Faculty Bibliography

Objective. The purpose of this study was to evaluate a new questionnaire to assess outcomes related to the midline anterior lumbar approach and to identify risk factors for negative patient responses. Methods. A retrospective review of 58 patients who underwent anterior lumbar surgery at a single institution for either degenerative disc disease or spondylolisthesis in 2009 was performed. The outcome measures included our newly developed Anterior Lumbar Surgery Questionnaire (ALSQ), ODI, and EQ-5D. Results. There were 58 patients available for followup, 27 women and 31 men. The average age at surgery was 50.8 years, with an average followup of 2.92 years. The average change in ODI was 34.94 (22.7) and EQ-5D was 0.28 (0.29). The rate of complications with the anterior approach was 10.3% and there was one male patient (3.2%) with retrograde ejaculation. Determination of the effectiveness of the new ALSQ revealed that it significantly correlated to the EQ-5D and ODI (P < 0.05). Smoking was associated with a negative response on thirteen questions. BMP use was not associated with a negative response on any sexual function questions. Conclusions. Our new Anterior Lumbar Surgery Questionnaire determines patient perceived complications related to the midline anterior lumbar surgical approach.

STUDY DESIGN.: Retrospective study from data from a single access surgeon at 2 hospitals. OBJECTIVE.: To increase the surgeon's awareness of iliolumbar vein (ILV) variants during the anterior approach to the lumbar spine. SUMMARY OF BACKGROUND DATA.: Although there are many advantages to using the anterior approach, serious risks are involved, namely, vascular injury. The ILV is especially vulnerable when exposing the L4 and L5 vertebrae, and its ligature is recommended to avoid massive hemorrhage from its disruption. Cadaver studies on ILV variants have mainly analyzed drainage patterns. To our knowledge, however, no studies on ILV variants have been conducted on live humans during anterior spinal surgical procedures. METHODS.: A total of 159 patients who underwent anterior spinal surgery of at least the L4-L5 levels were included. Cases not involving the L4-L5 level were excluded. Frequency of anomalous ILVs and their possible association with diagnosis (spondylolisthesis, herniated nucleus pulposus, degenerative disc disease, and stenosis), sex, comorbidities, and pelvic history was evaluated. ILV was classified into 5 types: type 0 (missing ILV), type 1 (single ILV), type 2 (2 ILVs), type 3 (3 ILVs), and type 4 (>3 ILVs). RESULTS.: Most patients had a single ILV (73%, N = 116). Multiple ILVs were found in 25.8% of cases: 27 cases (17%) for type 2, 11 cases (6.9%) for type 3, and 3 cases (1.9%) for type 4. A higher frequency of multiple ILVs was found in males (32%) than in females (19.2%) (P = 0.034). Diagnosis, comorbidity, and pelvic surgical history were not associated with the number of ILVs. CONCLUSION.: The high frequency of multiple ILVs found during the anterior approach is crucial knowledge for access surgeons, as it will help them anticipate such anomalies and thus avoid the potentially catastrophic complications of an avulsion of an unexpected extra vein.Level of Evidence: 2.

BACKGROUND CONTEXT: The anterior approach to the lumbar spine has been increasingly used to treat numerous conditions, from degenerative diseases to deformities. While many advantages exist in using the anterior approach, one of the most serious risks involved is injury to the great vessels. The iliolumbar vein (ILV) is especially vulnerable when exposing the L4 and L5 vertebrae, and its ligature is recommended to avoid massive hemorrhage from its disruption. Although some cadaver studies have described the anatomical variations of the ILV, there are no known studies to date, on the presence of anomalous iliolumbar veins in live humans undergoing anterior spinal surgeries. PURPOSE: To increase the surgeon's awareness of anatomic variations of the ILV in patients in whom the anterior approach is indicated. STUDY DESIGN/SETTING: Retrospective study of data from two independent hospitals. PATIENT SAMPLE: 159 patients undergoing anterior spinal surgery of at least the L4-L5 levels, by a single access surgeon and thirteen orthopedic and neurosurgical spine surgeons. OUTCOME MEASURES: Frequency of anomalous ILV's found and its possible association with various factors. METHODS: Variables assessed were: diagnosis for which surgery was indicated for at least the L4-L5 level (spondylolisthesis, herniated nucleus pulposus, scoliosis, degenerative disk disease and stenosis), age, gender, comorbidities, past surgical history, number of levels exposed and ILV description. ILV was classified into missing ILV, single, two, three, or more than three ILV's. Chi-square values were used to evaluate associations between the variables and number of ILV's found. RESULTS: Fifty-one percent were males. The average age was 49.7 years. The ILV was present in 157 (98.7%) patients. In 2 (1.3%) cases, the ILV was not seen in the course the exposure. In 116 (73%) patients, a single ILV was found. In 25.8% of patients, multiple ILV's were found: 27 (17%) cases had 2 ILVs, 11 (6.9%) had 3 ILVs, 3 cases (1.9%) had more than 3 ILVs. Men were found to have a higher frequency of multiple (>2) veins than females (p=0.07). Diagnosis, comorbidity and past pelvic surgical history were not associated with the number of veins found. CONCLUSIONS: A high frequency of multiple veins was observed during the anterior approach. This knowledge is crucial to helping surgeons avoid the potentially catastrophic complications of an avulsion of an unexpected extra vein

