Faculty Bibliography

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.

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:The literature documents that laminoforaminotomy (CLF), whether performed open, minimally invasively, or microendoscopically, is safer than anterior cervical diskectomy/fusion (ACDF) for lateral cervical disease. METHODS/UNASSIGNED:ACDF for lateral cervical disc disease and/or spondylosis exposes patients to multiple major surgical risk factors not encountered with CLF. These include; carotid artery or jugular vein injuries, esophageal tears, dysphagia, recurrent laryngeal nerve injuries, tracheal injuries, and dysphagia. CLF also exposes patients to lower rates of vertebral artery injury, dural tears (DT)/cerebrospinal fluid fistulas, instability warranting fusion, adjacent segment disease (ASD), plus cord and/or nerve root injuries. RESULTS/UNASSIGNED:Further, CLF vs. ACDF for lateral cervical pathology offer reduced tissue damage, operative time, estimated blood loss (EBL), length of stay (LOS), and cost. CONCLUSION/UNASSIGNED:CLFs', whether performed open, minimally invasively, or microendoscopically, offer greater safety, major pros with few cons, and decreased costs vs. ACDF for lateral cervical disease.

BACKGROUND/UNASSIGNED:The incidence of cerebrospinal fluid (CSF) leaks/dural tears (DT) occurring during anterior cervical diskectomy and fusion (ACDF) are typically relatively low. However, this frequency markedly increases when anterior corpectomy and fusion (ACF) are performed to address ossification of the posterior longitudinal ligament (OPLL). METHODS/UNASSIGNED:The reported frequencies of CSF leaks/DT occurring during elective ACDF (i.e. exclusive of trauma), ranges from 0.24% to 1.7%. Notably, this incidence substantially rises for multilevel ACF addressing anterior OPLL, markedly varying from 3.4 - 44.7%. RESULTS/UNASSIGNED:The classical risks of anterior cervical CSF leaks/DT with anterior cervical surgery may be minimized utilizing an operating microscope. For OPLL, careful evaluation of preoperative non-contrast CT studies is critical, especially to document whether any of the 3 signs of dural penetrance is present. Here, posterior operative choices should be strongly considered in the presence of sufficient lordosis and/or a Positive K Line (+ K Line) as this will avoid an anterior cervical CSF leak/dural fistula. Alternatively, for patients with kyphosis and a Negative K Line (- K Line), preoperative anticipation and planning to treat an intraoperative anterior CSF leak/DT (i.e. direct anterior primary dural graft repair with 7-0 Gore-Tex sutures, microdural staples, microfibrillar collagen, wound-peritoneal shunt, and lumbar drain or lumboperitneal shunt) are essential in the course of performing direct anterior OPLL resection. CONCLUSION/UNASSIGNED:The incidence of anterior cervical CSF leaks/DT is relatively low (i.e. range 0.24 - 1.7%) where ACDF is performed for disc disease/spur/spondylosis exclusive of OPLL. However, where ACF is performed for multilevel OPLL, the risk of CSF Leaks/DT is substantially higher (i.e. range 4.3-44.7%).

BACKGROUND/UNASSIGNED:Interspinous devices (ISD) constitute a minimally invasive (MI) alternative to open surgery (i.e., laminectomy/decompression with/without fusion (i.e., posterior lumbar interbody fusion (PLIF)/posterolateral instrumented fusion (PLF)) for treating lumbar spinal stenosis (LSS). Biomechanically, static and/or dynamic ISD "offload" pressure on the disc space, increase intervertebral foraminal/disc space heights, reverse/preserve lordosis, limit range of motion (ROM)/stabilize the surgical level, and reduce adjacent segment disease (ASD). Other benefits reported in the literature included; reduced operative time (OR Time), length of hospital stay (LOS), estimated blood loss (EBL), and improved outcomes (i.e., ODI (Oswestry Disability Index), VAS (Visual Analog Scale), and/or SF-36 (Short-Form 36)). METHODS/UNASSIGNED:Various studies documented the relative efficacy and outcomes of original (i.e., Wallis), current (i.e., X-STOP, Wallis, DIAM, Aperius PercLID), and new generation (i.e., Coflex, Superion Helifix, In-Space) ISD used to treat LSS vs. open surgery. RESULTS/UNASSIGNED:Although ISD overall resulted in comparable or improved outcomes vs. open surgery, the newer generation ISD provided the greatest reductions in critical cost-saving parameters (i.e., OR time, LOS, and lower reoperation rates of 3.7% for Coflex vs. 11.1% for original/current ISD) vs. original/current ISD and open surgery. Further, the 5-year postoperative study showed the average cost of new generation Coflex ISD/decompressions was $15,182, or $11,681 lower than the average $26,863 amount for PLF. CONCLUSION/UNASSIGNED:Patients undergoing new generation ISD for LSS exhibited comparable or better outcomes, but greater reductions in OR times, EBL, LOS, ROM, and ASD vs. those receiving original/current ISD or undergoing open surgery.

