Enhanced Recovery After Surgery Protocol in Minimally Invasive Lumbar Fusion Surgery Reduces Length of Hospital Stay and Inpatient Narcotic Use
Background/UNASSIGNED:The application of enhanced recovery after surgery (ERAS) has the potential to improve outcomes, hasten patient recovery, and reduce costs. ERAS has been applied to spine surgery for several years, but data are limited around the impact of ERAS on minimally invasive spine surgery, specifically. The authors report their experience implementing a multimodal ERAS protocol for patients receiving minimally invasive transforaminal lumbar interbody fusion. Methods/UNASSIGNED:The ERAS protocol was implemented at The Valley Hospital Hospital in Ridgewood, New Jersey in January 2020. Following implementation, all patients receiving minimally invasive transforaminal lumbar interbody fusion by a single surgeon were studied. The authors analyze the impact of the protocol on length of stay (LOS), disposition post discharge, and opioid consumption postoperatively in the inpatient and outpatient settings. Results/UNASSIGNED:Â = 0.00016). On average, patients in the ERAS cohort were prescribed fewer opioids analgesics post discharge. Conclusions/UNASSIGNED:ERAS application to minimally invasive transforaminal lumbar interbody fusion was safe and effective, significantly reducing LOS and inpatient opioid consumption. These data reflect the importance of uniformly applying a multimodal ERAS protocol to accelerate recovery and reduce narcotic use.
Commentary: Design and Testing of 2 Novel Scores that Predict Global Sagittal Alignment Utilizing Cervical or Lumbar Plain Radiographs [Comment]
Subependymomas Are Low-Grade Heterogeneous Glial Neoplasms Defined by Subventricular Zone Lineage Markers
OBJECTIVE:Subependymomas are infrequent, low-grade gliomas associated with the ventricular system and the spinal cord. Little is known about the origin and natural history of these slow-growing lesions. METHODS:We identified all patients with pathologically proven subependymomas presenting to our institution between 1998 and 2016. We retrospectively reviewed clinical, radiographic, histologic, and surgical outcomes data in all patients who underwent surgical resection. Immunohistochemical analyses for cell lineage markers were performed. RESULTS:A total of 31 patients with pathologically proven subependymomas were identified. Of these, 7 asymptomatic lesions were discovered at autopsy and 24 symptomatic cases were treated surgically. There were 15 (48%) lateral ventricle tumors, 11 (35%) fourth ventricular tumors, and 5 (17%) spinal tumors. Symptomatic intracranial lesions most commonly presented with headaches and balance and gait abnormalities. Subependymomas had no distinguishing radiographic features that provided definitive preoperative diagnosis. At last follow-up, no patient treated surgically experienced recurrence. Immunohistochemical analyses demonstrated a diffusely GFAP-positive glial neoplasm with mixed populations of cells that were variably positive for Olig2, NHERF1, Sox2, and CD44. The Ki67 proliferation index was generally low (<1% in many of the tumors). CONCLUSIONS:Subependymomas demonstrate mixed populations of cells expressing glial lineage markers as well as putative stem cell markers, suggesting these tumors may arise from multipotent glial progenitors that reside in the subventricular zone. Definitive diagnosis requires surgical sampling. Although the clinical course of subependymomas appears benign, the inability to radiographically diagnose these lesions, and the possibility of an alternative malignant lesion support a low threshold for early and safe maximal resection.
Assessment of Paraspinal Muscle Cross-sectional Area After Lumbar Decompression: Minimally Invasive Versus Open Approaches
STUDY DESIGN:A retrospective, blinded analysis of imaging studies. SUMMARY OF BACKGROUND DATA:To evaluate changes in paraspinal muscle cross-sectional area (CSA) after surgical treatment for lumbar stenosis and to compare these changes between minimally invasive and standard open approaches. The open approach to lumbar stenosis is effective, but it involves retraction and resection of muscle from the spinous process, which can result in ischemia and denervation of paraspinal musculature and may lead to muscle atrophy and pain. OBJECTIVE:It is hypothesized that the microendoscopic decompression of stenosis (MEDS) technique will better preserve the paraspinal muscles compared with the open procedure. MATERIALS AND METHODS:A total of 18 patients underwent a 1-level posterior decompression for lumbar stenosis, (9 open, 9 MEDS). Lumbar magnetic resonance imaging was obtained before surgery and after surgery (open approach average 16.3 mo; MEDS average 16.6 mo). CSA of paraspinal muscles were averaged over the distance of the surgical site. RESULTS:The mean age of patients treated with the open and MEDS approaches were 55.2 and 66.4 years, respectively (P=0.07). Paraspinal muscle CSA decreased by an average of 5.4% (SD=10.6%; range, -24.5% to +7.7%) in patients treated with the open approach and increased by an average of 9.9% (SD=14.4%; range, -9.8% to +33.1%) in patients treated with MEDS (P=0.02). For the open approach, changes in CSA did not differ significantly between the left and right sides for erector spinae (P=0.35) or multifidus muscles (P=0.90). After the MEDS approach there were no significant differences between the dilated and contralateral sides with regard to change in CSA for erector spinae (P=0.85) or multifidus muscles (P=0.95). CONCLUSIONS:Compared with the open approach for lumbar stenosis, MEDS had significantly less negative impact on the paraspinal muscle CSA. Previous reports have documented negative effects of paraspinal muscle injury, including weakness, disability, and pain. Collectively, these data suggest that the MEDS approach for lumbar decompression is less destructive to the paraspinous muscles than the open approach and may facilitate better clinical outcomes.
