Faculty Bibliography

BACKGROUND/UNASSIGNED:Retained foreign bodies (RFB), or those left behind following spine surgery, are considered "Never Events (NE < 1/1000: they should never happen)," or "Near Never Events (NNE < 1/100; they should nearly never happen)", but are not just "Adverse Events (AE >/= 1/100)." The vast majority of NE/NNE are due to cotton sponges, cottonoids, or residual cotton strands (i.e., collectively called Textilomas or Gossypibomas). However, RFB additionally included; fractured needles, guidewires, fractured screws/implants/drains, and/or broken instruments (i.e., scalpels). Notably, the spine surgeon of record, as captain of the ship, is primarily liable for RFB and is central to ensuing medicolegal suits. However, secondarily liable are the adjunctive surgical/medical personnel, (i.e., physicians, Physician Assistants, Nurses, Nurse Practitioners, Physical Therapists, Occupational Therapists), and others who are independent or work full-time for hospitals. METHODS/UNASSIGNED:Patients with RFB may present with acute, subacute, or chronic/delayed pain and suffering. Additional complaints include; lost wages, sustained physical disability and/or injury attributed to these objects. Most RFB are diagnosed on plain X-rays, followed by MR and/or CT studies. RESULTS/UNASSIGNED:RBS's may include; retained drain fragments, broken needles, fractured guidewires, broken scalpel blades, fractured screws, and/or instruments. Retrieval procedures warrant a wide variety of different techniques, some of which fail. Notably, RFB's largely occur due to the performance of; emergent procedures, doing an unfamiliar operation, encountering anatomical variants, or operating on patients with elevated body mass indexes (BMI). Additionally these include; surgeons' failure to order and/or radiologists' failure to correctly read intraoperative X-rays/fluoroscopic images, and/or nurses' failures to correctly perform end of surgery counts. CONCLUSION/UNASSIGNED:RFBs, or foreign bodies left behind following spine surgery, are considered "Never Events (< 1/1000)" or "Near Never Events (< 1/100)," and are not just "Adverse Events (> 1/100)". When they do occur, the operating surgeon bears primary responsibility, but the nursing/adjunctive staff and hospital are also liable.

BACKGROUND/UNASSIGNED:The Standard of Care (SOC) for treating significant spinal epidural abscesses (SEA) is STAT surgery for patients with the new-onset of neurological deficits following STAT contrast MR studies confirming significant neural (i.e. mild/moderate, moderate, or marked cord/nerve root) compression. Too many health care professionals, including physicians, and select spine surgeons still wrongly believe delaying "acute" spinal decompressions in patients with SEA for up to 8, 12, and even 24 hours is acceptable even in paralyzed patients. METHODS/UNASSIGNED:Here we review the fact that the standard of care for treating SEA is STAT surgery for patients demonstrating the new-onset of neurological deficits following STAT contrast MR scans confirming significant neural compression. RESULTS/UNASSIGNED:STAT surgery for newly neurologically symptomatic patients with SEA following STAT contrast MR scans documenting significant neural compression yields the best results. Notably, select patients without neural deficits or significant MR neural compression may be considered for non-surgical treatment. The "gold standard" for diagnosing SEA is the contrast MR, while non-contrast CT studies almost uniformly fail to diagnose SEA, and Myelogram-CT studies have significant limitations (i.e. risk of causing meningitis, and may fail to document cephalad extent of SEA if there is a distal total block to intrathecal contrast). CONCLUSION/UNASSIGNED:STAT surgery is the SOC and treatment of choice for patient with SEA demonstrating significant new-onset neurological deficits with significant STAT contrast MR findings of neural compression. Further, STAT means STAT, no waiting period is acceptable (i.e. 8, 12 or up to < 24 hours) particularly in paralyzed patients.

BACKGROUND/UNASSIGNED:For over a decade, STAT surgery has been the standard of care (SOC) for treating significant cauda equina syndromes (CES). Nevertheless, too many spinal surgeons, physician extenders, and other medical professionals still wrongly believe they have up to 24-48 hours to treat CES. METHODS/UNASSIGNED:To counter this misconception, we reviewed the evolution of treatment for significant CES from the outdated dominant protocols of < 48 h, to 24 - < 48 h, to < 24 h, to 0-< 24 h, to the present SOC; STAT, "prompt", surgery performed "the sooner the better". RESULTS/UNASSIGNED:A 2014 study found that there is no support in the literature for delaying CES surgery for up to 48 h, and further; "... the earlier the surgical intervention, the more beneficial the effect for compressed nerves." Subsequent studies advocated for < 24 h for early CES, finding they resulted in improved outcomes including bladder function especially for those with incomplete/partial (ICES) vs. total/retention CES (RCES). One study, involving 20,924 CES patients, showed the best improvement for surgery performed within 0 - < 24 h, leading to the present SOC for treating significant CES, as STAT or "the sooner the better". CONCLUSION/UNASSIGNED:Based on the up-to-date literature, the present SOC for managing significant CES is STAT surgery. Notably, the American Association of Neurological Surgeons (AANS) "guidelines" (published 4/5/24 on (www. aans.org)) cited the present treatment for CES; "Prompt surgery is the best treatment for patients with CES;" with the Merriam-Webster definition of prompt as "immediate" or "without delay". We agree that the present SOC for treating significant CES is STAT or "prompt" surgery.

BACKGROUND/UNASSIGNED:Intraoperative Neural Monitoring (IONM) is mandatory for performing anterior (i.e., transthoracic) or lateral extracavitary approaches to significant anterior/anterolateral thoracic ossification of the posterior longitudinal ligament (TOPLL) (i.e. often misdiagnosed as calcified Thoracic Disc Herniations) (TDH). Notably, the remaining "posterior procedures" (i.e. laminectomy, transpedicular, and costotransversectomy) are contraindicated for treating significant anterior/anterolateral TOPLL as they result in unacceptably high frequencies of spinal cord injury (SCI) typically correlated with significant intraoperative IONM losses. METHODS/UNASSIGNED:A review of multiple studies documented that IONM (i.e. especially Tc-MEP (Transcranial Motor Evoked Potentials)) is mandatory when performing anterior transthoracic or lateral extracavitary approaches to TOPLL. This is because IONM alerts signaling the onset of SCI may likely be remediated (i.e. minized vs. limited) utilizing appropriate resuscitative maneuvers. Alternatively, extremely high frequencies of significant IONM losses occurring with "posterior procedures" carried a much higher risk of permanent/irreversible neurological injury. RESULTS/UNASSIGNED:Multiple studies documented that IONM should be used with anterior transthoracic or lateral extracavitary approaches to anterior/anterolateral TOPLL surgery, and that "posterior procedures" were largely contraindicated. In one series, significant amplitude Tc-MEP losses occurred in 73% of posterior decompressions; 39% developed Tc-MEP amplitude losses, that correlated with new SCI. In another study of 249 TOPLL patients undergoing "posterior only operations", 50 developed new significant IONM alerts (i.e. of deterioration); only 40% (20/50) were successfully resuscitated. Overall, initiating immediate resuscitative maneuvers in response to IONM occurring during various types of TOPLL surgery can avert SCI in up to 10.4%, to 40%, to 57% of cases. CONCLUSION/UNASSIGNED:IONM is mandatory for anterior/anterolateral TOPLL surgery utilizing anterior transthoracic or lateral extracavitary approaches.

BACKGROUND/UNASSIGNED:The placement of Spinal Cord Stimulator (SCS) trial or permanent electrodes carries a 31.9-43% morbidity/adverse event (AE) rate. Most AEs are attributed to electrode migration (EM: device-related AE 26.7% older cohort vs. 9.7% newer cohort), spinal epidural hematomas (SEHs: 0.81-2.6%), infection (3.4% older vs. 1.9% recent cohort), SCI (spinal cord injury: percutaneous 0.45% vs. 0.36% paddle electrodes), dural tears (DT/ cerebrospinal fluid leaks (CSF leaks)), foreign body/fibrous reactions, or syrinx formation. METHODS/UNASSIGNED:SCSs are typically applied to address chronic neuropathic pain syndromes. Here, we evaluated 20 articles focusing on patients who developed postoperative myelopathy/radiculopathy, variously attributed to MR-documented AE warranting medical or surgical intervention. RESULTS/UNASSIGNED:Postoperative symptoms/signs of AE typically included the acute development of new/increased weakness, sensory loss, and/or sphincter dysfunction. Requisite STAT MR scans usually confirmed the etiology of AE including electrode migration, SEH, DT, SCI, and/or postoperative scarring/fibrosis. Most patients warranted STAT surgery, while a small subset could be managed conservatively. CONCLUSION/UNASSIGNED:The AE rate for spinal cord stimulators ranges from 31.9 to 43%. While the majority are due to electrode migration, other etiologies include SEH, SCI, DT, and foreign body reactions. Those who become acutely myelopathic usually warrant STAT MR scans with the majority additionally necessitating STAT surgical intervention to limit short/long-term neurological morbidity.

