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Comparing Predictors of Complications After Anterior Cervical Diskectomy and Fusion, Total Disk Arthroplasty, and Combined Anterior Cervical Diskectomy and Fusion-Total Disk Arthroplasty With a Minimum 2-Year Follow-Up

Shah, Neil V; Jain, Ishaan; Moattari, Cameron R; Beyer, George A; Kelly, John J; Hollern, Douglas A; Newman, Jared M; Stroud, Sarah G; Challier, Vincent; Post, Nicholas H; Lafage, Renaud; Passias, Peter G; Schwab, Frank J; Lafage, Virginie; Paulino, Carl B; Diebo, Bassel G
INTRODUCTION/BACKGROUND:Outcomes after anterior cervical diskectomy and fusion (ACDF) and cervical total disk arthroplasty (TDA) are satisfactory, but related morbidity and revision surgery rates are notable. This study sought to determine complication variations among ACDF, TDA, and combined ACDF-TDA as well as predictors of postoperative complications. METHODS:Patients undergoing 1- to 2-level ACDF and/or TDA with at least a 2-year follow-up from 2009 to 2011 were identified from the Statewide Planning and Research Cooperative System database. Patient demographics, hospital-related parameters, mortality, and postoperative outcomes were compared, and their predictors were identified using multivariate logistic regression. RESULTS:A total of 16,510 and 449 individuals underwent ACDF and cervical TDA, respectively, and 201 underwent ACDF-TDA. ACDF-TDA patients had the highest rates of cardiac complications and pulmonary embolism (PE) (P ≤ 0.006), whereas TDA patients had higher individual surgical and device/implant/internal fixation complications (P ≤ 0.025). ACDF-TDA patients experienced the lowest rate of revisions. Cervical TDA increased the odds of any surgical complications (OR = 2.5, P = 0.002), overall complications (OR = 1.57, P = 0.034), and revisions (OR = 2.29, P < 0.001). Deyo index predicted any medical/surgical complications (OR = 1.43 and 1.19, respectively). Female sex was associated with increased odds of readmission (OR 1.30, P < 0.001) but was protective against medical complications (OR = 0.81, P = 0.013). DISCUSSION/CONCLUSIONS:Combined ACDF-TDA procedures were not associated with increases in 2-year individual or overall complications, readmissions, or revisions. LEVEL OF EVIDENCE/METHODS:Level 3-Therapeutic study.
PMID: 31860582
ISSN: 1940-5480
CID: 4243182

122. Variation in 90-day neurological complications across increasing fusion levels for posterior cervical fusion: a five-year analysis [Meeting Abstract]

Shah, N V; Jain, I; Beyer, G A; Passias, P G; Lonjon, N; Post, N H; Paulino, C B; Challier, V; Diebo, B G
BACKGROUND CONTEXT: While neurological complications are known to occur following cervical fusions, few studies with sufficient power have quantified the difference in neurological outcomes as posterior cervical fusion (PCF) surgical invasiveness increases. PURPOSE: Compare longer vs shorter PCF complication rates. STUDY DESIGN/SETTING: Retrospective review of the New York State Statewide Planning and Research Cooperative System (SPARCS) database. PATIENT SAMPLE: All patients undergoing >=2 level PCF. OUTCOME MEASURES: Ninety-day neurological or medical complications status post short-cervical (SC), long-cervical (LC), or long cervicothoracic (LCT).
METHOD(S): From the NYS Statewide Planning and Research Cooperative System (SPARCS) database, retrospective review of all patients who underwent >=2 level PCF from 2009-13 with <= 90-day follow-up were identified and stratified by levels fused: 2-3 (SC), 4-8 (LC), and >= 9 (LCT). Data on demographics, hospital-related parameters, and 90-day neurological and other complications, readmissions, and revisions were collected. Regression analysis identified independent predictors of neurologic and overall complications.
RESULT(S): A total of 6,981 patients were included (SC, n=2,964, LC, n=3,899, LCT, n=118). LC patients were older than SC and LCT (60.8 vs 58.2 and 56.1), while LCT patients were more often female (59.3% vs LC 42.1% and SC 44%) and had higher total charges ($187,996 vs LC $99,020 and SC $82,239) and LOS (12.4 vs 6.1 and 6.9 days), all p<0.001. LC had the highest C5-C7 nerve palsy and overall neurological complication rates compared to SC and LCT patients (3.3 vs 1.8 and 1.7%, p=0.001; 3.8 vs 2.3 and 2.5%, p<0.001). Adverse events of the phrenic and recurrent laryngeal nerve were comparable. Implant infection (0.2 vs 0.3 vs 3.4%), and total complication rates (20.3 vs 23.7 vs 42.4%) increased with the number levels fused SC, LC, and LCT respectively, p<=0.017. 90-day readmissions and revisions were comparable. Only LC was a predictor of sustaining 90-day neurological complication (OR=1.7), while both LCT and LC predicted 90-day medical (OR=3.5, 1.3) and total complications (OR=2.7, 1.2), respectively, p<=0.008.
CONCLUSION(S): Compared to 2-3 levels, longer PCF had higher C5-C7 nerve palsy rates (3.3%) and 70% increased odds of sustaining >=1 neurological complication. Longer PCF was also associated with increased rates of medical and total complications. This data can improve the ability to counsel patients regarding the risks and expectations of potential adverse outcomes preceding cervical fusion via posterior or combined anterior-posterior approach. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
ISSN: 1878-1632
CID: 4597652