Unique microenvironmental responses to PDGF stimulation in brain and spinal cord gliomas determine tumor phenotype
Injection of a PDGF-B expressing retrovirus into the subcortical white matter of adult rats induces the rapid formation of brain tumors that have the histological features of glioblastoma. In contrast, when the same retrovirus is injected into the spinal cord of adult rats the resulting tumors are more indolent and display a unique histology characterized by nests of tumor cells separated by a dense vascular network without areas of necrosis. To study whether these differences are determined by the tumor cell of origin or due to microenvironmental influences, we conducted a series of transplantation experiments. Cells were independently isolated from PDGF-induced brain and cord tumors then subsequently transplanted into naive rat forebrains and spinal cords. The resulting tumors were characterized by histological analysis, marker expression profiling, PDGFR subtyping, and latency to tumor-induced morbidity. Tumor phenotypes were found to be consistently predicted by the tissue into which they were transplanted rather than by the tissue of origin. These results suggest that tumor microenvironment rather than the tumor cell of origin may be the primary determinant of glioma phenotype in the model presented.
Minimally invasive thoracic microendoscopic diskectomy: surgical technique and case series
OBJECTIVE:To present operative details and clinical follow-up of a series of patients with thoracic disk herniation treated with the minimally invasive technique of thoracic microendoscopic diskectomy (TMED). METHODS:TMED was performed in 16 consecutive patients (age range, 18-79 years old) with 18 thoracic disk herniations. One patient with a calcified herniation in a direct ventral location was not included in this series. Patients were positioned prone, and a tubular retractor system was placed through a muscle dilating approach. The procedure was performed with endoscopic visualization. Outcomes were assessed using modified McNab criteria. RESULTS:There were no complications, and no case required conversion to an open procedure. The mean operative time was 153 minutes per level, and mean blood loss was 69 mL per level. Mean hospital stay was 21 hours. At a mean follow-up of 24 months (median, 22 months), 13 patients (81%) had excellent or good outcomes, 1 patient (6%) had a fair outcome, and 2 patients (13%) had poor outcomes. The two patients with poor outcomes had neurologic diagnoses (multiple sclerosis and multiple systems atrophy) that were ultimately found to be responsible for their symptoms and deficits. CONCLUSIONS:TMED is a safe and effective minimally invasive posterolateral approach for the treatment of thoracic disk herniations that lacks the morbidity associated with traditional approaches.
Primary dural repair in minimally invasive spine surgery
We describe an effective surgical technique in primary repair of the spinal dura during minimally invasive spine surgery (MISS). Objective. Minimally invasive spine surgery includes the treatment of intradural lesions, and proper closure of the dura is necessary. However, primary dural closure can be difficult due to the restricted space of MIS retractors and the availability of appropriate surgical instrumentation. Methods. We describe the use of a needle already used in the pediatric neurosurgical arena that can facilitate easier and safer closure of spinal dura through MISS retractors in two illustrative intradural cases. Results and Discussion. The primary dural closure technique is described and patient demographics are included. The instruments specifically used for the intradural closure through MIS retractor systems include (1) 4-0 Surgilon braided nylon (Covidien, Dublin, Ireland) with a CV-20 taper 1/2 circle, 10â€‰mm diameter needle; (2) Scanlan (Saint Paul, MN, USA) dura closure set. Conclusion. Successful primary dural repair can be performed on primary and incidental durotomies during minimally invasive spinal surgery. We describe the novel use of a 10â€‰mm diameter needle to help surgeons safely and efficiently close the dura with more ease than previously described.
