A review of complications and outcomes following vertebral column resection in adults

The correction of rigid spinal deformities in adult patients can require a three-column osteotomy (pedicle subtraction osteotomy [PSO] or vertebral column resection [VCR]) to obtain spinal balance. Unfortunately, the existing adult deformity literature frequently reports the outcomes and complications of these procedures together even though VCR is a more extensive procedure with potentially higher rates of complications. We sought to address this shortcoming and provide clinicians with an overview of the existing literature regarding VCR in adult patients. The goals of this review are: to determine the rate of overall and neurologic complications following VCR, the rate of complications with VCR compared to PSO, and the impact of VCR on clinical and radiographic outcomes. An electronic literature search was used to identify studies reporting outcomes or complications following VCR in adult patients. Raw data on patient demographics, case information, radiographic outcomes, complications and clinical outcomes were extracted. Data were pooled to report a rate of overall complications and neurologic complications. A pooled relative risk of complications following PSO vs. VCR was also calculated. Eleven retrospective studies (Level IV) met our inclusion criteria. The overall rate of complications was 69.2%. The reoperation rate was 9.6%. The rate of neurologic complications was 13.3% (range, 6.3% to 15.8%) with most cases being transient. The rate of permanent neurologic deficits was 2.0%. We found a significantly higher rate of all complications with VCR compared to PSO (relative risk, 1.36; 95% confidence interval, 1.24–1.49; p<0.001). All studies reporting clinical outcomes showed significant improvements in functional outcome postoperatively

Cervical radiculopathy: Incidence and treatment of 1,420 consecutive cases

Study DesignRetrospective case series.PurposeTo determine the incidence of cervical radiculopathy requiring operative intervention by level and to report on the methods of treatment.Overview of LiteratureCervical radiculopathy is a common cause of pain and can result in progressive neurological deficits. Although the pathology is well understood, the actual incidence of cervical radiculopathy at particular spinal levels ultimately requiring operative intervention is unknown.MethodsA large consecutive series of patients operated on by a single surgeon were retrospectively analyzed. The incidence of cervical radiculopathy at each level was defined for every patient. Procedures used for operative treatment were noted. Health related quality of life (HRQL) scores were collected both pre-operatively and postoperatively.ResultsThere were 1305 primary and 115 revision operations performed. The most common primary procedures performed were anterior cervical discectomy and fusion (ACDF, 50%) and anterior cervical corpectomy and fusion (ACCF, 28%). The most commonly affected levels were C6 (66%) and C7 (62%). Reasons for revision were pseudarthrosis (27%), clinical adjacent segment pathology (CASP, 63%), persistent radiculopathy (11%), and hardware-related (2.6%). The most common procedures performed in the revision group were posterior cervical decompression and fusion (PCDF, 42%) and ACDF (40%). The most commonly affected levels were C7 (43%) and C5 (30%). Among patients that had their index surgery at our institution, the revision rate was 6.4%. In both primary and revision cases there was a significant improvement in Neck Disability Index and visual analogue scale scores postoperatively. Postoperative HRQL scores in the revision cases were significantly worse than those in the primary cases (p <0.01).ConclusionsThis study provides the largest description of the incidence of cervical radiculopathy by level and operative outcomes in patients undergoing cervical decompression. The incidence of CASP was 4.2% in 3.3 years in this single institution series

Osteotomies in the Cervical Spine

Rigid cervical deformities are difficult problems to treat. The goals of surgical treatment include deformity correction, achieving a rigid fusion, and performing a thorough neural decompression. In stiff and ankylosed cervical spines, osteotomies are required to restore sagittal and coronal balance. In this chapter, we describe the clinical and radiographic workup for patients with cervical deformities, and delineate the various factors that must be considered when planning surgical treatment. We also describe in detail the various types of cervical osteotomies, along with their surgical technique, advantages, and potential complications

Defining Cervical Sagittal Plane Deformity – When Are Sagittal Realignment Procedures Necessary in Patients Presenting Primarily With Radiculopathy or Myelopathy?

Objective It remains unclear whether cervical sagittal deformity (CSD) should be defined by radiographic parameters alone versus both clinical and radiographic factors, and whether radiographic malalignment by itself warrants a CSD corrective surgery in patients who present primarily with neurologic symptoms. Methods We administered a survey to a group of expert surgeons to evaluate whether radiographic parameters alone were sufficient to diagnose CSD, and in which scenarios surgeons recommend a CSD realignment procedure versus addressing the neurologic symptoms alone. Results No single radiographic criteria reached a 50% threshold as being sufficient to establish the diagnosis of CSD. When asymptomatic radiographic malalignment was present, a sagittal deformity correction was more likely to be recommended in patients with myelopathy versus those with radiculopathy alone. The majority of surgeons recommended deformity correction when symptoms of cervical deformity were present in addition to radiographic malalignment (85% with deformity symptoms and radiculopathy, 93% with deformity symptoms and myelopathy). Conclusion There is no consensus on which radiographic and/or clinical criteria are necessary to define the presence of CSD. We recommend that symptoms of cervical deformity, in addition to radiographic parameters, be considered when deciding whether to perform deformity correction in patients who present primarily with myelopathy or radiculopathy

Outcomes of Fusions From the Cervical Spine to the Pelvis.

