Faculty Bibliography

BACKGROUND:Ossification of the posterior longitudinal ligament (OPLL) may cause cervical myelopathy. In its multilevel form, it may not be easy to manage. Minimally invasive endoscopic posterior cervical decompression may be an alternative to traditional laminectomy surgery. METHODS:Thirteen patients with multilevel OPLL and symptomatic cervical myelopathy were treated with endoscopic spine surgery from January 2019 to June 2020. In this consecutive observational cohort study, pre- and postoperative Japanese Orthopaedic Association (JOA) score and Neck Disability Index (NDI) were analyzed at a final follow-up of 2 years postoperatively. RESULTS:< 0.001). There were no infections, wound complications, or reoperations. CONCLUSION/CONCLUSIONS:Direct posterior endoscopic decompression for multilevel OPLL is feasible in symptomatic patients when executed at a high skill level. While 2-year outcomes were encouraging and on par with historic data obtained with traditional laminectomy, future studies will need to show whether any long-term shortcomings exist.

BACKGROUND:The microsurgical anterior approach to the cervical spine is commonplace. Fewer surgeons perform posterior cervical microsurgical procedures on a routine basis for lack of indication, more bleeding, persistent postoperative neck pain, and risk of progressive misalignment. In comparison, the endoscopic technique is preferentially performed through the posterior approach. Many spine surgeons and even surgeons versed in lumbar endoscopy are often reluctant to consider endoscopic procedures in the cervical spine. We report the results of a surgeon survey to find out why. METHODS:A questionnaire of 10 questions was sent to spine surgeons by email and chat groups in social media networks including Facebook, WeChat, WhatsApp, and LinkedIn to collect practice pattern data about microscopic and endoscopic spine surgery in the lumbar and cervical spine. The responses were cross-tabulated by surgeons' demographic data. Pearson Chi-Square measures, Kappa statistics, and linear regression analysis of agreement or disagreement were performed by analyzing the distribution of variances using the statistical package SPSS Version 27.0. RESULTS:The survey response rate was 39.7%, with 50 of the 126 surgeons who started the survey submitting a completed questionnaire. Of the 50 surgeons, 56.2% were orthopedic, and 42% neurological surgeons. Most surgeons worked in private practice (42%). Another 26% were university-employed, 18% were in private practice affiliated with a university, and the remaining 14% were hospital employed. The majority of surgeons (55.1%) were autodidacts. The largest responding surgeon groups were between 35-44 years (38%) and between 45-54 years of age (34%). Half of the responding surgeons were routinely performing endoscopic cervical spine surgery. The other half did not perform it for the main hurdle of fear of complications (50%). Lack of appropriate mentorship was listed as second most reason (25.4%). More concerns for not performing cervical endoscopic approaches were the perception of lack of technology (20.8%) and suitable surgical indication (12.5%). Only 4.2% considered cervical endoscopy too risky. Nearly a third (30.6%) of the spine surgeons treated over 80% of their cervical spine patients with endoscopic surgeries. Most commonly performed were posterior endoscopic cervical discectomy (PECD; 52%), posterior endoscopic cervical foraminotomy (PECF; 48%), anterior endoscopic cervical discectomy (AECD; 32%), cervical endoscopic unilateral laminotomy for bilateral decompression (CE-ULBD; 30%), respectively. CONCLUSION:Cervical endoscopic spine surgery is gaining traction among spine surgeons. However, by far most surgeons performing cervical endoscopic spine surgery work in private practice and are autodidacts. This lack of a teacher to shorten the learning curve as well as fear of complications are two of the major impediments to the successful implementation of cervical endoscopic procedures.