Medulloblasoma: challenges for effective immunotherapy
For medulloblastoma patients, the current therapeutic paradigm of surgery followed by radiation and chemotherapy can lead to long-term remission. However, the sequelae of treatment can be very debilitating, particularly in young children. Immunotherapy is an attractive treatment approach to optimize the targeting of tumor cells while sparing the vulnerable surrounding brain that is still developing in children. Understanding the relationship between medulloblastoma and the immune system is critical to develop effective immunologic-based treatment strategies for these patients. This review focuses on current knowledge of tumor immunology and the factors that contribute to the lack of immune system recognition of these tumors. The specificity of tumor antigens present in medulloblastoma is also discussed along with a summary of early clinical immunotherapy results.
Spinal cord bypass surgery with intercostal and spinal accessory nerves: an anatomical feasibility study in human cadavers
OBJECT/OBJECTIVE:Despite extensive study, no meaningful progress has been made in encouraging healing and recovery across the site of spinal cord injury (SCI) in humans. Spinal cord bypass surgery is an unconventional strategy in which intact peripheral nerves rostral to the level of injury are transferred into the spinal cord below the injury. This report details the feasibility of using spinal accessory nerves to bypass cervical SCI and intercostal nerves to bypass thoracolumbar SCI in human cadavers. METHODS:Twenty-three human cadavers underwent cervical and/or lumbar laminectomy and dural opening to expose the cervical cord and/or conus medullaris. Spinal accessory nerves were harvested from the Erb point to the origin of the nerve's first major branch into the trapezius. Intercostal nerves from the T6-12 levels were dissected from the lateral border of paraspinal muscles to the posterior axillary line. The distal ends of dissected nerves were then transferred medially and sequentially inserted 4 mm deep into the ipsilateral cervical cord (spinal accessory nerve) or conus medullaris (intercostals). The length of each transferred nerve was measured, and representative distal and proximal cross-sections were preserved for axonal counting. RESULTS:Spinal accessory nerves were consistently of sufficient length to be transferred to caudal cervical spinal cord levels (C4-8). Similarly, intercostal nerves (from T-7 to T-12) were of sufficient length to be transferred in a tension-free manner to the conus medullaris. Spinal accessory data revealed an average harvested nerve length of 15.85 cm with the average length needed to reach C4-8 of 4.7, 5.9, 6.5, 7.1, and 7.8 cm. The average length of available intercostal nerve from each thoracic level compared with the average length required to reach the conus medullaris in a tension-free manner was determined to be as follows (available, required in cm): T-7 (18.0, 14.5), T-8 (18.7, 11.7), T-9 (18.8, 9.0), T-10 (19.6, 7.0), T-11 (18.8, 4.6), and T-12 (15.8, 1.5). The number of myelinated axons present on cross-sectional analysis predictably decreased along both spinal accessory and intercostal nerves as they coursed distally. CONCLUSIONS:Both spinal accessory and intercostal nerves, accessible from a posterior approach in the prone position, can be successfully harvested and transferred to their respective targets in the cervical spinal cord and conus medullaris. As expected, the number of axons available to grow into the spinal cord diminishes distally along each nerve. To maximize axon "bandwidth" in nerve bypass procedures, the most proximal section of the nerve that can be transferred in a tension-free manner to a spinal level caudal to the level of injury should be implanted. This study supports the feasibility of SAN and intercostal nerve transfer as a means of treating SCI and may assist in the preoperative selection of candidates for future human clinical trials of cervical and thoracolumbar SCI bypass surgery.
Platelet-derived growth factor receptor (PDGFR) expression in primary spinal cord gliomas
Abnormal signaling through the platelet-derived growth factor receptor (PDGFR) has been proposed as a possible mechanism of spinal cord glioma initiation and progression. However, the extent of PDGFR expression in human spinal cord gliomas remains unknown. In this study we perform immunohistochemical analysis of PDGFRÎ± expression in a series of 33 primary intramedullary spinal cord gliomas of different types and grades. PDGFRÎ± was seen to be expressed in a significant subset of these tumors across all major glioma types including ependymoma, oligodendroglioma, pilocytic astrocytoma, astrocytoma, and glioblastoma. These results support the hypothesis that growth factor signaling through the PDGFR may be important for the development of at least a subset of human spinal cord gliomas. Further studies investigating the prognostic significance of PDGFR expression as well as the role of PDGF signaling on the development of intramedullary spinal cord gliomas are warranted.