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Full-Endoscopic Lumbar Discectomy
Full-endoscopic spine surgery has been developed to decrease approach-related morbidity and provide superior visualization. Using a working channel endoscope, lumbar disc herniations can be approached via two complementary corridors: the transforaminal approach and the interlaminar approach. Indications, contraindications, surgical technique, complications, and outcomes are discussed in this article. Multiple published studies have demonstrated the feasibility, safety, and efficacy of full-endoscopic lumbar discectomies. Emerging evidence suggests that full-endoscopic discectomies result in similar functional outcomes compared with microsurgical technique and are associated with shorter hospital stays, less opioid consumption, and fewer perioperative complications.
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The benefit zone of full-endoscopic spine surgery
Minimally invasive spine procedures have undergone rapid development during the last decade. Efforts to decrease muscle crush injuries during prolonged retraction, avoid significant soft tissue stripping and minimize bony resection are surgical principles that are employed to prevent iatrogenic instability and provide patients with decreased post-operative pain and disability. Full-endoscopic spine surgery represents a tool for the spine surgeon to provide targeted access to spinal pathology utilizing these principles. Endoscopic techniques have seen over 30 years of evolution and innovation, however, early iterations of these techniques largely focused on transforaminal lumbar microdiscectomies. Currently, endoscopic techniques are utilized for approaching pathology in the cervical, thoracic and lumbar spine.
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Comparison of full-endoscopic and minimally invasive decompression for lumbar spinal stenosis in the setting of degenerative scoliosis and spondylolisthesis
OBJECTIVE The management of lumbar spinal stenosis (LSS) with concurrent scoliosis and/or spondylolisthesis remains controversial. Full-endoscopic unilateral laminotomy for bilateral decompression (ULBD) facilitates neural decompression while preserving stabilizing osseoligamentous structures and may be uniquely suited for the treatment of LSS with concurrent mild to moderate degenerative deformity. The safety and efficacy of full-endoscopic versus minimally invasive surgery (MIS) ULBD in this patient population is studied here for the first time. METHODS A retrospective analysis of prospectively collected data was conducted on 45 consecutive LSS patients with concurrent scoliosis (≥ 10° coronal Cobb angle) and/or spondylolisthesis (≥ 3 mm).
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Endoscopic Spine Surgery Past, Present, and Future
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Arm Pain Versus Neck Pain: A Novel Ratio as a Predictor of Post-Operative Clinical Outcomes in Cervical Radiculopathy Patients
Background: Informed patient selection and counseling is key in improving surgical outcomes. Understanding the impact that certain baseline variables can have on postoperative outcomes is essential in optimizing treatment for certain symptoms, such as radiculopathy from cervical spine pathologies. The aim was to identify baseline characteristics that were related to improved or worsened postoperative outcomes for patients undergoing surgery for cervical spine radiculopathic pain. Methods: Retrospective review of prospectively collected data. Patient Sample: Surgical cervical spine patients with a diagnosis classification of "degenerative." Diagnoses included in the "degenerative" category were those that caused radiculopathy: cervical disc herniation, cervical stenosis, and cervical spondylosis without myelopathy.
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Oblique Lateral Lumbar Interbody Fusion: OLIF
Advancements in surgical techniques and instrumentation have led to minimally invasive methods to achieve interbody fusion. The oblique lateral interbody fusion procedure represents a minimally invasive modification of the traditional anterolateral approach to the lumbar spine that allows quicker mobilization and less post-operative pain. The dissection plane is extraperitoneal and provides access to the discs anterior to the psoas muscle. This anterolateral corridor minimizes psoas-related injury, with early evidence of less post-operative lumbar plexus- and psoas-related morbidity, particularly at L4-5 which may be difficult to access via the direct lateral approach.
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Lack of Consensus in Physician Recommendations Regarding Return to Driving After Cervical Spine Surgery
Study design: Cross-Sectional Study. Objective: The goal of this study is to investigate how surgeons differ in collar and narcotic use, as well as return to driving recommendations following cervical spine surgeries and the associated medico-legal ramifications of these conditions. Summary of background data: Restoration of quality of life is one of the main goals of cervical spine surgery. Patients frequently inquire when they may safely resume driving after cervical spine surgery. There is no consensus regarding post-operative driving restrictions. This study addresses how surgeons differ in their recommendations concerning cervical immobilization, narcotic analgesia, and suggested timeline of return to driving following cervical spine surgery.
