain undetected via contemporary diagnostic methods, including swabbing. Implant biofilm is frequently present in "aseptic" pseudarthrosis cases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.22603/ssrr.2020-0147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026210PMC
September 2020

The prevalence of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in patients undergoing circumferential minimally invasive surgical (cMIS) correction for adult spinal deformity: long-term 2- to 13-year follow-up.

Spine Deform 2021 Sep 16;9(5):1433-1441. Epub 2021 Mar 16.

Department of Orthopaedics, Cedars Sinai Medical Center, 444 S. San Vicente Blvd., #900, Los Angeles, CA, 90048, USA.

Objectives: This aim of this study is to evaluate the prevalence of PJK and PJF in patients who underwent circumferential minimally invasive surgery (cMIS) for ASD.

Methods: A prospective database of patients who underwent cMIS correction of ASD from November 2006 to July 2018 was queried. PJK was defined as angle > 10° and at least 10° greater than the baseline when measuring UIV to UIV + 2. PJF was defined as any type of symptomatic PJK which required surgery. Pre-op, latest and delta SVA and PI-LL mismatch were compared between patients with PJK and without. Only patients instrumented at 4 or more levels with full length 36″ films and a minimum 2-year follow-up were included.

Results: A total of 184 patients met inclusion criteria for this study. Mean follow-up time was 85.2 months (24-158.9 months, SD 39.1). Mean age was 66 years (22-85 years). The mean number of operated levels was 6.9 levels (4-16 levels, SD 2.8). A total of 21 patients (10.8%) met PJK criteria. Only 10 (4.9%) were symptomatic (PJF) and underwent revision surgery. The other 11 patients remained asymptomatic. Comparing PJK to non-PJK patients, there was no statistically significant difference in the post-op SVA, delta SVA, post-op PI/LL and delta PI/LL between the two groups.

Conclusion: Our study would suggest that in the appropriately selected and well-optimized patient, CMIS deformity correction is associated with a low prevalence of PJK and PJF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s43390-021-00319-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8363539PMC
September 2021

A Risk-Benefit Analysis of Increasing Surgical Invasiveness Relative to Frailty Status in Adult Spinal Deformity Surgery.

Spine (Phila Pa 1976) 2021 Aug;46(16):1087-1096

Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO.

Study Design: Retrospective review of a prospectively enrolled multicenter Adult Spinal Deformity (ASD) database.

Objective: Investigate invasiveness and outcomes of ASD surgery by frailty state.

Summary Of Background Data: The ASD Invasiveness Index incorporates deformity-specific components to assess correction magnitude. Intersections of invasiveness, surgical outcomes, and frailty state are understudied.

Methods: ASD patients with baseline and 3-year (3Y) data were included. Logistic regression analyzed the relationship between increasing invasiveness and major complications or reoperations and meeting minimal clinically important differences (MCID) for health-related quality-of-life measures at 3Y. Decision tree analysis assessed invasiveness risk-benefit cutoff points, above which experiencing complications or reoperations and not reaching MCID were higher. Significance was set to P < 0.05.

Results: Overall, 195 of 322 patients were included. Baseline demographics: age 59.9 ± 14.4, 75% female, BMI 27.8 ± 6.2, mean Charlson Comorbidity Index: 1.7 ± 1.7. Surgical information: 61% osteotomy, 52% decompression, 11.0 ± 4.1 levels fused. There were 98 not frail (NF), 65 frail (F), and 30 severely frail (SF) patients. Relationships were found between increasing invasiveness and experiencing a major complication or reoperation for the entire cohort and by frailty group (all P < 0.05). Defining a favorable outcome as no major complications or reoperation and meeting MCID in any health-related quality of life at 3Y established an invasiveness cutoff of 63.9. Patients below this threshold were 1.8[1.38-2.35] (P < 0.001) times more likely to achieve favorable outcome. For NF patients, the cutoff was 79.3 (2.11[1.39-3.20] (P < 0.001), 111 for F (2.62 [1.70-4.06] (P < 0.001), and 53.3 for SF (2.35[0.78-7.13] (P = 0.13).

Conclusion: Increasing invasiveness is associated with increased odds of major complications and reoperations. Risk-benefit cutoffs for successful outcomes were 79.3 for NF, 111 for F, and 53.3 for SF patients. Above these, increasing invasiveness has increasing risk of major complications or reoperations and not meeting MCID at 3Y.Level of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000003977DOI Listing
August 2021

Revision Surgery Rates After Minimally Invasive Adult Spinal Deformity Surgery: Correlation with Roussouly Spine Type at 2-Year Follow-Up?

World Neurosurg 2021 04 11;148:e482-e487. Epub 2021 Jan 11.

Department of Neurosurgery University of California, San Francisco, San Francisco, California, USA.

Background: Spinopelvic parameters have hitherto dictated much of adult spinal deformity (ASD) correction. The Roussouly classification is used for the normal adult spine. We evaluated whether a correlation would be found between the Roussouly type and the rate of revision surgery in patients with ASD undergoing circumferential minimally invasive spinal (cMIS) correction.

Methods: A multicenter retrospective review of patients who had undergone cMIS surgery for ASD was performed. The inclusion criteria were age ≥18 years and 1 of the following: coronal Cobb angle >20°, sagittal vertical axis >5 cm, pelvic tilt >20°, pelvic incidence (PI) to lumbar lordosis (LL) mismatch >10°, cMIS surgery, and a minimum of 2 years of follow-up data available. The patients were classified by Roussouly type, and the clinical and radiographic outcomes were evaluated.

Results: A total of 104 patients were included in the present analysis. Of the 104 patients, 41 had Roussouly type 1, 32 had type 2, 23 had type 3, and 8 had type 4. Preoperatively, the patients with type 4 had the highest PI (P = 0.002) and LL (P < 0.001). Postoperatively, the PI-LL mismatch, Cobb angle, and sagittal vertical axis were not different among the 4 groups. However, the patients with type 2 had had the highest rate of complications (type 1, 29.3%; type 2, 61.3%; type 3, 34.8%; type 4, 25.0%; P = 0.031). The reoperation rates were comparable (type 1, 19.5%; type 2, 38.7%; type 3, 13.0%; type 4, 12.5%; P = 0.097). The reoperation rates for adjacent segment degeneration or proximal junctional kyphosis were also comparable (P = 0.204 and P = 0.060, respectively).

Conclusions: We did not find a clear correlation between Roussouly type and the rate of revision surgery for adjacent segment disease or proximal junctional kyphosis in patients who had undergone cMIS surgery for ASD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2021.01.011DOI Listing
April 2021

Factors affecting approach selection for minimally invasive versus open surgery in the treatment of adult spinal deformity: analysis of a prospective, nonrandomized multicenter study.

J Neurosurg Spine 2020 Jun 19:1-6. Epub 2020 Jun 19.

5Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California.

Objective: Surgical decision-making and planning is a key factor in optimizing outcomes in adult spinal deformity (ASD). Minimally invasive spinal (MIS) strategies for ASD have been increasingly used as an option to decrease postoperative morbidity. This study analyzes factors involved in the selection of either a traditional open approach or a minimally invasive approach to treat ASD in a prospective, nonrandomized multicenter trial. All centers had at least 5 years of experience in minimally invasive techniques for ASD.

Methods: The study enrolled 268 patients, of whom 120 underwent open surgery and 148 underwent MIS surgery. Inclusion criteria included age ≥ 18 years, and at least one of the following criteria: coronal curve (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, or thoracic kyphosis (TK) > 60°. Surgical approach selection was made at the discretion of the operating surgeon. Preoperative significant differences were included in a multivariate logistic regression analysis to determine odds ratios (ORs) for approach selection.