BACKGROUND/UNASSIGNED:Morbid obesity (MO) is defined by the World Health Organization (WHO) as Class II (i.e. Body Mass Index (BMI) >/= 35 kg/M2 + 2 comorbidities) or Class III (i.e. BMI >/= 40 kg/M2). Here, we reviewed the rates for adverse event/s (AE)/morbidity/mortality for MO patients undergoing anterior cervical surgery as inpatients/in-hospitals, and asked whether this should be considered the standard of care? METHODS/UNASSIGNED:We reviewed multiple studies to document the AE/morbidity/mortality rates for performing anterior cervical surgery (i.e., largely ACDF) for MO patients as inpatients/in-hospitals. RESULTS/UNASSIGNED:MO patients undergoing anterior cervical surgery may develop perioperative/postoperative AE, including postoperative epidural hematomas (PEH), that can lead to acute/delayed cardiorespiratory arrests. MO patients in-hospitals have 24/7 availability of anesthesiologists (i.e. to intubate/run codes) and surgeons (i.e. to evacuate anterior acute hematomas) who can best handle typically witnessed cardiorespiratory arrests. Alternatively, after average 4-7.5 hr. postoperative care unit (PACU) observation, Ambulatory Surgical Center (ASC) patients are sent to unmonitored floors for the remainder of their 23-hour stays, while those in Outpatient SurgiCenters (OSC) are discharged home. Either for ASC or OSC patients, cardiorespiratory arrests are usually unwitnessed, and, therefore, are more likely to lead to greater morbidity/mortality. CONCLUSION/UNASSIGNED:Anterior cervical surgery for MO patients is best/most safely performed as inpatients/in-hospitals where significant postoperative AE, including cardiorespiratory arrests, are most likely to be witnessed events, and appropriately emergently treated with better outcomes. Alternatively, MO patients undergoing anterior cervical procedures in ASC/OSC will more probably have unwitnessed AE/cardiorespiratory arrests, resulting in poorer outcomes with higher mortality rates. Given these findings, isn't it safest for MO patients to undergo anterior cervical surgery as inpatients/in-hospitals, and shouldn't this be considered the standard of care?

BACKGROUND/UNASSIGNED:Lumbar synovial cysts (LSC), best diagnosed on MR studies, may cause symptoms/signs ranging from unilateral radiculopathy to cauda equina compressive syndromes. Attempts at percutaneous treatment of LSC typically fail. Rather, greater safety/efficacy is associated with direct surgical resection with/without fusion. METHODS/UNASSIGNED:Treatment of LSC with percutaneous techniques, including cyst aspiration/perforation, injection (i.e., with/without steroids, saline/other), dilatation, and/or disruption/bursting, classically fail. This is because LSCs' tough, thickened, and adherent fibrous capsules cause extensive thecal sac/nerve root compression, and contain minimal central "fluid" (i.e., "crank-case" and non-aspirable). Multiple percutaneous attempts at decompression, therefore, typically cause several needle puncture sites risking dural tears (DT)/cerebrospinal fluid (CSF) leaks, direct root injuries, failure to decompress the thecal sac/nerve roots, infections, hematomas, and over the longer-term, adhesive arachnoiditis. RESULTS/UNASSIGNED:Alternatively, many studies document the success of direct or even partial resection of LSC (i.e., partial removal with marked cyst/dural adhesions with shrinking down the remnant of capsular tissue). Surgical decompressions of LSC, ranging from focal laminotomies to laminectomies, may or may not warrant additional fusions. CONCLUSIONS/UNASSIGNED:Symptomatic LSC are best managed with direct or even partial operative resection/decompression with/without fusion. The use of varying percutaneous techniques classically fails, and increases multiple perioperative risks.