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Predictors of Hospital Length of Stay and 30-Day Readmission in Cervical Spondylotic Myelopathy Patients: An Analysis of 3057 Patients Using the ACS-NSQIP Database
Background: Hospital length of stay (LOS), 30-day readmission rate, and other metrics are increasingly being used to evaluate quality of surgical care. The factors most relevant to cervical spondylotic myelopathy (CSM) are not yet established. Objective: To identify peri-operative factors associated with extended LOS and/or 30-day readmission following elective surgery for CSM. Methods: Surgical CSM patients at institutions represented by the American-College-of-Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) from 2010-2012 were included. Patients with fracture, ≥9 levels fused, or cancer were excluded. Extended LOS was defined as 75th percentile of the cohort. Univariate analysis and multivariate logistic regression identified predictors for extended LOS, 30-day readmission, and reoperation.
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Incidence of Congenital Spinal Abnormalities Among Pediatric Patients and Their Association With Scoliosis and Systemic Anomalies
Background: Congenital abnormalities when present, according to VACTERL theory, occur nonrandomly with other congenital anomalies. This study estimates the prevalence of congenital spinal anomalies, and their concurrence with other systemic anomalies. Methods: A retrospective cohort analysis on Health care Cost and Utilization Project's Kids Inpatient Database (KID), years 2000, 2003, 2006, 2009 was performed. ICD-9 coding identified congenital anomalies of the spine and other body systems. Outcome measures: Overall incidence of congenital spinal abnormalities in pediatric patients, and the concurrence of spinal anomaly diagnoses with other organ system anomalies.
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Cervical and Gross Trunk Range of Motion Required During Safe Operation of a Vehicle: A Study of Healthy Adults
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Determinants of Cost-to-Charge Ratio Variation among US Hospitals
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Congenital Etiology is an Independent Risk Factor for Complications in Adolescents Undergoing Corrective Scoliosis Surgery: Comparison of In-hospital Comorbidities Using Nationwide KID’s Inpatient Database
Background: Congenital scoliosis (CS) is associated with more rigid, complex deformities relative to adolescent idiopathic scoliosis (AIS) which theoretically increases surgical complications. Despite extensive literature studying AIS patients, few studies have been performed on CS patients. The purpose of this study was to evaluate complications associated with spinal fusions for CS and AIS. Methods: A retrospective review of the Kid's Inpatient Database (KID) years 2000 to 2009 was performed. Inclusion: patients under 20 years with ICD-9 diagnosis codes for idiopathic scoliosis (IS-without concomitant congenital anomalies) and CS, undergoing spinal fusion from the KID years 2000 to 2009. Two analyses were performed according to age below 10 years and 10 years and above.
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Congenital versus Idiopathic Scoliosis: Comparison of In-Hospital Comorbidities Using Nationwide Inpatient Database (KID)
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Incidence of Congenital Spinal Abnormalities among Pediatric Patients and Their Association with Scoliosis and Systemic Anomalies
The incidence of hemivertebra formation was reported to be 0.09 per 1000 births, and the rate of a second congenital spine anomaly was reported to be 10%. 9 If it is considered that only some of second congenital anomalies are diastematomyelia and only some of these patients develop scoliosis, one can easily say that the combination of the hemivertebra formation with diastematomyelia is quite rare. In the case described by the current study, the hemivertebra formation was in the lumbar region and there were two of Fig. 4. Schematic of L2, L3, and L4 nerve roots together in one intervertebral foramen, exiting through the space between L2 and L5 vertebral bodies following L3, L4 resection.