Results: Significant preoperative differences (p < 0.05) between open and MIS groups were noted for age (61.9 vs 66.7 years), numerical rating scale (NRS) back pain score (7.8 vs 7), CC (36° vs 26.1°), PT (26.4° vs 23°), T1 pelvic angle (TPA; 25.8° vs 21.7°), and pelvic incidence-lumbar lordosis (PI-LL; 19.6° vs 14.9°). No significant differences in BMI (29 vs 28.5 kg/m2), NRS leg pain score (5.2 vs 5.7), Oswestry Disability Index (48.4 vs 47.2), Scoliosis Research Society 22-item questionnaire score (2.7 vs 2.8), PI (58.3° vs 57.1°), LL (38.9° vs 42.3°), or SVA (73.8 mm vs 60.3 mm) were found. Multivariate analysis found that age (OR 1.05, p = 0.002), VAS back pain score (OR 1.21, p = 0.016), CC (OR 1.03, p < 0.001), decompression (OR 4.35, p < 0.001), and TPA (OR 1.09, p = 0.023) were significant factors in approach selection.

Conclusions: Increasing age was the primary driver for selecting MIS surgery. Conversely, increasingly severe deformities and the need for open decompression were the main factors influencing the selection of traditional open surgery. As experience with MIS surgery continues to accumulate, future longitudinal evaluation will reveal if more experience, use of specialized treatment algorithms, refinement of techniques, and technology will expand surgeon adoption of MIS techniques for adult spinal deformity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2020.4.SPINE20169DOI Listing
June 2020

Updates on Evidence-Based Practices to Reduce Preoperative and Intraoperative Contamination of Implants in Spine Surgery: A Narrative Review.

Spine Surg Relat Res 2020 21;4(2):111-116. Epub 2019 Jun 21.

Department of Biology, Bioengineering and Orthopaedics Surgery, University of Toledo, Toledo, USA.

The current communication seeks to provide an updated narrative review on latest methods of reducing implant contaminations used during spine surgery. Recent literature review has shown that both preoperative reprocessing and intraoperative handling of implants seem to contaminate implants. In brief, during preoperative phase, the implants undergo repeated bulk cleaning with dirty instruments from the OR, leading to residue buildup at the interfaces and possibly on the surfaces too. This, due to its concealed nature, remains unnoticed by the SPD (sterile processing department) or other hospital staff. Nevertheless, these can be avoided by using individually prepackaged presterilized implants. In the intraoperative phase, the implants (in the sterile field) are directly touched by the scrub tech with soiled (assisting the surgeon dispose the tissues from the instruments in use) gloves for loading onto an insertion device. It is then kept exposed on the working table (either separately or next to the used instruments as the pedicles hole are being prepared). Latest investigation has shown that by the time it is implanted in the patient, it can harbor up to 10e7 bacterial colony-forming units. The same implants were devoid of such colony-forming units, when sheathed by an impermeable sterile sheath around the sterile implant.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.22603/ssrr.2019-0038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7217678PMC
June 2019

Intermediate-term clinical and radiographic outcomes with less invasive adult spinal deformity surgery: patients with a minimum follow-up of 4 years.

Acta Neurochir (Wien) 2020 06 14;162(6):1393-1400. Epub 2020 Apr 14.

Department of Neurological Surgery, University of California, San Francisco, CA, USA.

Background: Little information exists regarding longer-term outcomes with minimally invasive spine surgery (MISS), particularly regarding long-segment and deformity procedures. We aimed to evaluate intermediate-term outcomes of MISS for adult spinal deformity (ASD).

Methods: This retrospective review of a prospectively collected multicenter database examined outcomes at 4 or more years following circumferential MIS (cMIS) or hybrid (HYB) surgery for ASD. A total of 53 patients at 8 academic centers satisfied the following inclusion criteria: age > 18 years and coronal Cobb > 20°, pelvic incidence-lumbar lordosis (PI-LL) > 10°, or sagittal vertical axis (SVA) > 5 cm.

Results: Radiographic outcomes demonstrated improvements of PI-LL from 16.8° preoperatively to 10.8° and coronal Cobb angle from 38° preoperatively to 18.2° at 4 years. The incidence of complications over the follow-up period was 56.6%. A total of 21 (39.6%) patients underwent reoperation in the thoracolumbar spine, most commonly for adjacent level disease or proximal junctional kyphosis, which occurred in 11 (20.8%) patients. Mean Oswestry Disability Index (ODI) at baseline and years 1 through 4 were 49.9, 33.1, 30.2, 32.7, and 35.0, respectively. The percentage of patients meeting minimal clinically important difference (MCID) (defined as 12% or more from baseline) decreased over time, with leg pain reduction more durable than back pain reduction.

Conclusions: Intermediate-term clinical and radiographic improvement following MISS for ASD is sustained, but extent of improvement lessens over time. Outcome variability exists within a subset of patients not meeting MCID, which increases over time after year two. Loss of improvement over time was more notable in back than leg pain. However, average ODI improvement meets MCID at 4 years after MIS ASD surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00701-020-04320-xDOI Listing
June 2020

A Multicenter Trial Demonstrating Presence or Absence of Bacterial Contamination at the Screw-Bone Interface Owing to Absence or Presence of Pedicle Screw Guard, Respectively, During Spinal Fusion.

Clin Spine Surg 2020 10;33(8):E364-E368

Department of Orthopaedics, University of California, San Diego, CA.

Study Design: A prospective multicenter study.

Objective: The objective of this study was to assess bacterial contamination in current practices of pedicle screw handling and comparing it to a novel method of using an intraoperative, sterile implant guard for screws.

Summary Of Background Data: Postoperative infections occur at the higher end of 2%-13%, as cited in the literature, and are underestimated due to various reasons in such publications. Despite concerns associated with vancomycin application immediately before closure, it is theoretically impossible to irrigate the screw-bone interface postimplantation. Consequently, any contamination of pedicle screw before implantation is permanent, and has the potential to cause deep-bone infection, or hardware loosening due to encapsulation of biofilm between the bone and the screw. Therefore, continued vigilance and effective preventive measures should be undertaken if available.

Materials And Methods: Two groups of presterile individually-packaged pedicle screws, one incased in a sterile, protective guard (group 1: G) and the other without such a guard (group 2: NG), 31 samples in each group were distributed over 28 spinal fusion surgeries at 5 independent hospitals groups. Each were loaded onto the insertion device by the scrub tech and left on the sterile table. Twenty minutes later, the lead surgeon who had just finished preparing the surgical site, handles the pedicle screw, to check the fit with the insertion device. Then, instead of implantation, it was transferred to a sterile container using fresh sterile gloves for bacterial analysis.

Results: The standard unguarded pedicle screws presented bioburden in the range of 10 to 10 colonies forming units per screw, whereas the guarded pedicle screws showed no bioburden.

Conclusion: Standard, current, handling of pedicle screws leads to bacterial contamination, which can be avoided if the screws are sterilely prepackaged with an intraoperative guard (preinstalled).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BSD.0000000000000976DOI Listing
October 2020

Minimally Invasive Spinal Deformity Surgery: Analysis of Patients Who Fail to Reach Minimal Clinically Important Difference.

World Neurosurg 2020 05 12;137:e499-e505. Epub 2020 Feb 12.

Department of Neurological Surgery, Scripps Clinic Torrey Pines, La Jolla, USA.