BACKGROUND:Treatment of intermediate-stage painful degenerative disc disease is controversial, with few reliable options. Allogenic mesenchymal stem cells (MSCs)are an alternative to autologous stem cell transplantation. Allogeneic MSCs in the treatment of discogenic low back pain have some practical advantages, ranging from availability to ease of treatment in a procedure-room setting. OBJECTIVES:To assess the efficacy and safety of allogenic MSC injection into painful lumbar intervertebral discs and associated clinical outcomes. STUDY DESIGN:Retrospective observational cohort study. SETTING:Private practice. METHODS:There were 33 patients: 15 women and 18 men with an average age of 47.6 years. The patients' average follow-up was 26.88 months Patients were treated with intradiscal injection of approximately 5 million allogeneic polyclonal MSCs in 1% hyaluronic acid derived from immunoselected umbilical cord stem cells. Patients were monitored for adverse event reactions. Clinical outcomes were assessed with reductions in the reported Visual Analog Scale (VAS) for back pain, the Oswestry Disability Index (ODI) scores, and the use of the modified Macnab criteria. RESULTS:No patient required any additional treatments for low back pain stemming from the level treated with MSC injections. At a 2-year follow-up, the average VAS low back score reduction was 6.565 ± 1.619 and 38.333 ± 14.865 for the ODI (P < 0.001). Reported Macnab outcomes were excellent in 11 patients (33.3%), good in 19 (57.6%), and fair in 3 (9.1%). LIMITATIONS:Our observational study is limited by patient selection, hindsight bias, and low patient numbers. CONCLUSION:The results of our feasibility study suggest that the injection of allogeneic MSCs to treat patients with painful intermediate-stage degenerative disc disease has merit. No adverse reactions were observed. The authors recommend further study in a randomized prospective study setting with a placebo control group or a natural history study group of patients to solidify this research.

BACKGROUND:Casually cauterizing the radicular magna during routine thoracic discectomy may have dire consequences. METHODS:We performed a retrospective observational cohort study on patients scheduled for decompression of symptomatic thoracic herniated discs and spinal stenosis who underwent a preoperative computed tomography angiography (CTA) to assess the surgical risks by anatomically defining the foraminal entry level of the magna radicularis artery into the thoracic spinal cord and its relationship to the surgical level. RESULTS:< 0.0001) at the final follow-up. The Adamkiewicz was most frequently found at T10/11 (15.4%), T11/12 (23.1%), and T9/10 (30.8%). There were eight patients where the painful pathology was found far from the AKA foraminal entry-level (type 1), three patients with near location (type 2), and another four patients needing decompression at the foraminal (type 3) entry-level. In five of the fifteen patients, the magna radicularis entered the spinal canal on the ventral surface of the exiting nerve root through the neuroforamen at the surgical level requiring a change of surgical strategy to prevent injury to this important contributor to the spinal cord's blood supply. CONCLUSIONS:The authors recommend stratifying patients according to the proximity of the magna radicularis artery to the compressive pathology with CTA to assess the surgical risk with targeted thoracic discectomy methods.

BACKGROUND:BACKGROUND: The controversy continues on how to best become proficient in contemporary minimally invasive spinal surgery techniques (MISST). Postgraduate training programs typically lag behind the innovation. Other subspecialty spine care providers often compete with spine surgeons particularly when they do not offer the treatments needed by their patients. The public debate centers around who should be taught and credentialed in providing surgical spine care. OBJECTIVES:The purpose of this study was to conduct an opinion survey amongst spine care providers regarding the learning curve of MISST and which credentialing standards should be established. SETTING:Surgeon online opinion survey sent by email, and chat groups in social media networks, including WeChat, WhatsApp, and LinkedIn. METHODS:Surgeons were asked the following questions: 1) Do you think MISS is harder to learn compared to open surgery? 2) Do you perform MISS? 3) What type of MISS do you perform? 4) If you perform endoscopic surgery, which approach(es)/technique(s) do you employ? 5) In your opinion, where does the innovation take place? 6) Where should MISST be taught? 7) Do you think mastering the MISST learning curve and surgeon skill level affect patient outcomes? 8) Which credentialing criteria do you recommend? Demographic data of responding surgeons, including age, postgraduate training and years from graduation, and practice setting, were also obtained. Descriptive statistics were employed to count the responses and compared to the surgeon's training using statistical package SPSS Version 27.0 (IBM Corporation, Armonk, NY). RESULTS:The online survey was viewed by 806 surgeons, started by 487, and completed by 272, yielding a completion rate of 55.9%. Orthopedic surgeons comprised 52.6% (143/272) of respondents, followed by 46.7% (127/272) neurosurgeons, and 0.7% pain management physicians (2/272). On average, respondents had graduated from a postgraduate training program 15.43 ± 10.13 years. Nearly all respondents employed MISST (252/272; 92.8%) and thought that proficiency in MISST affects patients' outcomes (270/272; 98.2%). Some 54.1% (146/270) opined that MISS is more challenging to learn than traditional open spine surgery. Preferred credentialing criteria were 1) number of MISST cases (87.5%; 238/272), b) skill level (69.9%; 190/272), and c) proficiency assessment (59.9%; 163/272). A case log review (42.3%; 116/272) or an oral examination (26.1%; 71/272) was not favored by surgeons. Surgeons reported academia (43.4%; 116/267) and private practice (41.2%; 110/267) as the centers of innovation. Only 15.4% (41/267) of respondents opined that industry was the main driver over innovation. LIMITATIONS:Geographical and cultural biases may impact the opinions of responding surgeons. CONCLUSIONS:Respondents preferred case volume, skill level, and proficiency assessment as credentialing criteria. Surgeons expect academic university programs and specialty societies to provide the necessary training in novel MISST while working with governing boards to update the certification programs.