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Changes in Driving Performance Following Shoulder Arthroplasty
Background: With this study, we sought to quantify perioperative changes in driving performance among patients who underwent anatomic or reverse shoulder arthroplasty. Methods: Using a driving simulator, 30 patients (20 anatomic and 10 reverse total shoulder arthroplasties) were tested preoperatively and at 2 weeks (PO2), 6 weeks (PO6), and 12 weeks (PO12) postoperatively. The total number of collisions, centerline crossings, and off-road excursions (when the vehicle traversed the lateral road edge), and scores on a visual analog scale (VAS) for pain and the Shoulder Pain and Disability Index (SPADI) were recorded at each driving trial. Results: The mean number of collisions increased from 5.9 preoperatively to 7.4 at PO2 and subsequently decreased to 5.6 at PO6 and 4.0 at PO12 (p = 0.0149). In addition, the number of centerline crossings decreased from 21.4 preoperatively to 16.3 at PO12 (p < 0.05).
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Change in Driving Performance following Arthroscopic Shoulder Surgery
The current study aimed to measure perioperative changes in driving performance following arthroscopic shoulder surgery using a validated driving simulator.21 patients who underwent arthroscopic surgery for rotator cuff or labral pathology were tested on a driving simulator preoperatively, and 6 and 12 weeks postoperatively. An additional 21 subjects were tested to establish driving data in a control cohort. The number of collisions, centerline crossings, and off-road excursions were recorded for each trial. VAS and SPADI scores were obtained at each visit.The mean number of collisions in the study group significantly increased from 2.05 preoperatively to 3.75 at 6 weeks (p<0.001), and significantly decreased to 1.95 at 12 weeks (p<0.001).
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“Reverse Bohlman” technique for the treatment of high grade spondylolisthesis in an adult population
Background/aims: Surgical techniques for effective high-grade spondylolisthesis (HGS) remain controversial. This study aims to evaluate radiographic/clinical outcomes in HGS patients treated using modified "Reverse Bohlman" (RB) technique. Methods: Review of consecutive HGS patients undergoing RB at a single university-center from 2006 to 2013. Clinical, surgical, radiographic parameters collected. Results: Six patients identified: five with L5-S1 HGS with L4-L5 instability and one had an L4-5 isthmic spondylolisthesis and grade 1 L5-S1 isthmic spondylolisthesis.
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Risk Factors for Developing Staphylococcus aureus Nasal Colonization in Spine and Arthroplasty Surgery
Staphylococcus aureus nasal colonization is a risk factor for surgical site infection. We conducted a retrospective case-control study of 1,708 consecutively enrolled patients to identify criteria that places orthopaedic surgery patients undergoing spine and total joint arthroplasty surgery at risk for nasal colonization by MRSA and MSSA. Multivariate analysis showed obesity and asthma as significant risk fac - tors for MRSA colonization. The identification of these two risk factors for MRSA colonization may help decolonization programs target patients with these factors for treatment prior to surgery, which could potentially lead to reductions in the rates of surgical site infections.
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The Effect of Platelet-rich Fibrin Matrix on Rotator Cuff Healing in a Rat Model
The purpose of the current study was to determine if the application of platelet-rich fibrin matrix could improve regeneration of the tendon-bone insertion site in a rat rotator cuff repair model. 25 Lewis syngeneic rats underwent bilateral tenotomy and repair of the supraspinatus tendon. 10 separate rats were used for PRFM harvest. All left (control) shoulders underwent transosseous rotator cuff repair, while all right (treatment) shoulders were repaired similarly with PRFM augmentation. 9 rats were sacrificed at 2-weeks and ten at 4-weeks for biomechanical testing. 3 separate rats were sacrificed at 2-weeks and 4-weeks each for histologic analysis of the insertion site.
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Selective versus nonselective thoracic fusion in Lenke 1C curves: A meta-analysis of baseline characteristics and postoperative outcomes
Object: Lenke 1C curves are challenging to manage surgically due to the structural thoracic deformity and nonstructural lumbar curve. Selective thoracic fusion (STF) is considered the standard of care because it preserves motion of the lumbar segment, yet nonselective STF (NSTF) remains prevalent. This study aims to identify baseline patient characteristics that drive treatment and to compare postoperative outcomes for both procedures. Methods: Studies that compared baseline and postoperative demographic data, health-related quality of life (HRQL) questionnaires, and radiographic parameters of patients with Lenke 1C curves undergoing STF or NSTF were identified for meta-analysis. The effect measure is expressed as a mean difference (MD) with 95% CI.