Background: It is well known that clinical improvements following surgical intervention are variable. While all surgeons strive to maximize reliability and degree of improvement, certain patients will fail to achieve meaningful gains. We aim to analyze patients who failed to reach minimal clinically important difference (MCID) in an effort to improve outcomes for minimally invasive deformity surgery.

Methods: Data were collected on a multicenter registry of minimally invasive surgery adult spinal deformity surgeries. Patient inclusion criteria were age ≥18 years, coronal Cobb ≥20 degrees, pelvic incidence-lumbar lordosis ≥10 degrees, or a sagittal vertical axis >5 cm. All patients had minimum 2 years' follow-up (N = 222). MCID was defined as 12.8 or more points of improvement in the Oswestry Disability Index. Up to 2 different etiologies for failure were allowed per patient.

Results: We identified 78 cases (35%) where the patient failed to achieve MCID at long-term follow-up. A total of 82 identifiable causes were seen in these patients with 14 patients having multiple causes. In 6 patients, the etiology was unclear. The causes were subclassified as neurologic, medical, structural, under treatment, degenerative progression, traumatic, idiopathic, and floor effects. In 71% of cases, an identifiable cause was related to the spine, whereas in 35% the cause was not related to the spine.

Conclusions: Definable causes of failed MIS ASD surgery are often identifiable and similar to open surgery. In some cases the cause is treatable and structural. However, it is also common to see failure due to pathologies unrelated to the index surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.02.025DOI Listing
May 2020

Predicting the combined occurrence of poor clinical and radiographic outcomes following cervical deformity corrective surgery.

J Neurosurg Spine 2019 Nov;32(2):182-190

15Department of Neurological Surgery, University of California, San Francisco, California.

Objective: Cervical deformity (CD) correction is clinically challenging. There is a high risk of developing complications with these highly complex procedures. The aim of this study was to use baseline demographic, clinical, and surgical factors to predict a poor outcome following CD surgery.

Methods: The authors performed a retrospective review of a multicenter prospective CD database. CD was defined as at least one of the following: cervical kyphosis (C2-7 Cobb angle > 10°), cervical scoliosis (coronal Cobb angle > 10°), C2-7 sagittal vertical axis (cSVA) > 4 cm, or chin-brow vertical angle (CBVA) > 25°. Patients were categorized based on having an overall poor outcome or not. Health-related quality of life measures consisted of Neck Disability Index (NDI), EQ-5D, and modified Japanese Orthopaedic Association (mJOA) scale scores. A poor outcome was defined as having all 3 of the following categories met: 1) radiographic poor outcome: deterioration or severe radiographic malalignment 1 year postoperatively for cSVA or T1 slope-cervical lordosis mismatch (TS-CL); 2) clinical poor outcome: failing to meet the minimum clinically important difference (MCID) for NDI or having a severe mJOA Ames modifier; and 3) complications/reoperation poor outcome: major complication, death, or reoperation for a complication other than infection. Univariate logistic regression followed by multivariate regression models was performed, and internal validation was performed by calculating the area under the curve (AUC).

Results: In total, 89 patients with CD were included (mean age 61.9 years, female sex 65.2%, BMI 29.2 kg/m2). By 1 year postoperatively, 18 (20.2%) patients were characterized as having an overall poor outcome. For radiographic poor outcomes, patients' conditions either deteriorated or remained severe for TS-CL (73% of patients), cSVA (8%), horizontal gaze (34%), and global SVA (28%). For clinical poor outcomes, 80% and 60% of patients did not reach MCID for EQ-5D and NDI, respectively, and 24% of patients had severe symptoms (mJOA score 0-11). For the complications/reoperation poor outcome, 28 patients experienced a major complication, 11 underwent a reoperation, and 1 had a complication-related death. Of patients with a poor clinical outcome, 75% had a poor radiographic outcome; 35% of poor radiographic and 37% of poor clinical outcome patients had a major complication. A poor outcome was predicted by the following combination of factors: osteoporosis, baseline neurological status, use of a transition rod, number of posterior decompressions, baseline pelvic tilt, T2-12 kyphosis, TS-CL, C2-T3 SVA, C2-T1 pelvic angle (C2 slope), global SVA, and number of levels in maximum thoracic kyphosis. The final model predicting a poor outcome (AUC 86%) included the following: osteoporosis (OR 5.9, 95% CI 0.9-39), worse baseline neurological status (OR 11.4, 95% CI 1.8-70.8), baseline pelvic tilt > 20° (OR 0.92, 95% CI 0.85-0.98), > 9 levels in maximum thoracic kyphosis (OR 2.01, 95% CI 1.1-4.1), preoperative C2-T3 SVA > 5.4 cm (OR 1.01, 95% CI 0.9-1.1), and global SVA > 4 cm (OR 3.2, 95% CI 0.09-10.3).

Conclusions: Of all CD patients in this study, 20.2% had a poor overall outcome, defined by deterioration in radiographic and clinical outcomes, and a major complication. Additionally, 75% of patients with a poor clinical outcome also had a poor radiographic outcome. A poor overall outcome was most strongly predicted by severe baseline neurological deficit, global SVA > 4 cm, and including more of the thoracic maximal kyphosis in the construct.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.7.SPINE18651DOI Listing
November 2019

The MISDEF2 algorithm: an updated algorithm for patient selection in minimally invasive deformity surgery.

J Neurosurg Spine 2019 Oct;32(2):221-228

11Department of Neurosurgery, Cornell Medical Center, New York, New York.

Objective: Minimally invasive surgery (MIS) can be used as an alternative or adjunct to traditional open techniques for the treatment of patients with adult spinal deformity. Recent advances in MIS techniques, including advanced anterior approaches, have increased the range of candidates for MIS deformity surgery. The minimally invasive spinal deformity surgery (MISDEF2) algorithm was created to provide an updated framework for decision-making when considering MIS techniques in correction of adult spinal deformity.

Methods: A modified algorithm was developed that incorporates a patient's preoperative radiographic parameters and leads to one of 4 general plans ranging from basic to advanced MIS techniques to open deformity surgery with osteotomies. The authors surveyed 14 fellowship-trained spine surgeons experienced with spinal deformity surgery to validate the algorithm using a set of 24 cases to establish interobserver reliability. They then re-surveyed the same surgeons 2 months later with the same cases presented in a different sequence to establish intraobserver reliability. Responses were collected and analyzed. Correlation values were determined using SPSS software.

Results: Over a 3-month period, 14 fellowship-trained deformity surgeons completed the surveys. Responses for MISDEF2 algorithm case review demonstrated an interobserver kappa of 0.85 for the first round of surveys and an interobserver kappa of 0.82 for the second round of surveys, consistent with substantial agreement. In at least 7 cases, there was perfect agreement between the reviewing surgeons. The mean intraobserver kappa for the 2 surveys was 0.8.

Conclusions: The MISDEF2 algorithm was found to have substantial inter- and intraobserver agreement. The MISDEF2 algorithm incorporates recent advances in MIS surgery. The use of the MISDEF2 algorithm provides reliable guidance for surgeons who are considering either an MIS or an open approach for the treatment of patients with adult spinal deformity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.7.SPINE181104DOI Listing
October 2019

Less invasive spinal deformity surgery: the impact of the learning curve at tertiary spine care centers.

J Neurosurg Spine 2019 Aug 23:1-8. Epub 2019 Aug 23.

13Department of Neurological Surgery, University of California, San Francisco, California.