Study designRetrospective cohort study.ObjectiveDetermine the indications, complications, and clinical outcomes in patients requiring fusions from the cervical spine to the pelvis. Several investigators have examined fusions from the thoracic spine to the sacrum, but no similar study has been performed for cervical-to-pelvis fusions.MethodsPatients from 2003 to 2014 with an upper instrumented vertebrae (UIV) in the cervical spine (any level) and a lower instrumented vertebrae (LIV) in the sacrum or pelvis were included in the study. Those with infectious or acute trauma-related deformities were excluded. Patient demographics, medical history, diagnosis, operative procedure, and health-related quality of life measures were analyzed. Student's t test, Kruskal-Wallis test, and χ2 test were used as appropriate; significance was set at P &lt; .05 for all tests.ResultsFifty-five patients met inclusion criteria for the study. Average follow-up was 2.8 years. Proximal junctional kyphosis was the most common indication for cervical-to-pelvis fusions (36%). The most common UIV was C2 (29%) followed by C7 (24%). There was an average 31° correction in maximum kyphosis and a 3.3 cm improvement in sagittal vertical axis. In adults, the rate of complication was 71.4%, with a major complication rate of 39.3% and reoperation rate of 53.6%. There was significant improvement in the Scoliosis Research Society (SRS-22r) score (3.0 to 3.5; P &lt; .01).ConclusionProximal junctional kyphosis is the most common indication for patients requiring fusion to the cervical spine. Adult patients incur a significant risk of major complications and reoperations. However, significant improvement in SRS-22r outcomes are noted in these patients

EFFECTS OF 23.4% SODIUM CHLORIDE SOLUTION IN REDUCING INTRACRANIAL PRESSURE IN PATIENTS WITH TRAUMATIC BRAIN INJURY: A PRELIMINARY STUDY

OBJECTIVE: Mannitol is the standard of care for patients with increased intracranial pressure (ICP), but multiple administrations of mannitol risk renal toxicity and fluid accumulation in the brain parenchyma with consequent worsening of cerebral edema. This preliminary study assessed the safety and efficacy of small-volume injections of 23.4% sodium chloride solution for the treatment of intracranial hypertension in patients with traumatic brain injury who became tolerant to mannitol. METHODS: We retrospectively reviewed the charts of 13 adult patients with traumatic brain injury who received mannitol and 23.4% sodium chloride independently for the treatment of intracranial hypertension at San Francisco General Hospital between January and October 2003. Charts were reviewed to determine ICP, cerebral perfusion pressure, mean arterial pressure, serum sodium values, and serum osmolarity before and after treatment with 23.4% sodium chloride and mannitol. Complications were noted. RESULTS: The mean reductions in ICP after treatment were significant for both mannitol (PϽ0.001) and hypertonic saline (PϽ0.001); there were no significant differences between reductions in ICP when comparing the two agents (P ϭ 0.174). The ICP reduction observed for hypertonic saline was durable, and its mean duration of effect (96 min) was significantly longer than that of mannitol treatment (59 min) (P ϭ 0.016). No complications were associated with treatment with hypertonic saline. CONCLUSION: This study suggests that 23.4% hypertonic saline is a safe and effective treatment for elevated ICP in patients after traumatic brain injury. These results warrant a rigorous evaluation of its efficacy as compared to mannitol in a prospective randomized controlled trial

Outcomes of Fusions From the Cervical Spine to the Pelvis.

Study designRetrospective cohort study.ObjectiveDetermine the indications, complications, and clinical outcomes in patients requiring fusions from the cervical spine to the pelvis. Several investigators have examined fusions from the thoracic spine to the sacrum, but no similar study has been performed for cervical-to-pelvis fusions.MethodsPatients from 2003 to 2014 with an upper instrumented vertebrae (UIV) in the cervical spine (any level) and a lower instrumented vertebrae (LIV) in the sacrum or pelvis were included in the study. Those with infectious or acute trauma-related deformities were excluded. Patient demographics, medical history, diagnosis, operative procedure, and health-related quality of life measures were analyzed. Student's t test, Kruskal-Wallis test, and χ2 test were used as appropriate; significance was set at P &lt; .05 for all tests.ResultsFifty-five patients met inclusion criteria for the study. Average follow-up was 2.8 years. Proximal junctional kyphosis was the most common indication for cervical-to-pelvis fusions (36%). The most common UIV was C2 (29%) followed by C7 (24%). There was an average 31° correction in maximum kyphosis and a 3.3 cm improvement in sagittal vertical axis. In adults, the rate of complication was 71.4%, with a major complication rate of 39.3% and reoperation rate of 53.6%. There was significant improvement in the Scoliosis Research Society (SRS-22r) score (3.0 to 3.5; P &lt; .01).ConclusionProximal junctional kyphosis is the most common indication for patients requiring fusion to the cervical spine. Adult patients incur a significant risk of major complications and reoperations. However, significant improvement in SRS-22r outcomes are noted in these patients