BACKGROUND CONTEXT:Surgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence. PURPOSE:The purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database. DESIGN:This is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases. PATIENT SAMPLE:A total of 1277 noninstrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients. OUTCOME MEASURES:The occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake. METHODS:All FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching. RESULTS:In the nonpropensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009-0.461, p=.006) favoring FESS. CONCLUSIONS:FESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.

BACKGROUND:Evidence regarding the consequence of efforts to increase patient throughput and decrease length of stay in the context of elective spine surgery is limited. OBJECTIVE:To evaluate whether early time of discharge results in increased rates of hospital readmission or return to emergency department for patients admitted after elective, posterior, lumbar decompression surgery. METHODS:We conducted a retrospective cohort study of 779 patients admitted to hospital after undergoing elective, posterior, lumbar decompression surgery. Multiple logistic regression evaluated the relationship between time of discharge and the primary outcome of return to acute care within 30 days, while controlling for sociodemographic, procedural, and discharge characteristics. RESULTS:In multiple logistic regression, time of discharge earlier in the day was not associated with increased odds of return to acute care within 30 days (odds ratio [OR] 1.18, 95% CI 0.92-1.52, P = .19). Weekend discharge (OR 1.99, 95% CI 1.04-3.79, P = .04) increased the likelihood of return to acute care. Surgeon experience (<1 year of attending practice, OR 0.43, 95% CI 0.19-1.00, P = .05 and 2-5 years of attending practice, OR 0.50, 95% CI 0.25-1.01, P = .054), weekend discharge (OR 0.49, 95% CI 0.27-0.89, P = .02), and physical therapy evaluation (OR 0.20, 95% CI 0.12-0.33, P < .001) decreased the likelihood of discharge before noon. CONCLUSION:Time of discharge is not associated with risk of readmission or presentation to the emergency department after elective lumbar decompression. Weekend discharge is independently associated with increased risk of readmission and decreased likelihood of prenoon discharge.

BACKGROUND:Due to its ultraminimally invasive nature, endoscopic spinal surgery is an attractive tool in spinal oncologic care. To date, there has been no comprehensive review of this topic. The authors therefore present a thorough search of the medical literature on endoscopic techniques for spinal oncology. METHODS:A systematic review using PubMed was conducted using the following keywords: endoscopic spine surgery, spinal oncology, and spinal tumors. RESULTS:Collectively, 19 cases described endoscopic spine surgery for spinal oncologic care. Endoscopic spine surgery has been employed for the care of patients with spinal tumors under the following 4 circumstances: (1) to obtain a reliable tissue diagnosis; (2) to serve as an adjunct during traditional open surgery; (3) to achieve targeted debulking; or (4) to perform definitive resection. These cases employing endoscopic techniques highlight the versatility of this approach and its utility when applied to the right patient and with an experienced surgeon. CONCLUSIONS:Our systematic review suggests that, given the right patient and an experienced surgeon, endoscopic spine surgery should be considered in the armamentarium for spinal oncologic care for both staging and definitive resection. CLINICAL RELEVANCE/CONCLUSIONS:This systematic literature review showed that endoscopic techniques have been successfully applied across the spectrum of care in spinal oncology, from diagnosis to definitive treatment.