Objective: The past decade has seen major advances in techniques for treating more complex spinal disorders using minimally invasive surgery (MIS). While appealing from the standpoint of patient perioperative outcomes, a major impediment to adoption has been the significant learning curve in utilizing MIS techniques.

Methods: Data were retrospectively analyzed from a multicenter series of adult spinal deformity surgeries treated at eight tertiary spine care centers in the period from 2008 to 2015. All patients had undergone a less invasive or hybrid approach for a deformity correction satisfying the following inclusion criteria at baseline: coronal Cobb angle ≥ 20°, sagittal vertical axis (SVA) > 5 cm, or pelvic tilt > 20°. Analyzed data included baseline demographic details, severity of deformity, surgical metrics, clinical outcomes (numeric rating scale [NRS] score and Oswestry Disability Index [ODI]), radiographic outcomes, and complications. A minimum follow-up of 2 years was required for study inclusion.

Results: Across the 8-year study period, among 222 patients, there was a trend toward treating increasingly morbid patients, with the mean age increasing from 50.7 to 62.4 years (p = 0.013) and the BMI increasing from 25.5 to 31.4 kg/m2 (p = 0.12). There was no statistical difference in the severity of coronal and sagittal deformity treated over the study period. With regard to radiographic changes following surgery, there was an increasing emphasis on sagittal correction and, conversely, less coronal correction. There was no statistically significant difference in clinical outcomes over the 8-year period, and meaningful improvements were seen in all years (ODI range of improvement: 15.0-26.9). Neither were there statistically significant differences in major complications; however, minor complications were seen less often as the surgeons gained experience (p = 0.064). Operative time was decreased on average by 47% over the 8-year period.Trends in surgical practice were seen as well. Total fusion construct length was unchanged until the last year when there was a marked decrease in conjunction with a decrease in interbody levels treated (p = 0.004) while obtaining a higher degree of sagittal correction, suggesting more selective but powerful interbody reduction methods as reflected by an increase in the lateral and anterior column resection techniques being utilized.

Conclusions: The use of minimally invasive methods for adult spinal deformity surgery has evolved over the past decade. Experienced surgeons are treating older and more morbid patients with similar outcomes. A reliance on selective, more powerful interbody approaches is increasing as well.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.6.SPINE19531DOI Listing
August 2019

Analysis of Spino-Pelvic Parameters and Segmental Lordosis with L5-S1 Oblique Lateral Interbody Fusion at the Bottom of a Long Construct in Circumferential Minimally Invasive Surgical Correction of Adult Spinal Deformity.

World Neurosurg 2019 Oct 16;130:e1077-e1083. Epub 2019 Jul 16.

Spine Center, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Background: Lateral interbody fusion (LIF) is an effective adjuvant for circumferential minimally invasive surgery (CMIS) treatment of adult spinal deformity (ASD). Accessing L5-S1 via an oblique LIF (OLIF) approach (OLIF 5-1) allows for anterior LIF (ALIF) at the lumbosacral junction without repositioning the patient. We review the early outcomes and complications of OLIF 5-1 at the bottom of a long construct for an MIS approach to treat ASD.

Methods: We queried a prospectively collected registry of 111 consecutive patients with ASD (Cobb angle >20°, sagittal vertical alignment [SVA] >50, or pelvic incidence [PI]-lumbar lordosis [LL] mismatch>10) patients who underwent CMIS correction between January 2015 and January 2019. Sixty patients had ≥4 levels fused and OLIF 5-1. Multilevel pre-psoas LIF + OLIF 5-1 were performed in the first stage. Three days later, stage 2 involved MIS installation of pedicle screws with aggressive rod contouring and derotation/translation.

Results: The mean patient age was 66.8 years (range, 48-79 years), and the mean duration of follow-up was 24 months (range, 3-60 months). A mean of 7 levels were fused (range, 4-9). Significant improvements in L5-S1 segmental lordosis (SL), LL, SVA, PI-LL mismatch, and pelvic tilt were seen following the first stage (P < 0.05). There was no intraoperative vascular, ureteral, or sympathetic chain injury, and no transient or permanent lumbar plexopathy. In 2 patients, OLIF 5-1 was abandoned due to difficult access, and transforaminal LIF was done at L5-S1 at the second stage. Five patients required intraoperative transfusion. No patient experienced postoperative ileus or L5-S1 pseudarthrosis. Significant improvements in visual analog scale pain score, Oswestry Disability Index, 36-Item Short Form Health Survey, and Scoliosis Research Society Outcomes Questionnaire were found.

Conclusions: A single-position MIS OLIF 5-1 at the bottom of a long construct in conjunction with multilevel pre-psoas LIF seems to be a safe and effective technique for improving SL, global LL, and SVA with a low risk of perioperative and postoperative complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.07.091DOI Listing
October 2019

Harboring Contaminants in Repeatedly Reprocessed Pedicle Screws.

Global Spine J 2019 Apr 25;9(2):173-178. Epub 2018 Jun 25.

Cedars-Sinai Medical Center, Los Angeles CA, USA.

Study Design: It consisted of evaluation of the pedicle screws for presence of residual nonmicrobial contaminants and tabulation of the minimum steps and time required for reprocessing implants as per guidelines and its comparison with actual practice.

Objective: An evaluation of the nonmicrobial contaminants prevalent on the pedicle screws used for spine surgery and the underlying practice cause behind the source.

Methods: The first component consisted of a random selection of 6 pedicle screws and its assessment using optical microscopy, scanning electron microscopy with energy dispersive spectroscopy, and Fourier transform infrared spectroscopy. The second component consisted of review of implant reprocessing guidelines and its applicability.

Results: Three types of contaminants were identified: corrosion, saccharide of unknown origin, and soap residue mixed with and were mostly present at the interfaces with low permeability. In addition, manufacturer's guideline recommends 19 hours of reprocessing, whereas the real-time observation revealed a turnaround time of 1 hour 17 minutes.

Conclusion: Repeatedly reprocessed pedicle screws host corrosion, carbohydrate, fat, and soap, which could be a cause of surgical site infection and inflammatory responses postsurgery. The cause behind it is the impracticality of repeated cleaning and inspection of such devices.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568218784298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448207PMC
April 2019

Minimally Invasive Surgery for Mild-to-Moderate Adult Spinal Deformities: Impact on Intensive Care Unit and Hospital Stay.

World Neurosurg 2019 Jul 1;127:e649-e655. Epub 2019 Apr 1.

Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.

Objective: To compare circumferential minimally invasive (cMIS) versus open surgeries for mild-to-moderate adult spinal deformity (ASD) with regard to intensive care unit (ICU) and hospital lengths of stay (LOS).

Methods: A retrospective review of 2 multicenter ASD databases with 426 ASD (sagittal vertical axis <6 cm) surgery patients with 4 or more fusion levels and 2-year follow-up was conducted. ICU stay, LOS, and estimated blood loss (EBL) were compared between open and cMIS surgeries.

Results: Propensity matching resulted in 88 patients (44 cMIS, 44 open). cMIS were older (61 vs. 53 years, P = 0.005). Mean levels fused were 6.5 in cMIS and 7.1 in open (P = 0.368). Preoperative lordosis was higher in open than in cMIS (42.7° vs. 40.9°, P = 0.016), and preoperative visual analog score back pain was greater in open than in cMIS (7 vs. 6.2, P = 0.033). Preoperative and postoperative spinopelvic parameters and coronal Cobb angles were not different. EBL was 534 cc in cMIS and 1211 cc in open (P < 0.001). Transfusions were less in cMIS (27.3% vs. 70.5%, P < 0.001). ICU stay was 0.6 days for cMIS and 1.2 days for open (P = 0.009). Hospital LOS was 7.9 days for cMIS versus 9.6 for open (P = 0.804).