BACKGROUND/UNASSIGNED:"Never Events" (<1/1000) likely never occur without a breach in the standard of care (SOC), while "Near Never Events" (<1/100) are typically not far behind. METHODS/UNASSIGNED:"Never Events" are described as "Harmful hospital-acquired conditions that the Center for Medicare and Medicaid Services identified in 2008." Here, we focused on wrong-site spine surgery (WSSS)/wrong-level spine surgery (WLSS), 3 select cases of Caspar Distraction Screws causing hematomas, and one medicolegal case involving multiple simultaneous "Never Events." RESULTS/UNASSIGNED:The spine literature documented the following frequencies of wrong-site spine surgery WSSS/"Never Events" as occurring in 4.5/10,000 lumbar, 6.8/10,000 cervical, and 2.2/10,000 cranial procedures; other series focused on the incidence of wrong-level spine surgery (WLSS). Three "Never Events" consisting of cervical epidural hematomas were attributed to Caspar Distraction Screws. A medicolegal case is also presented in which a spine surgeon caused multiple simultaneous "Never Events" (i.e., ipsilateral surgical errors) during an anterior cervical fusion. Finally, the definition of "Never Events" was newly expanded to better assess "Near Never Events", as the latter applied to varied frequencies of esophageal perforations, plate/screw migration/erosions/displacement, cerebrospinal fluid leaks, infection, and other factors. CONCLUSION/UNASSIGNED:"Never Events" (<1/1000) likely never occur without a breach in the SOC, while "Near Never Events" (<1/100) are typically not far behind.

BACKGROUND/UNASSIGNED:Predominantly Dorsal Thoracic Spinal Arachnoid Webs (DAW/SAW: 90%-100%), attributed to arachnoidal scarring obstructing cerebrospinal fluid (CSF) dynamics, typically cause dorsal cord compression. Their multiple etiologies include; trauma, idiopathic/post-surgical, inflammatory/infection, subarachnoid hemorrhage, and/or congenital defects. METHODS/UNASSIGNED:Patients with DAW/SAW are typically in their early/mid-fifties, and present with; back pain (i.e., 41.2%-88.9%), motor deficits (i.e. 59%-77.8%), sensory loss (i.e., numbness 65%-66.7%), and/or sphincter dysfunction (i.e., 33.3%). RESULTS/UNASSIGNED:MR and Myelo-CT studies for DAW/SAW classically demonstrate the positive scalpel sign (i.e., single or multilevel dorsally compressive "fluid" collections often containing multiple loculations/fenestrations usually accompanied by Syrinxes (i.e., 44 - 83%), and/or Spinal Arachnoid Cyst (SAC) formation. Conservative treatment is rarely effective. Alternatively, surgery consisting of laminectomy/decompression, resection/ lysis, marsupialization and/or fenestration of loculated collections including attendant SAC resections, and decompression/shunting of Syrinxes, results in postoperative improvement in up to 91% of patients. CONCLUSION/UNASSIGNED:Patients with DAW/SAW typically present with MR/Myelo-CT studies that demonstrate the dorsal thoracic positive scalpel sign in conjunction with Syrinxes, and/or SAC. Surgery typically includes laminectomy/ decompression, lysis/resection of arachnoidal adhesions with marsupialization/fenestration, and/or shunting, to achieve up to a 91% incidence of postoperative neurological improvement.

BACKGROUND/UNASSIGNED:Can we document that posterior cervical surgery (i.e., Laminoforaminotomy (LF) and Laminectomy (L) with Posterior Fusion (PF)) exposes patients to fewer adverse events (i.e., including negligence, multiple risks, negligence, errors, and mistakes) vs. anterior cervical surgery (i.e., Anterior Cervical Diskectomy/Fusion (ACDF) or Anterior Corpectomy/Fusion (ACF))? METHODS/UNASSIGNED:Posterior cervical surgery avoids many of the adverse events uniquely attributed to anterior cervical operations. These include; avoiding fusions with LF vs. ACDF for disc herniations, a lower rate of pseudarthrosis, the avoidance of direct laceration/indirect traction-related carotid/jugular vascular and/or dysphagia/esophageal injuries, fewer neural/cord injuries, vertebral artery injuries, and cerebrospinal fluid (CSF) leaks/dural tears (i.e., particularly with Ossification of the Posterior Longitudinal Ligament (OPLL)). RESULTS/UNASSIGNED:Posterior cervical surgery also poses no direct risks to the following anteriorly-located nerves: recurrent laryngeal nerve (i.e., vocal cord paralysis), phrenic nerve (i.e., diaphragmatic paralysis), the Vagus nerve (i.e., hypotension, reflux, arrhythmias), and sympathetic trunk (i.e., Horner's Syndrome). However, posterior cervical surgery is generally associated with a higher risk of infection (i.e., 2-10%) vs. anterior surgery (i.e., > 1%), more posterior muscle pain, and a higher risk of kyphosis. CONCLUSIONS/UNASSIGNED:Posterior cervical surgery exposes patients to many fewer adverse events vs. anterior cervical surgery. We therefore recommend that in appropriately chosen patients, posterior cervical surgical approaches should be chosen over anterior surgery.

BACKGROUND/UNASSIGNED:Early treatment of cerebrospinal fluid (CSF) infections, including meningitis and/or ventriculitis (MV) is critical to minimize morbidity/mortality. Infections/MV are typically attributed to; recurrent postoperative lumbar CSF fistulas with drainage through the skin (12.2-33.3%), lumbar drains, and/or various intracranial devices (i.e. external ventricular drains, intracranial pressure monitors). METHODS/UNASSIGNED:Lumbar MR examinations best document recurrent postoperative dural fistulas with subcutaneous extension leading to leaking wounds; the longer these leaks persist, the greater the risk of CSF infection and MV. Classical cranial MR findings of MV due to prior lumbar surgery, lumbar drains or multiple intracranial devices include; ventricular debris, ependymal enhancement, hydrocephalus, extra-axial fluid collections, infarcts (arteritis/ventriculitis), abscesses, and granulomas. RESULTS/UNASSIGNED:Surgery for recurrent postoperative lumbar CSF leaks typically warrant wound reexploration with direct sutured-dural repairs, use of muscle patch grafts (avoid fat - it resorbs), fibrin sealants/fibrin glues (FS/FG), lumbar drains, lumboperitoneal and/or pseudomeningocele-peritoneal shunts. For patients who additionally develop meningitis/ventriculitis, one should consider adding intraventricular (IVT) or lumbar intrathecal (IT) antibiotic therapy to routine intravenous antibiotics. Notably, all efforts should be made to avoid the high mortality rates associated with VM (i.e., 13% to 60%). CONCLUSION/UNASSIGNED:Recurrent postoperative lumbar CSF leaks (i.e., especially after CSF breaches the skin), lumbar drains, and/or intracranial devices/implants may cause infections including meningitis and ventriculitis (MV). It is critical to recognize and treat these infections/MV early to avoid high morbidity and mortality rates.

BACKGROUND/UNASSIGNED:In this short review/perspective, we asked what the frequencies would be for both postoperative spinal epidural hematomas (SpEH) and postoperative surgical site infections (SSI) in predominantly posterior lumbar procedures performed with or without the placement of wound drains? METHODS/UNASSIGNED:Many spine surgeons are trained to use wound drains to decrease the risk of postoperative SpEH, despite the potential increased risk of SSI. Alternatively, avoiding drains may increase the risk of SpEH but likely decrease the potential for SSI. RESULTS/UNASSIGNED:Performing predominantly posterior lumbar procedures with or without wound drains resulted in largely comparable frequencies of postoperative spinal epidural hematomas (SpEH; range of 0.10%-0.69%) and postoperative surgical site infections (SSI: range of 0.75%-7.3%). Notably, however, two studies documented that drains increased transfusion requirements, with one study showing a prolongation of the in-hospital length of stay. Critically, these series emphasized the importance of early/emergent diagnosis (i.e., with MR) and surgical treatment of SpEH to minimize residual neurological deficits. CONCLUSION/UNASSIGNED:Here, we showed that patients undergoing predominantly lumbar spine surgery performed with or without wound drains demonstrated comparable frequencies of postoperative SpEH and SSI. Nevertheless, spine surgeons must assess on a case-by-case basis whether, based on their education, training, and experience, placing a wound drain is appropriate for their particular patient.