Restoration of Global Sagittal Alignment After Surgical Correction of Cervical Hyperlordosis in a Patient with Emery-Dreifuss Muscular Dystrophy: A Case Report

Diebo, Bassel G; Shah, Neil V; Messina, James C; Naziri, Qais; Post, Nicholas H; Riew, K Daniel; Paulino, Carl B
CASE/METHODS:We report a rare cervical hyperlordotic deformity in a 19-year-old woman with Emery-Dreifuss muscular dystrophy and concomitant scoliosis. After standard posterolateral instrumentation and fusion of C2-T1 and extensive soft-tissue release, her neck pain improved and unassisted maintenance of cervical alignment and horizontal gaze were preserved through an 8-year follow-up. More importantly, she exhibited reciprocal correction of compensatory global sagittal malalignment, including lumbar lordosis. CONCLUSIONS:This case highlights the importance of full-spine analysis for all patients with spinal deformity to identify and differentiate primary driver(s) of deformity from compensatory mechanisms to individualize treatment toward what truly drives the patient's disability.
PMID: 31899720
ISSN: 2160-3251
CID: 4251962

Motion analysis in the axial plane after realignment surgery for adolescent idiopathic scoliosis

Patel, Ashish; Pivec, Robert; Shah, Neil V; Leven, Dante M; Margalit, Adam; Day, Louis M; Godwin, Ellen M; Lafage, Virginie; Post, Nicholas H; Yoshihara, Hiroyuki; Diebo, Bassel G; Paulino, Carl B
BACKGROUND:This study aimed to define changes occurring in axial plane motion after scoliosis surgery in patients with adolescent idiopathic scoliosis (AIS) using gait analysis. Pre- and postoperative axial plane motion was compared to healthy/control subjects. This may potentially improve our understanding of how motion is impacted by deformity and subsequent surgical realignment. METHODS:15 subjects with AIS underwent pre- and postoperative radiographic and gait analysis, with focus on axial plane motion (clockwise [CW] and counterclockwise [CCW]). Age, weight, and gender-matched controls (n = 13) were identified for gait analysis. Control, preoperative and postoperative groups were compared with paired student's t-tests. RESULTS:Surgical realignment resulted in significantly decreased in upper thoracic, thoracic, thoracolumbar and lumbar Cobb angles pre-to-postoperatively (36.7° vs. 15.2°, 60.1° vs. 25.6°, 47.7° vs. 17.7° and 27.2° vs. 4.8°, respectively) (all p < 0.05), with no significant change in thoracic kyphosis, lumbar lordosis, central sacral vertical line, pelvic incidence, and sagittal vertical axis. However, pelvic tilt significantly increased from 4.9° to 8.1° (p = 0.035). Using gait analysis: preoperative thoracic axial rotation differed (mean CW and CCW rotation was 1.9° and 3.1° [p = 0.01]), whereas mean CW & CCW pelvic rotation remained symmetric (2.0° and 3.0°; p = 0.44). Postoperatively, CCW thoracic rotation range of motion decreased (CW: 0.6° and CCW: 1.4°; p = 0.31). No significant difference in postoperative pelvic rotation occurred (1.1° and 3.4°; p = 0.10). Compared to controls, AIS patients demonstrated no significant difference in total CW & CCW thoracic motion relative to the pelvis both pre- (14.9° and 12.3°, respectively; p = 0.45) and postoperatively (12.9° and 12.3°, respectively; p = 0.82). SIGNIFICANCE/CONCLUSIONS:AIS patients demonstrated abnormal gait patterns in the axial plane compared to normal controls. After surgical realignment and de-rotation, marked improvement in axial plane motion was observed, highlighting how motion analysis can afford surgeons three-dimensional perspective into the patient's functional status.
PMID: 30195821
ISSN: 1879-2219
CID: 3286532

From Static Spinal Alignment to Dynamic Body Balance: Utilizing Motion Analysis in Spinal Deformity Surgery

Diebo, Bassel G; Shah, Neil V; Pivec, Robert; Naziri, Qais; Patel, Ashish; Post, Nicholas H; Assi, Ayman; Godwin, Ellen M; Lafage, Virginie; Schwab, Frank J; Paulino, Carl B
PMID: 29994800
ISSN: 2329-9185
CID: 3199962

Pedicle Reduction Osteotomy in the Upper Cervical Spine: Technique, Case Report and Review of the Literature

Post, Nicholas; Naziri, Qais; Cooper, Colin S; Pivec, Robert; Paulino, Carl B
OBJECTIVE: To present a case report of the correction of a degenerative cervical 45-degree kyphosis centered at C4 with a single stage PSO. SUMMARY OF BACKGROUND DATA: Correction of a fixed cervical kyphosis is a surgical challenge that is frequently managed with a combination of anterior and posterior surgical procedures. An alternative the three stage operation is a single stage pedicle subtraction osteotomy (PSO). A PSO releases the posterior, middle and anterior columns of the spine by resecting the facet joints, pedicles, and a portion of the vertebral body at the apex of a kyphosis through a posterior approach. METHODS: This was a case report of a patient who had degenerative cervical 45 degree kyphosis and was corrected with a single stage pedicle subtraction osteotomy. We did a literature review to provide information on current techniques to treat these patients. RESULTS: With careful resection of the lateral mass and decompression of the vertebral artery by removal of the posterior margin of the foramen transversarium the upper cervical pedicles can be accessed and a PSO can be performed. The vertebral arteries were not obstructed or kinked with posterior reduction of the PSO in this case. CONCLUSIONS: A closing wedge PSO is a useful tool for correcting fixed kyphotic deformities in the upper cervical spine. Further studies are necessary to evaluate the long-term outcomes in these patients.
PMID: 26609512
ISSN: 2211-4599
CID: 2040812

Reduced lateral center of mass sway during gait after ais fusion surgery [Meeting Abstract]

Goz, V; Patel, A; Paul, J C; Godwin, E M; Bianco, K; Post, N H; Naziri, Q; Errico, T J; Lafage, V; Paulino, C
BACKGROUND CONTEXT: The effects of spinal fusion on gait kinematics in AIS are poorly understood. Center of mass (COM) displacement during gait has been used as an indicator of gait efficiency with the least energy consumption when the COM travels in a straight line. PURPOSE: Sixteen patients with adolescent idiopathic scoliosis (AIS) were studied for the interaction between center of mass and center of pressure (COM-COP) before and after scoliosis fusion surgery to evaluate the effect of fusion and curve correction on measures of balance and efficiency during gait. STUDY DESIGN/SETTING: Prospective clinical cohort. PATIENT SAMPLE: 16 subjects with operative AIS. OUTCOME MEASURES: COM and COP interaction and COM sway. METHODS: Prospective clinical, radiographic, and formal 3D motioncapture gait analysis were collected pre- and post spinal fusion for AIS (n, 5, 16). COM-sway was calculated based on side-to-side displacement from a straight line fitted to the patient's path. In sagittal and coronal planes, the left- and right-sided peak COM-COP inclination angles were also measured during gait. Pre- and Postoperative COM sway, and sagittal/coronal plane left- and right-sided peak inclination angles were evaluated with paired t-test. Multivariate analysis was used to identify radiographic parameters with the greatest influence on motion. RESULTS: Sixteen patients (12 females, age 14.4 +/- 3.8 at surgery, with predominantly 1AN and 5CN curves) were included in the analysis. Sixteen patients were included in the analysis. The preoperative COM peak lateral displacement decreased from a mean of 7.2 cm (SD58.0) to 2.6 cm (SD52.5) (p=0.012). In the sagittal plane left pre- and postoperative means of peak inclination angles were 25.6degree and 21.6degree (p=0.029), and right pre- and postoperative means were 26.4 and 22.8 (p=0.026), while left and right coronal peak inclination did not reach significance (p=0.349 and 0.055, respectively). A multivariate linear regression identified changes in sagittal al!
ISSN: 1529-9430
CID: 628032