Conclusions: For patients with mild-to-moderate ASD, cMIS surgery had a significantly lower EBL and shorter ICU stay. Major and minor complication rates were lower in cMIS patients than open patients. Overall LOS was shorter in cMIS patients, but did not reach statistical significance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.03.237DOI Listing
July 2019

Analysis of Complications with Staged Surgery for Less Invasive Treatment of Adult Spinal Deformity.

World Neurosurg 2019 Jun 18;126:e1337-e1342. Epub 2019 Mar 18.

San Diego Center for Spinal Disorders, La Jolla, California, USA.

Background: Spinal deformity surgery is often invasive and lengthy. Staging surgery over separate operative days may reduce complications. Staging is often used in minimally invasive treatment of adult spinal deformity (ASD).

Objective: To investigate the impact of staging on complication rates between hybrid (HYB; minimally invasive interbody with open posterior screw and rod fixation) and circumferential minimally invasive surgery (cMIS; minimally invasive interbody and screw/rod placement) procedures in patients with ASD.

Methods: A multicenter database of patients with ASD was reviewed. Patients who underwent staging (at least 3 levels) and 2 years of follow-up were analyzed. A total of 99 patients underwent staging: 53 cMIS and 46 HYB surgeries. Propensity matching for levels fused resulted in 19 patients in each group. Intra- and perioperative complications were assessed.

Results: Three HYB but no cMIS intraoperative complications occurred. More HYB patients had perioperative complications than cMIS patients. Neurologic complications were more frequent in HYB versus cMIS. Other complications did not differ significantly. Thirty-day reoperations were higher with cMIS than HYB, but there was no difference in reoperation rate at long-term follow-up. cMIS patients had greater improvement in the Oswestry Disability Index. There was no difference in complications between staged versus unstaged cMIS surgeries.

Conclusions: cMIS staged surgeries appear safer than HYB staged surgeries, and equally safe to cMIS unstaged surgeries. Perioperative complications were significantly higher for HYB staged surgeries. HYB surgeries may have better results when performed in a single setting, whereas cMIS surgeries can be performed in 1 or 2 stages depending on surgeon preference.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.03.090DOI Listing
June 2019

Is achieving optimal spinopelvic parameters necessary to obtain substantial clinical benefit? An analysis of patients who underwent circumferential minimally invasive surgery or hybrid surgery with open posterior instrumentation.

J Neurosurg Spine 2019 Feb 22:1-6. Epub 2019 Feb 22.

12Department of Neurosurgery, University of California, San Francisco, California.

OBJECTIVEIt is now well accepted that spinopelvic parameters are correlated with clinical outcomes in adult spinal deformity (ASD). The purpose of this study was to determine whether obtaining optimal spinopelvic alignment was absolutely necessary to achieve a minimum clinically important difference (MCID) or substantial clinical benefit (SCB).METHODSA multicenter retrospective review of patients who underwent less-invasive surgery for ASD was conducted. Inclusion criteria were age ≥ 18 years and one of the following: coronal Cobb angle > 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 20°, or pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°. A total of 223 patients who were treated with circumferential minimally invasive surgery or hybrid surgery and had a minimum 2-year follow-up were identified. Based on optimal spinopelvic parameters (PI-LL mismatch ± 10° and SVA < 5 cm), patients were divided into aligned (AL) or malaligned (MAL) groups. The primary clinical outcome studied was the Oswestry Disability Index (ODI) score.RESULTSThere were 74 patients in the AL group and 149 patients in the MAL group. Age and body mass index were similar between groups. Although the baseline SVA was similar, PI-LL mismatch (9.9° vs 17.7°, p = 0.002) and PT (19° vs 24.7°, p = 0.001) significantly differed between AL and MAL groups, respectively. As expected postoperatively, the AL and MAL groups differed significantly in PI-LL mismatch (-0.9° vs 13.1°, p < 0.001), PT (14° vs 25.5°, p = 0.001), and SVA (11.8 mm vs 48.3 mm, p < 0.001), respectively. Notably, there was no difference in the proportion of AL or MAL patients in whom an MCID (52.75% vs 61.1%, p > 0.05) or SCB (40.5% vs 46.3%, p > 0.05) was achieved for ODI score, respectively. Similarly, no differences in percentage of patients obtaining an MCID or SCB for visual analog scale back and leg pain score were observed. On multivariate analysis controlling for surgical and preoperative demographic differences, achieving optimal spinopelvic parameters was not associated with achieving an MCID (OR 0.645, 95% CI 0.31-1.33) or an SCB (OR 0.644, 95% CI 0.31-1.35) for ODI score.CONCLUSIONSAchieving optimal spinopelvic parameters was not a predictor for achieving an MCID or SCB. Since spinopelvic parameters are correlated with clinical outcomes, the authors' findings suggest that the presently accepted optimal spinopelvic parameters may require modification. Other factors, such as improvement in neurological symptoms and/or segmental instability, also likely impacted the clinical outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2018.11.SPINE181261DOI Listing
February 2019

Efficacy of Intraoperative Implant Prophylaxis in Reducing Intraoperative Microbial Contamination.

Global Spine J 2019 Feb 12;9(1):62-66. Epub 2018 Jun 12.

University of Toledo, Toledo, OH, USA.

Study Design: A prospective single-center study.

Objectives: Assess to what degree contamination of pedicle screws occur in standard intraoperative practice and if use of an impermeable guard could mitigate or reduce such an occurrence.

Methods: Two groups of sterile prepackaged pedicle screws, one with an intraoperative guard (group 1) and the other without such a guard (group 2), each consisting of 5 samples distributed over 3 time points, were loaded onto the insertion device by the scrub tech and left on the sterile table. Approximately 20 minutes later, the lead surgeon who had just finished preparing the surgical site touches the pedicle screw. Then instead of implantation it was transferred to a sterile container using fresh clean gloves for bacterial and gene analysis. Guarded screw implies that even after unwrapping from the package, the screw carries an impermeable barrier along its entire length, which is only removed seconds prior to implantation.

Results: The standard unguarded pedicle screws presented bioburden in the range of 10 to 10 (colony forming units/implant) with bacterial genus mostly consisting of and , the 2 most common genera found in surgical site infection reports. The common species among them were , , , and , whereas the guarded pedicle screws showed no bioburden.

Conclusions: Shielding the pedicle screws intraoperatively using a guard provides a superior level of asepsis than currently practiced. All unshielded pedicles screws were carrying bioburden of virulent bacterial species, which provides an opportunity for the development of postoperative infections.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568218780676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362554PMC
February 2019

Early and Late Reoperation Rates With Various MIS Techniques for Adult Spinal Deformity Correction.

Global Spine J 2019 Feb 10;9(1):41-47. Epub 2018 May 10.

University of California, San Francisco, CA, USA.

Study Design: A multicenter retrospective review of an adult spinal deformity database.

Objective: We aimed to characterize reoperation rates and etiologies of adult spinal deformity surgery with circumferential minimally invasive surgery (cMIS) and hybrid (HYB) techniques.

Methods: Inclusion criteria were age ≥18 years, and one of the following: coronal Cobb >20°, sagittal vertical axis >5 cm, pelvic tilt >20°, and pelvic incidence-lumbar lordosis >10°. Patients with either cMIS or HYB surgery, ≥3 spinal levels treated with 2-year minimum follow-up were included.

