Sacroiliac Joint Fusion – Impact of a New Image-Guidance Protocol on Safety and Complications

INTRODUCTION Low back pain is a common affliction impacting patients worldwide. The burden of low back pain on modern society in terms of direct costs associated with diagnosis and treatment, as well as indirect costs such as time missed from work for both patients and caregivers, is estimated to be as high as $100 billion annually in the United States alone.1,2 Up to 2-3% of physician visits are thought to be related to chronic low back pain.1,3 While the traditional focus of healthcare providers has been on lumbosacral pathology, sacroiliac joint dysfunction is an underappreciated and underdiagnosed cause of low back pain. Previous studies3-8 have suggested that 15-30% of chronic low back pain is due to pathology located in the sacroiliac joint. Historically, recognition of this pathology was difficult, limited by lack of standardized diagnostic criteria and disease-specific outcome measures. Traditional treatment focused on conservative therapy, such as physical therapy with focus on core and pelvic stability, orthoses, pain and anti-inflammatory medication, weight loss, intra- or peri-articular injections, and radiofrequency ablation.4,5,9-12 Early surgical intervention came in the form of morbid open approaches often utilizing iliac crest autografting. More recently, minimally invasive techniques for sacroiliac fusion have been developed that allow for significant sparing of muscle dissection, shorter operating room times and blood loss, reduced length of stay, and fewer complications.13-17 Such techniques are often performed with fluoroscopic guidance. However, three-dimensional sacral anatomy can be challenging to conceptualize on fluoroscopic imaging and several centers are now beginning to perform the procedure utilizing image-guidance with intraoperative CT data. This is particularly helpful in patients with transitional lumbosacral anatomy or those undergoing revision procedures. Complications such as pseudarthrosis and neural injuries, while rare, are often associated with need for revision surgery and poorer outcome.18,19 The transition to CT-based image-guidance aims to reduce such complications. The purpose of this study is to review our series of minimally invasive sacroiliac fusion with a focus on safety and complications, and to review differences in these parameters between patients undergoing fluoroscopic technique versus CT-based image-guidance

Spinal Cord Stimulation in the 21st Century — Reviewing Innovation in Neuromodulation

INTRODUCTION Low back pain (LBP) is a pervasive problem impacting health systems across the world. In the United States, chronic LBP impacts up to 40% of Americans and results in excessive financial strain on the healthcare budget, estimated at up to $100 billion annually.1 Furthermore, treatment results are often disappointing, with the traditional pathway of conservative measures, narcotic pain medication, and surgical decompression and/or fusion leading to both patient and provider frustration, complications, and diminished patient productivity and quality of life. This has naturally led to questions from policymakers regarding the utility of healthcare dollars spent on back pain. In this milieu, a variety of neuromodulation techniques have found a niche in the management of this patient population, with indications commonly quoted including failed back surgery syndrome (FBSS), chronic neuropathic pain, and complex regional pain syndrome (CRPS), among others.1,2 From its inception on the basis of Melzak and Wall’s gate theory³, to its first human trial in the 1960s,⁴ and to the modern era, spinal cord stimulation has undergone a series of innovations that have expanded indications and improved patient outcomes. The goal of this study is to summarize the most important clinical trials involving both traditional SCS and newer stimulation paradigms to provide an overview of the current state of affairs of this rapidly-growing field

Ossification of the Posterior Longitudinal Ligament: Surgical Approaches and Associated Complications.

Ossification of the posterior longitudinal ligament (OPLL) is a rare but potentially devastating cause of degenerative cervical myelopathy (DCM). Decompressive surgery is the standard of care for OPLL and can be achieved through anterior, posterior, or combined approaches to the cervical spine. Surgical correction of OPLL via any approach is associated with higher rates of complications and the presence of OPLL is considered a significant risk factor for perioperative complications in DCM surgeries. Potential complications include dural tear (DT) and subsequent cerebrospinal fluid leak, C5 palsy, hematoma, hardware failure, surgical site infections, and other neurological deficits. Anterior approaches are technically more demanding and associated with higher rates of DT but offer greater access to ventral OPLL pathology. Posterior approaches are associated with lower rates of complications but may allow for continued disease progression. Therefore, the decision to pursue either an anterior or posterior approach to surgical decompression may be critically influenced by complications associated with each procedure. The authors critically review anterior and posterior approaches to surgical decompression of OPLL with particular focus on the complications associated with each approach. We also review the recent work in developing new surgical treatments for OPLL that aim to reduce complication incidence

The Impact of Intraoperative Image-Guidance Modalities and Neurophysiologic Monitoring in the Safety of Sacroiliac Fusions.