BACKGROUND/UNASSIGNED:Despite the lack of FDA (Food and Drug Administration) approval, cervical and lumbar epidural spinal injections are frequently performed in the US to address back pain and/or painful radiculopathy. The three major types of injections include; interlaminar/translaminar (ESI), transforaminal (TFESI), or caudal injections. Notably, most studies document little to no clear short-term, and no long-term benefits/efficacy for these injections vs. various placebos. METHODS/UNASSIGNED:More adverse events (AE) occurred with cervical© rather than lumbar (L) injections, and more severe AE were attributed to C-TFESI vs. CESI injections. RESULTS/UNASSIGNED:nerve cranial palsies. AE for lumbar LESI/L-TFESI included; infections/abscess, epidural hematomas/subdural hematomas, intravascular injections, cerebrospinal fluid (CSF) leaks/dural tears (DT), and intracranial/postural hypotension. Notably, the vast majority of studies showed little to no short-term, and no long-term benefits for cervical or lumbar ESI/TFESI vs placebos (i.e. mostly consisting of normal saline alone, or saline plus local anesthesia). CONCLUSION/UNASSIGNED:Epidural cervical and lumbar ESI or TFESI spinal injections demonstrated minimal to no short-term, and no long-term benefits for the treatment of cervical and/or lumbar pain/radiculopathy vs. placebos. Further, more AE were observed for cervical vs. lumbar epidural injections overall, with more AE usually seen with TFESI vs. ESI procedures.

BACKGROUND/UNASSIGNED:Our review of 12 articles for this perspective showed the frequency of intraoperative thoracic and/or lumbar CSF fistulas/dural tears (DT) ranged from 2.6% - 8% for primary surgical procedures. Delayed postoperative CSF leak/DT were also diagnosed in 0.83% (17/2052 patients) to 14.3% (2/14 patients) of patients undergoing thoracic and/or lumbar procedures. Further, the rate of recurrent postoperative CSF leaks/DT varied from 13.3% (2/15 patients) to 33.3% (4/12 patients). METHODS/UNASSIGNED:Intraoperative, postoperative delayed, and recurrent postoperative traumatic postsurgical thorac CSF leaks/DT can be limited by performing initially sufficient operative decompressions and/or decompressions/fusions (i.e., utilizing adequate open exposures vs. inadequate minimally invasive (MI) approaches). The incidence of CSF leaks/DT can be further reduced by spine surgeons' utilization of operating microscopes, and their avoiding routine attempts at total synovial cyst excision and/or complete resection of hypertrophied/ossified yellow ligament in the presence of significant dural adhesions. RESULTS/UNASSIGNED:Multiple CSF leak/CT repair techniques included; using interrupted, non-resorbable sutures for direct dural repairs (i.e. 7-0 Gore-Tex sutures where the suture is larger than the needle thus plugging needle holes), and adding where needed muscle patch grafts, microfibrillar collagen, the rotation of Multifidus muscle pedicle flaps, fibrin sealants (FS)/fibrin glues (FG), lumbar drains (LD), and/or lumbo-peritoneal (LP) shunts. CONCLUSION/UNASSIGNED:Intraoperative, postopertive delayed, and/or recurrent postoperative thorac and/or lumbar traumatic surgical CSF leaks can be reduced by choosing to initially perform the appropriately extensive open operative decompressions and/or decompresssions/fusions. It is critical to use an operating microscope, non-resorbable interrupted sutures, and where necessary, muscle patch grafts, microfibrillar collagen, the rotation of Multifidus Muscle Pedicle Flaps, FS/FG, LD, and/or LP shunts.

Background: Why are spine surgeons sued, how successfully, and for how much? Typical bases for spinal medicolegal suits have included; the failure to timely diagnose and treat, surgical negligence, (i.e. especially resulting in significant neurological deficits), and the lack of informed consent. We reviewed 17 medicolegal spinal articles looking for additional reasons for suits, along with identifying other factors contributing to defense verdicts, plaintiffs' verdicts, or settlements. Methods: After confirming the same three most likely causes of medicolegal suits, other factors leading to such suits included; the lack of patient access to surgeons postoperatively, poor postoperative management (i.e. contributing to new postoperative neurological deficits), failure to communicate between specialists/surgeons perioperatively, and failure to brace. Results: Critical factors leading to more plaintiffs' verdicts and settlements along with higher payouts for both included new severe and/or catastrophic postoperative neurological deficits. Conversely, defense verdicts were more likely for those with less severe new and/or residual injuries. The total number of plaintiffs' verdicts ranged from 17-35.2%, settlements, from 8.3-37%, and defense verdicts from 27.7-75%. Conclusion: The three most frequent bases for spinal medicolegal suits continue to include; failure to timely diagnose/treat, surgical negligence, and lack of informed consent. Here, we identified the following additional causes of such suits; the lack of patient access to surgeons perioperatively, poor postoperative management, lack of specialist/surgeon communication, and failure to brace. Further, more plaintiffs' verdicts or settlements and greater respective payouts were observed for those with new and/or more severe/catastrophic deficits, while more defense verdicts were typically rendered for patients with lesser new neurological injuries.