Results: A total of 133 patients met inclusion for this study (65 HYB and 68 cMIS). Junctional failure (13.8%) was the most common reason for reoperation in the HYB group, while fixation failure was the most common reason in the cMIS group (14.7%). There was a higher incidence of proximal junctional failure (PJF) than distal junctional failure (DJF) within HYB (12.3% vs 3.1%), but no significant differences in PJF or DJF rates when compared to cMIS. Early (<30 days) reoperations were less common (cMIS = 1.5%; HYB = 6.1%) than late (>30 days) reoperations (cMIS = 26.5%; HYB = 27.7%), but early reoperations were more common in the HYB group after propensity matching, largely due to infection rates (10.8% vs 0%, = .04).

Conclusions: Adult spinal deformity correction with cMIS and HYB techniques result in overall reoperation rates of 27.9% and 33.8%, respectively, at minimum 2-year follow-up. Junctional failures are more common after HYB approaches, while pseudarthrosis/fixation failures happen more often with cMIS techniques. Early reoperations were less common than later returns to the operating room in both groups, but cMIS demonstrated less risk of infection and early reoperation when compared with the HYB group.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568218761032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362559PMC
February 2019

The Prevalence of the Use of MIS Techniques in the Treatment of Adult Spinal Deformity (ASD) Amongst Members of the Scoliosis Research Society (SRS) in 2016.

Spine Deform 2019 03;7(2):319-324

Department of Orthopaedics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.

Study Design: Electronic survey administered to Scoliosis Research Society members.

Objective: To determine the prevalence of minimally invasive surgery (MIS) techniques for the treatment of adult spinal deformity.

Summary Of Background Data: There is a paucity of data available on the practice pattern, prevalence of minimally invasive spine surgery, and the preferred minimally invasive techniques in the treatment of adult spine deformity.

Methods: An electronic nine-question survey regarding individual usage pattern of minimally invasive spine surgery techniques was administered in 2016 to the members of the Scoliosis Research Society. Determinants included complexity in condition of patient population, prevalence of use of minimally invasive techniques in the surgeon's practice, prevalence of use of a particular MIS technique, strategy elected during surgery, adoption of staging of procedures and timing between staging of procedures.

Results: A total of 357 surgeons responded (61.3% response rate), and 154 (43.1%) of the respondents said that they use MIS as a part of their surgical treatment of adult spinal deformity. However, of these 154 respondents, 67 (43.5%) said that their MIS usage in deformity practice was between 1% and 20%. Only 11 (7.2%) said that they used MIS 81% to 100% of the time. The top MIS approaches that surgeons chose were MIS lateral lumbar interbody fusion 109 (70.59%) and MIS percutaneous screws 91 (58.8%).

Conclusions: The low rate of adoption of these techniques among the SRS members may be due to the false perception that there is not enough data to support that MIS techniques are better. This and the fact that a practitioner needs to be facile at different MIS techniques may be the true impediment to the adoption of MIS techniques in the treatment of ASD.

Level Of Evidence: Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jspd.2018.08.014DOI Listing
March 2019

Clinical and Radiologic Fate of the Lumbosacral Junction After Anterior Lumbar Interbody Fusion Versus Axial Lumbar Interbody Fusion at the Bottom of a Long Construct in CMIS Treatment of Adult Spinal Deformity.

J Am Acad Orthop Surg Glob Res Rev 2018 Oct 23;2(10):e067. Epub 2018 Oct 23.

Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Dr. Anand, Dr. Alayan, and Dr. Khandehroo); Albert Einstein College of Medicine, New York, NY (Dr. J. Cohen); and Boston University School of Medicine, Boston, MA (Dr. R. Cohen).

Introduction: Surgeons use numerous arthrodesis strategies for fusion of the lumbosacral junction including anterior lumbar interbody fusion (ALIF) and axial lumbar interbody fusion (AxiaLIF). The optimal L5-S1 fusion strategy remains inconclusive. The purpose of this study is to compare the fate of the lumbosacral junction in ALIF versus AxiaLIF patients in terms of clinical and radiographic outcomes.

Methods: Adult spinal deformity patients, treated with CMIS techniques, with at least 2-year follow-up who underwent AxiaLIF or ALIF at the lumbosacral junction were included. Patients were separated into two groups: AxiaLIF (56 patients) and ALIF (38 patients). Outcome measures included segmental lordosis, sagittal vertical alignment, lumbar lordosis (LL), pelvic incidence-LL mismatch, and pseudarthrosis, major complication, and revision surgery rates.

Results: The ALIF group achieved greater postoperative and delta segmental lordosis, higher delta sagittal vertical alignment, higher delta LL, and lower postoperative pelvic incidence-LL mismatch. The pseudarthrosis, major complication, and revision surgery rates were higher in the AxiaLIF group. Five cases of pseudarthrosis at L5-S1 were seen, all in the AxiaLIF group.

Discussion And Conclusion: ALIF patients showed more favorable radiographic correction parameters and lower rates of pseudarthrosis, major complications, and revision surgeries. ALIF is the preferred strategy for L5-S1 arthrodesis at a bottom of a long construct.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOSGlobal-D-18-00067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324885PMC
October 2018

Treatment of the Fractional Curve of Adult Scoliosis With Circumferential Minimally Invasive Surgery Versus Traditional, Open Surgery: An Analysis of Surgical Outcomes.

Global Spine J 2018 Dec 10;8(8):827-833. Epub 2018 May 10.

Scripps Clinic Torrey Pines, La Jolla, CA, USA.

Study Design: Retrospective, multicenter review of adult scoliosis patients with minimum 2-year follow-up.

Objective: Because the fractional curve (FC) of adult scoliosis can cause radiculopathy, we evaluated patients treated with either circumferential minimally invasive surgery (cMIS) or open surgery.

Methods: A multicenter retrospective adult deformity review was performed. Patients included: age >18 years with FC >10°, ≥3 levels of instrumentation, 2-year follow-up, and one of the following: coronal Cobb angle (CCA) > 20°, pelvic incidence and lumbar lordosis (PI-LL) > 10°, pelvic tilt (PT) > 20°, and sagittal vertical axis (SVA) > 5 cm.

Results: The FC was treated in 118 patients, 79 open and 39 cMIS. The FCs had similar coronal Cobb angles preoperative (17° cMIS, 19.6° open) and postoperative (7° cMIS, 8.1° open), but open had more levels treated (12.1 vs 5.7). cMIS patients had greater reduction in VAS leg (6.4 to 1.8) than open (4.3 to 2.5). With propensity matching 40 patients for levels treated (cMIS: 6.6 levels, N = 20; open: 7.3 levels, N = 20), both groups had similar FC correction (18° in both preoperative, 6.9° in cMIS and 8.5° postoperative). Open had more posterior decompressions (80% vs 22.2%, < .001). Both groups had similar preoperative (Visual Analogue Scale [VAS] leg 6.1 cMIS and 5.4 open) and postoperative (VAS leg 1.6 cMIS and 3.1 open) leg pain. All cMIS patients had interbody grafts; 35% of open did. There was no difference in change of primary CCA, PI-LL, LL, Oswestry Disability Index, or VAS Back.

Conclusion: Patients' FCs treated with cMIS had comparable reduction of leg pain compared with those treated with open surgery, despite significantly fewer cMIS patients undergoing direct decompression.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568218775069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6293429PMC
December 2018

Implant Prophylaxis: The Next Best Practice Toward Asepsis in Spine Surgery.

Global Spine J 2018 Oct 24;8(7):761-765. Epub 2018 Apr 24.

USC Spine Center, Los Angeles, CA, USA.