STUDY DESIGN: Retrospective observational cohort. OBJECTIVE: A review of efficiency and safety of fluoroscopy and stereotactic navigation system for minimally invasive (MIS) Sacroiliac (SI) fusion through a lateral technique. METHODS: Retrospective analysis of an observational cohort of 96 patients greater than 18 years old, that underwent MIS SI fusion guided by fluoroscopy or navigation between January 2013 and April 2020 with a minimum of 3 months follow-up. Intraoperative neuromonitoring (IONM) with a variable combination of electromyography (EMG), somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) was also utilized. RESULTS: The overall complication rate in the study was 9.4%, and there was no difference between the fluoroscopy (10.1%), and navigation groups (8%). Neurological complication rate was 2.1%, without a significant difference between both intraoperative guidance modality groups (p = 0.227). There was a significant difference between the modalities of IONM used and the occurrence of neurological injury (p = 0.01).The 2 patients who had a neurological complication postoperatively were monitored only with EMG and SSEP, but none of the patients (n = 76) in which MEPs were utilized had neurologic complication. The mean pain improvement 3 months after surgery was greater in the navigation group (2.44 ± 2.72), but was not statistically different than the improvement in the fluoroscopy group (1.90 ± 2.07) (p = 0.301). CONCLUSIONS: No difference in the safety of the procedure was found between the fluoroscopy and the stereotactic navigation techniques. The contribution of the IONM to the safety of SI fusions could not be determined, but the data indicates that MEPs provide the highest level of sensitivity

The relative efficacy of antifibrinolytics in adolescent idiopathic scoliosis: a prospective randomized trial.

BACKGROUND: Antifibrinolytics can reduce intraoperative blood loss. The primary aim of this study was to determine the efficacy of intraoperative tranexamic acid, epsilon-aminocaproic acid, and placebo at reducing perioperative blood loss and the transfusion rate in patients with adolescent idiopathic scoliosis undergoing posterior spinal arthrodesis. METHODS: This is a prospective, randomized, double-blind comparison of tranexamic acid, epsilon-aminocaproic acid, and placebo used intraoperatively in patients with adolescent idiopathic scoliosis. One hundred and twenty-five patients with adolescent idiopathic scoliosis were randomly assigned to the tranexamic acid, epsilon-aminocaproic acid, or control groups. Parameters recorded included estimated blood loss, hematocrit, blood product usage, drain output, and total blood losses. The primary outcomes were intraoperative blood loss and postoperative drainage. Secondary outcomes were transfusion requirements and hematocrit changes both intraoperatively and postoperatively. RESULTS: One hundred and twenty-five patients (ninety-seven female and twenty-eight male, with a mean age of fifteen years) were randomized to receive tranexamic acid (thirty-six patients), epsilon-aminocaproic acid (forty-two patients), or saline solution (forty-seven patients). The groups were similar at baseline, with one exception: the saline solution group had a higher estimated blood volume at baseline than the tranexamic acid group. Both tranexamic acid and epsilon-aminocaproic acid reduced the estimated blood loss per degree and estimated blood loss per pedicle screw. Epsilon-aminocaproic acid, but not tranexamic acid, reduced estimated blood loss and estimated blood loss per level. Tranexamic acid also reduced total blood losses compared with epsilon-aminocaproic acid or saline solution. In an analysis controlling for level, degree, and number of anchors, tranexamic acid reduced drain output and total blood losses. Tranexamic acid or epsilon-aminocaproic acid had a smaller decrease in hematocrit postoperatively. In an analysis controlling for the mean arterial pressure during surgical exposure, tranexamic acid reduced estimated blood loss and total blood losses. Overall, antifibrinolytics (tranexamic acid or epsilon-aminocaproic acid) reduced estimated blood loss, total blood losses, and the decline in hematocrit postoperatively compared with saline solution. There was no difference among the groups with respect to the transfusion rate, duration of surgery, levels fused, or pedicle screws placed. CONCLUSIONS: Tranexamic acid and epsilon-aminocaproic acid reduced operative blood loss but not transfusion rate. Tranexamic acid is more effective at reducing postoperative drainage and total blood losses compared with epsilon-aminocaproic acid. Maintenance of the mean arterial pressure atbenefit. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence