Comparison of Lumbar Laminectomy Alone, Lumbar Laminectomy and Fusion, Stand-alone Anterior Lumbar Interbody Fusion, and Stand-alone Lateral Lumbar Interbody Fusion for Treatment of Lumbar Spinal Stenosis: A Review of the Literature.

Lumbar spinal stenosis is defined as narrowing of the lumbar spinal canal, which causes compression of the spinal cord and nerves. Spinal stenosis can cause leg pain and potentially back pain that can affect the quality of life. Ultimately, surgical decompression is required to alleviate the symptoms. In this review, we first utilize several important studies to compare lumbar laminectomy alone versus lumbar laminectomy and fusion. We also compare the effectiveness of more novel surgical approaches, stand-alone anterior lumbar interbody fusion (ALIF), and stand-alone lateral lumbar interbody fusion (LLIF). These techniques have their own advantages and disadvantages in which many factors must be taken into account before choosing a surgical approach. In addition, the patient\u27s anatomy and pathology, lifestyle, and desires should be analyzed to help determine the ideal surgical strategy

Reattachment of the Multifidus Tendon in Lumbar Surgery to Decrease Postoperative Back Pain: A Technical Note.

The posterior midline approach to the lumbar spine requires significant manipulation of the paraspinal muscles. Muscle detachment and retraction results in iatrogenic damage such as crush injury, devascularization, and denervation, all of which have been associated with postoperative pain. The muscle most directly affected by the posterior approach is the lumbar multifidus (LM), the largest and most medial of the deep lumbar paraspinal muscles. The effects of the posterior approach on the integrity of the LM is concerning, as multiple studies have demonstrated that intraoperative injuries sustained by the LM lead to postoperative muscle atrophy and potentially worsening low back pain. Given the inevitability of intraoperative paraspinal muscle manipulation when using the posterior approach, this technical note describes methods by which surgeons may minimize LM tissue disruption and restore the anatomical position of the LM to ultimately expedite recovery, minimize postoperative pain, and improve patient satisfaction

Quality and Clinical Care Development in Spine Surgery-Connecting the Dots: An Expanded Clinical Narrative.

Our health care system is an evidenced-based quality-centric environment. Pursuit of quality is a process that encompasses knowledge development and care advancements through collaboration and expertise. Depicted here is the foundational knowledge, process, and contributions that hallmark successful clinical quality programs. Beginning with methodology, followed by process and form, we create the foundational knowledge and exemplars demonstrating framework and continuum of process in pursuit and attainment of successful clinical quality and care development for patients. Although our protocol has been devised for complex spine care, this could be implemented across all health care specialties to provide individualized and high-quality care for all current and future patients, all while creating a culture of accountability for physicians

Estimation of the national disease burden of influenza-associated severe acute respiratory illness in Kenya and Guatemala : a novel methodology

Background: Knowing the national disease burden of severe influenza in low-income countries can inform policy decisions around influenza treatment and prevention. We present a novel methodology using locally generated data for estimating this burden. Methods and Findings: This method begins with calculating the hospitalized severe acute respiratory illness (SARI) incidence for children <5 years old and persons ≥5 years old from population-based surveillance in one province. This base rate of SARI is then adjusted for each province based on the prevalence of risk factors and healthcare-seeking behavior. The percentage of SARI with influenza virus detected is determined from provincial-level sentinel surveillance and applied to the adjusted provincial rates of hospitalized SARI. Healthcare-seeking data from healthcare utilization surveys is used to estimate non-hospitalized influenza-associated SARI. Rates of hospitalized and non-hospitalized influenza-associated SARI are applied to census data to calculate the national number of cases. The method was field-tested in Kenya, and validated in Guatemala, using data from August 2009–July 2011. In Kenya (2009 population 38.6 million persons), the annual number of hospitalized influenza-associated SARI cases ranged from 17,129–27,659 for children <5 years old (2.9–4.7 per 1,000 persons) and 6,882–7,836 for persons ≥5 years old (0.21–0.24 per 1,000 persons), depending on year and base rate used. In Guatemala (2011 population 14.7 million persons), the annual number of hospitalized cases of influenza-associated pneumonia ranged from 1,065–2,259 (0.5–1.0 per 1,000 persons) among children <5 years old and 779–2,252 cases (0.1–0.2 per 1,000 persons) for persons ≥5 years old, depending on year and base rate used. In both countries, the number of non-hospitalized influenza-associated cases was several-fold higher than the hospitalized cases. Conclusions: Influenza virus was associated with a substantial amount of severe disease in Kenya and Guatemala. This method can be performed in most low and lower-middle income countries

Extraforaminal compression of the L5 nerve: An anatomical study with application to failed posterior decompressive procedures.

This anatomical study was performed to elucidate the pertinent foraminal and lateral L5 nerve anatomy to enhance our understanding of possible neurologic causes of failed decompression surgery. Persistent extraforaminal L5 nerve compression is a possible cause of persistent symptoms following lumbosacral surgery. The amount of extraforaminal space for the L5 ventral ramus was examined in fifty adult human skeletons (100 sides). Based on morphology, the specimens were then categorized (types I-IV) on the basis of the bony space available for the nerve at this location. Next, 25 embalmed adult cadavers (50 sides) underwent bilateral dissection of the lower lateral lumbar region. The type of bony extraforaminal outlet was documented for each cadaver on the basis of our skeletal analysis. Lastly, segments (intra- and extra-foraminal) of the L5 ventral ramus were excised and examined histologically. Types I-IV outlets were found in 43, 31, 20 and 6 skeletal sides, respectively. For cadavers, 22,15, 10 and 3 sides were found to have types I-IV bony outlets, respectively. In cadavers, all type IV outlets and 70% of the type III bony configurations adjacent to the L5 ventral ramus had signs of neural irritation/injury including vascular hyalinization and increased fibrosis distal to the intervertebral foramen. No distal segments of type I and type II outlets showed histological signs of neural compromise. Patients with symptoms referable to L5 nerve compression for whom no proximal pathology is identified could warrant investigation of the more distal extraforaminal segment of this nerve

Primary intracranial sarcomatoid carcinoma arising from a recurrent/residual epidermoid cyst of the cerebellopontine angle: a case report.

Primary intracranial squamous cell carcinomas (SCCs) are rare and mostly associated with an intracranial epidermoid or dermoid cyst. Sarcomatoid carcinoma is a rare biphasic tumor composed of both carcinomatous and sarcomatous components and has not previously been reported as a primary intracranial tumor. Here, we present a case of a 60-year-old man with a primary intracranial sarcomatoid carcinoma, arising from the remnants of the previously resected epidermoid cyst in the cerebellopontine angle. The resected material had portions of an epidermoid cyst lined by normal and dysplastic squamous epithelia and invasive keratinizing SCC. This area was in continuity with areas of highly pleomorphic, anaplastic sarcomatoid cells. Brisk mitotic activity and extensive areas of necrosis were found. On immunohistochemical staining, the cells of the conventional SCC were positive for cytokeratin 5/6, pancytokeratin, epithelial membrane antigen, p63, and p53. The sarcomatoid cells were diffusely and strongly positive for vimentin, p53, smooth muscle actin, and, focally, muscle-specific actin. Occasional sarcomatoid cells coexpressed cytokeratin 5/6, pancytokeratin, p63, and S100 protein. The patient subsequently developed leptomeningeal spread and died 4 months after the second surgery. This rare entity expands the morphologic spectrum encountered in primary intracranial carcinoma

Advancement of Surgical Visualization Methods: Comparison Study Between Traditional Microscopic Surgery and a Novel Robotic Optoelectronic Visualization Tool for Spinal Surgery.

INTRODUCTION: The operating microscope (OM) has become instrumental in aiding surgeons during key microdissection with greater safety and detail. An exoscope offers similar detail with improved functionality and greater implications for live teaching and improved operating room flow. METHODS: Eleven senior neurosurgery residents and fellows performed unilateral, single-level laminotomies on fresh cadavers using an OM and exoscope. Three attending spine surgeons blinded for the visualization technique used then reviewed and graded each decompression. Data points gathered included time of procedure, grading of decompression (1-5), and complications, including dural tear, nerve root injury, and pars fracture. RESULTS: Operative times between the 2 systems were not significantly different (14.9 minutes OM vs. 15.6 minutes exoscope, P = 0.766). Despite high variability between evaluators in assessing complications and adequacy of decompression, there was no significant difference between either system. Postprocedural surveys indicated greater comfort with the exoscope, greater ease of use, and superior teaching potential for the exoscope over the standard OM. CONCLUSION: In our simulated operating room model, an exoscope is a valid alternative to the standard OM that affords the surgeon greater comfort with greater teaching potential while maintaining many of the microscope\u27s benefits

Cervical fracture from chronic steroid usage presenting as a stroke: A case report

Introduction: Misdiagnosis of Brown-Séquard-like presentations can delay treatment; potentially endangering the positive outcomes a patient might otherwise have had. Stroke mimics can be perceived as signaling the end of urgent investigation and care once stroke is ruled out; however, stroke mimics themselves can require prompt care. Herein, we discuss an extremely rare case where stroke was ruled out, resulting in a lapse in care that lead to an exacerbated hemiparesis over the following week. Presentation of case: We present a patient with an occult cervical spine fracture with extension of the neck, caused by reduced bone density from a chronic steroid regimen. Nine days after the initial onset of her neurological symptoms, the patient presented to the ED with the complaint of left sided weakness and right-sided sensory loss. She was determined to have a left- sided Brown Séquard syndrome, which resolved following anterior cervical discectomy and fusion at C4-C6 and a laminectomy from C4-C6. Discussion: This case indicated that patients with dangerously low bone density should be weaned off chronic steroid therapy to prevent the onset of osteoporotic symptoms early in adulthood. Furthermore, this case emphasizes the importance of continued investigation of symptoms if a stroke is ruled out and the need for more diligent monitoring of bone density of chronic steroid users. Conclusion: Stroke mimics can require the same urgency in care and diagnosis as strokes themselves