Study Design: A literature review.

Objectives: An evaluation of the contaminants prevalent on implants used for surgery and the aseptic methods being employed against them.

Methods: PubMed was searched for articles published between 2000 and 2017 for studies evaluating the contaminants present on spine implants, and associated pre- and intraoperative implant processing and handling methodology suggested to avoid them. Systematic reviews, observational studies, bench-top studies, and expert opinions were included.

Results: Eleven studies were identified whose major focus was the asepsis of implants to reduce the incidence of surgical site infection incidences during surgery. These studies measured the colony forming units of bacteria on sterilized implants and/or gloves from the surgeon, scrub nurse, and assistants, as well as reductions of surgical site infection rates in spine surgery due to changes in implant handling techniques. Additionally, the search included assessments of endotoxins and carbohydrates present on reprocessed implants. The suggested changes to surgical practice based on these studies included handling implants with only fresh gloves, keeping implants covered until the immediate time of use, reducing operating room traffic, avoiding reprocessing of implants (ie, providing terminally sterilized implants), and avoiding touching the implants altogether.

Conclusions: Both reprocessing (preoperative) and handling (intraoperative) of implants seem to lead to contamination of sterilized implants. Using a terminally sterilized device may mitigate reprocessing (preoperative implant prophylaxis), whereas the use of fresh gloves for handling each implant and/or a permanent shielding technique (intraoperative implant prophylaxis) could potentially avoid recontamination at the theatre.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568218762380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232723PMC
October 2018

The impact of age on surgical goals for spinopelvic alignment in minimally invasive surgery for adult spinal deformity.

J Neurosurg Spine 2018 Nov;29(5):560-564

14Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois.

OBJECTIVEAchieving appropriate spinopelvic alignment in deformity surgery has been correlated with improvement in pain and disability. Minimally invasive surgery (MIS) techniques have been used to treat adult spinal deformity (ASD); however, there is concern for inadequate sagittal plane correction. Because age can influence the degree of sagittal correction required, the purpose of this study was to analyze whether obtaining optimal spinopelvic alignment is required in the elderly to obtain clinical improvement.METHODSA multicenter database of ASD patients was queried. Inclusion criteria were age ≥ 18 years; an MIS component as part of the index procedure; at least one of the following: pelvic tilt (PT) > 20°, sagittal vertical axis (SVA) > 50 mm, pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°, or coronal curve > 20°; and minimum follow-up of 2 years. Patients were stratified into younger (< 65 years) and older (≥ 65 years) cohorts. Within each cohort, patients were categorized into aligned (AL) or mal-aligned (MAL) subgroups based on postoperative radiographic measurements. Mal-alignment was defined as a PI-LL > 10° or SVA > 50 mm. Pre- and postoperative radiographic and clinical outcomes were compared.RESULTSOf the 185 patients, 107 were in the younger cohort and 78 in the older cohort. Based on postoperative radiographs, 36 (33.6%) of the younger patients were in the AL subgroup and 71 (66.4%) were in the MAL subgroup. The older patients were divided into 2 subgroups based on alignment; there were 26 (33.3%) patients in the AL and 52 (66.7%) in the MAL subgroups. Overall, patients within both younger and older cohorts significantly improved with regard to postoperative visual analog scale (VAS) scores for back and leg pain and Oswestry Disability Index (ODI) scores. In the younger cohort, there were no significant differences in postoperative VAS back and leg pain scores between the AL and MAL subgroups. However, the postoperative ODI score of 37.9 in the MAL subgroup was significantly worse than the ODI score of 28.5 in the AL subgroup (p = 0.019). In the older cohort, there were no significant differences in postoperative VAS back and leg pain score or ODI between the AL and MAL subgroups.CONCLUSIONSMIS techniques did not achieve optimal spinopelvic alignment in most cases. However, age appears to impact the degree of sagittal correction required. In older patients, optimal spinopelvic alignment thresholds did not need to be achieved to obtain similar symptomatic improvement. Conversely, in younger patients stricter adherence to optimal spinopelvic alignment thresholds may be needed.https://thejns.org/doi/abs/10.3171/2018.4.SPINE171153.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2018.4.SPINE171153DOI Listing
November 2018

Home Versus Rehabilitation: Factors that Influence Disposition After Minimally Invasive Surgery in Adult Spinal Deformity Surgery.

World Neurosurg 2018 Oct 10;118:e610-e615. Epub 2018 Jul 10.

Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California, USA; Department of Orthopedic Surgery, San Diego Spine Foundation, San Diego, California, USA.

Background: Minimally invasive surgery (MIS) correction for adult spinal deformity (ASD) may reduce the need the need for postoperative skilled nursing facility (SNF) or inpatient rehabilitation (IR) placement following surgery. The likelihood of requiring placement in a facility rather than home disposition may be influenced by various factors. In addition, the associations between discharge location and outcomes and complication rates have not been elucidated in these patients. In this study, we aimed to define factors predicting disposition to an SNF/IR and to elucidate the rates of complications occurring in patients sent to home versus to a facility.

Methods: A retrospective review of a multicenter ASD database, which included patients who underwent surgery between 2009 and 2014. Inclusion criteria were age >18 years, MIS as part of index surgery, location of discharge, and at least 1 of the following: pelvic tilt >20°, sagittal vertical axis >5 cm, pelvic incidence-lumbar lordosis mismatch >10, or lumbar scoliosis >20°. Patients with a 2-year follow-up were included. Preoperative demographic and radiographic data, postoperative (<30 day) complications, and health-related quality of life were analyzed.

Results: A total of 182 patients met our inclusion criteria, including 113 who were discharged to home and 69 who were discharged to an SNF/IR. Older patients (>50 years) were more likely to be discharged to an SNF/IR (P = 0.043). Those aged >70 years were 6-fold more likely to go to an SNF/IR. No association was identified between discharge to an SNF/IR and any radiographic parameters except preoperative pelvic tilt (odds ratio [OR], 1.11; P = 0.009). Staged cases were more likely to be discharged to an SNF/IR (OR, 3.24; 95% confidence interval, 1.11-9.46; P = 0.032); otherwise, there was no difference in levels treated, operating time, estimated blood loss, osteotomy, or length of hospital stay. Patients requiring discharge to an SNF/IR had a higher rate of complications (58% vs. 39.8%; P = 0.017), including major complications (19.5% vs. 42%; P = 0.001), perioperative complications (14.2% vs. 31.9%; P = 0.004) and infections (3.5% vs. 13%; P = 0.016). Patients discharged to an SNF/IR had a higher rate of revision (19.5% vs. 33%; P = 0.035). Health-related quality of life measures were similar regardless of disposition.

Conclusions: Older patients and those undergoing staged MIS deformity correction have a higher likelihood of postoperative disposition to an SNF/IR. Complications occurred more commonly in those patients requiring transfer to an SNF/IR after hospitalization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2018.06.249DOI Listing
October 2018

Can Minimally Invasive Transforaminal Lumbar Interbody Fusion Create Lordosis from a Posterior Approach?

Neurosurg Clin N Am 2018 Jul;29(3):453-459

Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 800, Los Angeles, CA 90048, USA.

The transforaminal lumbar interbody fusion (TLIF) is a well-established 3-column fusion technique that can be used to manage lumbar stenosis, instability, and deformity. Having been in use for more than 20 years, it has evolved into many different renditions. This includes protocols using minimally invasive surgery (MIS) approaches. To avoid the development of flatback syndrome, it is important that a TLIF procedural technique is capable of reproducibly restoring lordosis. This article describes one of many MIS TLIF protocols and presents some of its previously published outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.nec.2018.03.010DOI Listing
July 2018

Curve Laterality for Lateral Lumbar Interbody Fusion in Adult Scoliosis Surgery: The Concave Versus Convex Controversy.