Sutton's law in epilepsy: because that is where the lesion is [Case Report]

Mortati, Katherine A; Arnedo, Vanessa; Post, Nicholas; Jimenez, Elpidio; Grant, Arthur C
Successful epilepsy surgery requires unambiguous identification of the epileptogenic zone. This determination may be a challenge when the pre-surgical evaluation yields conflicting data. We evaluated an adult patient with a right insular mass, but a seizure semiology, interictal EEG, and ictal EEG, suggesting left temporal lobe epilepsy. Resection of the mass, a ganglioglioma, resulted in seizure freedom and disappearance of interictal left temporal lobe epileptiform discharges. This case illustrates the principle that in localization-related epilepsy, the money is usually in the mass.
PMID: 22542999
ISSN: 1525-5050
CID: 952352

Large cell neuroendocrine carcinoma of the lung metastatic to the cauda equina [Case Report]

Tsimpas, Asterios; Post, Nicholas H; Moshel, Yaron; Frempong-Boadu, Anthony K
BACKGROUND CONTEXT: Large cell neuroendocrine carcinoma of the lung is an aggressive tumor with unique histopathological features. It is not known to metastasize to the spine. PURPOSE: To report a metastatic case of this rare tumor to the cauda equina. STUDY DESIGN: Case report. METHODS: Retrospective case review and review of the literature. RESULTS: The authors report a rare case of a large cell neuroendocrine lung metastasis to the lumbar spine, causing right foot drop. Magnetic resonance imaging revealed a heterogeneously enhancing intradural extramedullary mass at L2/L3 level compressing the surrounding nerve roots. During surgery, the identified nerve roots were encased by the tumor, and the dissection was tedious. Postoperatively, the patient reported significantly improved back pain and he had severe foot weakness. The functional outcome was poor because the patient lost entirely his foot function; however, his back pain improved significantly after surgery. CONCLUSIONS: This is the first published study in which the authors described a metastasis of a rather uncommon lung cancer to the cauda equina. When a lesion of the cauda equina presents with a rapid progressive neurological deficit, leptomeningeal metastasis should be in the differential diagnosis.
PMID: 20494806
ISSN: 1529-9430
CID: 155734

Transient syringomyelia leading to acute neurological deterioration after repair of a lipomyelomeningocele: case report

Post, Nicholas H; Wisoff, Jeffrey H; Thorne, Charles H; Weiner, Howard L
OBJECTIVE: Transient paraplegia in the immediate postoperative period after lipomyelomeningocele repair is uncommon and is not discussed in the literature. We present the unique case of a patient who developed transient paraplegia 48 hours after lipomyelomeningocele repair attributable to the acute development of a thoracic syrinx. CLINICAL PRESENTATION: At birth, the patient was noted to have a large skin-covered mass in the lumbosacral region. On neurological examination, both iliopsoas and quadriceps exhibited 3/5 motor function, and the plantar flexors and dorsiflexors exhibited 1/5 motor function. Urodynamic studies were normal. Magnetic resonance imaging demonstrated the presence of a lipomyelomeningocele associated with tethering of the spinal cord in the lumbosacral region. INTERVENTION: At 5 months of age, the patient underwent repair of the lipomyelomeningocele. After surgery, the patient developed progressive paraplegia along with bowel and bladder dysfunction. Given the concern about a postoperative hematoma resulting in cauda equina syndrome, the patient returned to the operating room for a wound exploration. No compressive lesion such as a hematoma was found at surgery. A postoperative magnetic resonance imaging scan obtained afterward, however, demonstrated the presence of a large thoracic syrinx. CONCLUSION: Syrinx formation can occur as early as 48 hours after lipomyelomeningocele repair, leading to progressive lower extremity weakness and bowel and bladder incontinence. In the immediate postoperative period, an acute syrinx can mimic cauda equina syndrome, and a magnetic resonance imaging scan is necessary to distinguish between these two entities. In this patient, the syrinx was transient and resolved without a shunting procedure
PMID: 17762730
ISSN: 1524-4040
CID: 74117