BACKGROUND CONTEXT: Anterior lumbar surgery is a common procedure for anterior lumbar interbody fusion and disc replacement but the impact of obesity on this procedure has not been determined. PURPOSE: To assess the perioperative outcomes of anterior retroperitoneal lumbar surgery in obese versus non-obese patients. STUDY DESIGN/SETTING: Prospective review of patients with anterior retroperitoneal lumbar disc procedures PATIENT SAMPLE: Seventy-four patients with anterior retroperitoneal lumbar disc procedures performed were evaluated. OUTCOME MEASURES: Access-related parameters included tissue depth (skin-to-fascia and fascia-to-spine depths), length of incision, estimated blood loss during the anterior procedure, the duration of the anterior exposure, and the duration of the entire anterior procedure. Outcome measures included complications attributable to the anterior procedure, analgesic use, length of time to ambulation, and length of hospitalization. METHODS: Seventy-four anterior retroperitoneal lumbar disc procedures were prospectively analyzed. Patient age, sex, body mass index, comorbidities, diagnosis, and operative parameters were collected. Access-related parameters and outcome measures were compared between obese and non-obese patients. Obesity was defined as body mass index greater than or equal to 30. RESULTS: There were 35 males and 39 females. Mean age was 46.6 years. The main diagnosis (63.5%) was discogenic back pain. Forty-one (55%) patients were non-obese and 33 were obese. The two patient groups were comparable in terms of age, sex, diagnosis, mean number of anterior levels operated, and previous abdominal surgery (all p>.05). In obese patients, there were two iliac vein lacerations (major complication rate, 6.1%), one superficial infection, and one urinary tract infection (minor complication rate, 6.1%). In non-obese patients, there were two iliac vein lacerations, one intestinal serosal tear (major complication rate, 7.3%), and two urinary tract infections (minor complication rate, 4.9%). There was no significant difference in the complication rates between obese and non-obese patients (p=.6). Obese patients have significantly longer duration of anterior exposure, duration of entire anterior surgery, longer length of anterior incision, and more depth from skin to fascia and from fascia to spine compared with non-obese patients. However, obesity does not affect blood loss, analgesic use, length of time to ambulation, and length of hospitalization. CONCLUSION: Perioperative outcomes in obese and non-obese patients were comparable and obesity is not related to an increased risk of morbidity in anterior lumbar surgery

Endovascular intervention can provide an alternative method of treatment for visceral artery aneurysms. We conducted a retrospective review of all patients with visceral artery aneurysms at a single university medical center from 1990 to 2003, focusing on the outcome of endovascular therapy. Sixty-five patients with visceral artery aneurysms were identified: 39 splenic (SAA), 13 renal, seven celiac, three superior mesenteric (SMA), and three hepatic. Eleven patients (16.9%) had symptoms attributable to their aneurysms, which included a total of four ruptures (6.2%): three splenic and one hepatic. Management consisted of 18 (27.7%) endovascular interventions, nine (13.9%) open surgical repairs, and 38 (58.5%) observations. Mean aneurysm diameter for patients treated expectantly was significantly less than for those who underwent intervention (p = 0.001). Endovascular interventions included 15 (83.3%) embolizations (11 SAA, three renal, one hepatic) and three (16.7%) stent grafts (two SMA, one renal). The initial technical success rate of the endovascular procedures was 94.4% (17/18). However, there were four patients (22.2%) with major endovascular procedure-related complications: one late recurrence requiring open surgical repair, two large symptomatic splenic infarcts, and one episode of severe pancreatitis. These four patients had distal splenic artery aneurysms at or adjacent to the splenic hilum. There were no endovascular procedure-related deaths. Reasons for performing open surgical repair included three SAA ruptures diagnosed at laparotomy and complex anatomy not amenable to endovascular intervention (six patients). One surgical patient had a postoperative small bowel obstruction treated nonoperatively; and there was one perioperative death in a patient operated on emergently for rupture. Endovascular management of visceral artery aneurysms is a reasonable alternative to open surgical repair in carefully selected patients. Individual anatomic considerations play an important role in determining the best treatment strategy if intervention is warranted. However, four of 11 (36.4%) patients with distal splenic artery aneurysms treated with endovascular embolization developed major complications. Based on our experience, traditional surgical treatment of SAA with repair or ligation and concomitant splenectomy when necessary may be preferred in these cases

This is a retrospective review of all carotid endarterectomies (CEA) (n=91) done from 1993 to 2002 at an inner-city hospital (Group I). This group was compared to a randomly selected group of patients (n=445) treated at a private hospital (Group II). The same high-volume surgeons performed CEAs at both hospitals. The majority of Group I patients (71.4%) were members of racial minority groups. They were also more likely to be younger (p<0.001), hypertensive (p<0.03), diabetic (p<0.001), and current smokers (p<0.001); have contralateral carotid artery occlusion (p=0.04); and present with stroke (p<0.001) than Group II patients. Despite this, the incidence of postoperative myocardial infarction (2.2% vs 0.2%, p=0.08), stroke (1.1% vs 1.6%, NS), and death (1.1% vs 0%, NS) was comparable between the 2 groups. Aggressive preoperative workup for occult cardiac disease in Group I revealed an incidence of 25.9% (n=15). Of these, 5 (33.3%) were found to have coronary artery disease severe enough to warrant intervention before CEA. In an inner-city population with increased medical comorbidities, more severe cerebrovascular disease, and relatively low volume of carotid surgery, the results of CEA were comparable to those in patients treated at a high-volume private hospital. The presence of high-volume surgeons, operating at the low-volume municipal hospital, may contribute to the low complication rate. Finally, aggressive preoperative cardiac workup in this underserved population revealed a meaningful incidence of occult coronary artery disease requiring intervention before CEA

Objectives Limb and pelvic ischemia are known complications after endovascular abdominal aortic aneurysm repair (EVAR). The objective of this paper is to present our experience with the incidence, presentation, and management of such complications. Methods Over 9 years 311 patients with aortic aneurysms underwent EVAR. A retrospective review identified 28 patients (9.0%) with ischemic complications. Results Among 28 patients with ischemic complications, 21 had lower extremity ischemia and 7 had pelvic ischemia: colon (n = 4), buttock (n = 2), and spinal cord (n = 2). Of the 21 patients with lower extremity ischemia, 15 had limb occlusions (71.4%), 3 due to embolization (14.7%) and 3 the result of common femoral artery thromboses (14.7%). Limb occlusions were manifested as severe acute arterial ischemia (n = 6), rest pain (n = 3), intermittent claudication (n = 5), and decreased femoral pulse (n = 1). Limb occlusions were managed with thrombectomy and stent placement (n = 4), femorofemoral bypass (n = 7), eventual explantation because of persistent endoleak (n = 1), and expectant management (n = 3). The 3 patients with occlusions managed expectantly all had intermittent claudication, which has subsequently improved. In the 6 patients with lower extremity ischemia due to embolization or common femoral artery injury presentation was acute, and embolectomy was performed, followed by femoral artery endarterectomy and patch angioplasty or placement of an interposition graft. One patient who had a prolonged postoperative course including cardiac arrest subsequently required distal bypass and ultimately above- knee amputation. Among the 7 patients with pelvic ischemia, 2 patients had unilateral hypogastric artery embolization before the original surgery. Among the patients with colonic ischemia, 3 were seen immediately postoperatively, and required colectomy and colostomy. Two patients who required urgent colectomy subsequently had multiple organ failure, and died in the perioperative period. One patient had abdominal pain 1 week after surgery, which was managed with bowel rest, with subsequent improvement. In 2 patients spinal cord ischemia developed immediately after surgery, w hich resulted in persistent paraplegia. Buttock ischemia developed in 2 patients, 1 of whom required fasciotomy because of gluteal compartment syndrome, and had transient renal failure. Conclusions Ischemic complications are not uncommon after EVAR, and may exceed the incidence with open surgical repair. Limb ischemia is most often a result of limb occlusion, and can be successfully managed with standard interventions. Pelvic ischemia often results from atheroembolization despite preservation of hypogastric arterial circulation. Colonic and spinal ischemia are associated with the highest morbidity and mortality

BACKGROUND: There is an ongoing debate regarding the merits of resident work-hour limitations. We postulated that this issue would be a factor in the decision-making process of applicants to surgical residency. METHODS: Candidates for surgical residency at a university-based program completed an anonymous survey during their visit. Data was analyzed by analysis of variance and the chi-square test. RESULTS: Most candidates viewed work-hour limitations as being favorable to their future training. Nevertheless, work-hour limitations ultimately were not a critical factor in the decision-making process compared with issues such as quality of training and program reputation. Candidates ranked 'reading in surgery' the most likely way they would spend the leisure time afforded by work-hour limitations. CONCLUSIONS: Most applicants for surgical residency consider work hour-limitations as being favorable to their training and view the extra free time as an opportunity for furthering their education. However, other issues take precedence when choosing a residency