Neurosurgery 2018 12;83(6):1219-1225

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Background: Minimally invasive lateral lumbar interbody fusion (LLIF) is an effective adjunct in adult degenerative scoliosis (ADS) surgery. LLIF approaches performed from the concavity or convexity have inherent approach-related risks and benefits.

Objective: To analyze LLIF approach-related complications and radiographic and clinical outcomes in patients with ADS.

Methods: A multicenter retrospective review of a minimally invasive adult spinal deformity database was queried with a minimum of 2-yr follow-up. Patients were divided into 2 groups as determined by the side of the curve from which the LLIF was performed: concave or convex.

Results: No differences between groups were noted in demographic, and preoperative or postoperative radiographic parameters (all P > .05). There were 8 total complications in the convex group (34.8%) and 21 complications in the concave group (52.5%; P = .17). A subgroup analysis was performed in 49 patients in whom L4-5 was in the primary curve and not in the fractional curve. In this subset of patients, there were 6 complications in the convex group (31.6%) compared to 19 in the concave group (63.3%; P < .05) and both groups experienced significant improvements in coronal Cobb angle, Oswestry Disability Index, and Visual Analog Scale score with no difference between groups.

Conclusion: Patients undergoing LLIF for ADS had no statistically significant clinical or operative complication rates regardless of a concave or convex approach to the curve. Clinical outcomes and coronal plane deformity improved regardless of approach side. However, in cases wherein L4-5 is in the primary curve, approaching the fractional curve at L4-5 from the concavity may be associated with a higher complication rate compared to a convex approach.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyx612DOI Listing
December 2018

Impact of case type, length of stay, institution type, and comorbidities on Medicare diagnosis-related group reimbursement for adult spinal deformity surgery.

Neurosurg Focus 2017 Dec;43(6):E11

University of California, San Francisco, California.

OBJECTIVE The aim of this study was to educate medical professionals about potential financial impacts of improper diagnosis-related group (DRG) coding in adult spinal deformity (ASD) surgery. METHODS Medicare's Inpatient Prospective Payment System PC Pricer database was used to collect 2015 reimbursement data for ASD procedures from 12 hospitals. Case type, hospital type/location, number of operative levels, proper coding, length of stay, and complications/comorbidities (CCs) were analyzed for effects on reimbursement. DRGs were used to categorize cases into 3 types: 1) anterior or posterior only fusion, 2) anterior fusion with posterior percutaneous fixation with no dorsal fusion, and 3) combined anterior and posterior fixation and fusion. RESULTS Pooling institutions, cases were reimbursed the same for single-level and multilevel ASD surgery. Longer stay, from 3 to 8 days, resulted in an additional $1400 per stay. Posterior fusion was an additional $6588, while CCs increased reimbursement by approximately $13,000. Academic institutions received higher reimbursement than private institutions, i.e., approximately $14,000 (Case Types 1 and 2) and approximately $16,000 (Case Type 3). Urban institutions received higher reimbursement than suburban institutions, i.e., approximately $3000 (Case Types 1 and 2) and approximately $3500 (Case Type 3). Longer stay, from 3 to 8 days, increased reimbursement between $208 and $494 for private institutions and between $1397 and $1879 for academic institutions per stay. CONCLUSIONS Reimbursement is based on many factors not controlled by surgeons or hospitals, but proper DRG coding can significantly impact the financial health of hospitals and availability of quality patient care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2017.7.FOCUS17278DOI Listing
December 2017

Complication rates associated with open versus percutaneous pedicle screw instrumentation among patients undergoing minimally invasive interbody fusion for adult spinal deformity.

Neurosurg Focus 2017 Dec;43(6):E7

Division of Orthopaedic Surgery, Scripps Clinic Medical Group, La Jolla, California.

OBJECTIVE High-quality studies that compare outcomes of open and minimally invasively placed pedicle screws for adult spinal deformity are needed. Therefore, the authors compared differences in complications from a circumferential minimally invasive spine (MIS) surgery and those from a hybrid surgery. METHODS A retrospective review of a multicenter database of patients with spinal deformity who were treated with an MIS surgery was performed. Database inclusion criteria included an age of ≥ 18 years and at least 1 of the following: a coronal Cobb angle of > 20°, a sagittal vertical axis of > 5 cm, a pelvic incidence-lumbar lordosis angle of > 10°, and/or a pelvic tilt of > 20°. Patients were propensity matched according to the levels instrumented. RESULTS In this database, a complete data set was available for 165 patients, and after those who underwent 3-column osteotomy were excluded, 137 patients were available for analysis; 76 patients remained after propensity matching (MIS surgery group 38 patients, hybrid surgery group 38 patients). The authors found no difference in demographics, number of levels instrumented, or preoperative and postoperative radiographic results. At least 1 complication was suffered by 55.3% of patients in the hybrid surgery group and 44.7% of those in the MIS surgery group (p = 0.359). Patients in the MIS surgery group had significantly fewer neurological, operative, and minor complications than those in the hybrid surgery group. The reoperation rates in both groups were similar. The most common complication category for the MIS surgery group was radiographic and for the hybrid surgery group was neurological. Patients in both groups experienced postoperative improvement in their Oswestry Disability Index and visual analog scale (VAS) back and leg pain scores (all p < 0.05); however, MIS surgery provided a greater reduction in leg pain according to VAS scores. CONCLUSIONS Overall complication rates in the MIS and hybrid surgery groups were similar. MIS surgery resulted in significantly fewer neurological, operative, and minor complications. Reoperation rates in the 2 groups were similar, and despite complications, the patients reported significant improvement in their pain and function.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2017.8.FOCUS17479DOI Listing
December 2017

A Staged Protocol for Circumferential Minimally Invasive Surgical Correction of Adult Spinal Deformity.

Neurosurgery 2017 Nov;81(5):733-739

Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois.

Background: Minimally invasive surgery (MIS) techniques used for management of adult spinal deformity (ASD) aim to decrease the physiological demand on patients and minimize postoperative complications. A circumferential MIS (cMIS) protocol offers the potential to maximize this advantage over standard open approaches, through the concurrent use of multiple MIS techniques.

Objective: To demonstrate through a case example the execution of a cMIS protocol for management of an ASD patient with severe deformity.

Methods: Thorough preoperative assessment, surgical planning, and medical optimization were completed. Deformity correction was performed over 2 stages. During the first stage, interbody fusion was performed via an oblique lateral approach at all levels of the lumbar spine intended to be included in the final construct. The patient was kept as an inpatient and mobilized postoperatively. They were then re-imaged with standing films. The second stage occurred after 3 d and involved percutaneous instrumentation of all levels. Posterior fusion of the thoracic levels was achieved through decortication of pars and facets. These areas were accessed through the intermuscular plane established by the percutaneous screws. The patient was mobilizing on their first postoperative day.

Results: In a 66-yr-old female with severe sagittal imbalance and debilitating back pain, effective use of this cMIS protocol allowed for correction of the Cobb angle from 52° to 4° correction of spinopelvic parameters and 13 cm of sagittal vertical axis improvement. No complications were identified by 2 yr postoperative.

Conclusion: As a systematization of multiple MIS techniques combined, in a specific and staged manner, this cMIS protocol could provide a safe and effective approach to the management of ASD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyx353DOI Listing
November 2017
-->