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Distal femoral varus osteotomy for unloading valgus knee malalignment: a biomechanical analysis
To investigate the biomechanical properties of the load shifting following opening-wedge distal femoral varus osteotomies (DFVOs) and determine the osteotomy correction needed to unload the lateral compartment. Five human cadaveric knees were tested with a load of 500 N of axial compression. Medial and lateral tibiofemoral compartment contact area and pressure were assessed utilizing a modified F-scan pressure-sensitive sensor. The knees were tested in their baseline anatomic alignment, 10° valgus malalignment and following corrective DFVOs of 5°, 10° and 15°. The load shifting effect of the various DFVO correction angles was analysed using a one-way ANOVA to determine the correction angle necessary to unload the lateral compartment.
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The Effect of Shoulder Immobilization on Driving Performance (SS-21)
Background The purpose of this study was to evaluate the effect of sling immobilization on driving performance with use of a driving simulator. Methods This is a prospective trial with a cohort of 21 healthy volunteers comparing their driving ability with and without sling immobilization on their dominant (driving) extremity. Multiple variables, including number of collisions, off-road excursions, and centerline crossings, were measured with a validated driving simulator. Trials were separated by 2 weeks to control for “adaptations” to the simulator. Statistical significance was found in collisions between sling and no-sling tests.
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Driving Performance after Shoulder Arthroplasty
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Ilizarov external fixator for length salvage in infected amputated nonunions
The technique of compression distraction induced osteogen- esis via the Ilizarov external fixator system has been used for a variety of traumatic limb pathologies that necessitate boney union and limb preservation. In this case report, we describe an uncommon scenario were an Ilizarov external fixator was used to treat an infected nonunion following a below knee amputation.
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Perioperative Changes in Driving Performance Following Arthroscopic Rotator Cuff Repair or Glenoid Labrum Repair
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A biomechanical comparison between locked 3.5-mm plates and 4.5-mm plates for the treatment of simple bicondylar tibial plateau fractures: Is bigger necessarily better?
Evolution of periarticular implant technology has led to stiffer, more stable fixation constructs. However, as plate options increase, comparisons between different sized constructs have not been performed. The purpose of this study is to biomechanically assess any significant differences between 3.5- and 4.5-mm locked tibial plateau plates in a simple bicondylar fracture model. A total of 24 synthetic composite bone models (12 Schatzker V and 12 Schatzker VI) specimens were tested. In each group, six specimens were fixed with a 3.5-mm locked proximal tibia plate and six specimens were fixed with a 4.5-mm locking plate.
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Ilizarov External Fixator for Stump Salvage in Infected Nonunions
Infected nonunions are potentially difficult complications to treat in the context of complex tibial fractures. Often, such complications necessitate amputation to prevent further sequelae, such as fulminant sepsis and complete loss of the limb. As such, the eradication of infection, the decision regarding when to amputate, and the length of the residual stump are important factors to optimize patient outcome. The authors present a unique scenario whereby an Ilizarov external fixation device was used to treat an infected tibial nonunion while simultaneously salvaging stump length to enable fitting for a below-knee prostheses.
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Diagnostic Accuracy of MRI in the Measurement of Glenoid Bone Loss
The purpose of this study is to assess the accuracy of MRI quantification of glenoid bone loss and to compare the diagnostic accuracy of MRI to CT in the measurement of glenoid bone loss. MRI, CT, and 3D CT examinations of 18 cadaveric glenoids were obtained after the creation of defects along the anterior and anteroinferior glenoid. The defects were measured by three readers separately and blindly using the circle method. These measurements were compared with measurements made on digital photographic images of the cadaveric glenoids. Paired sample Student t tests were used to compare the imaging modalities.
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The Effect of Platelet-Rich Fibrin Matrix on Rotator Cuff Healing in a Rat Model (SS-62)
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Flexible Reamers in Anatomic ACL Reconstruction: Effect of Knee Flexion on Femoral Tunnel Length and Latrogenic Peroneal Nerve Injury (SS-67)
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Comparison of ultrasound-guided versus blind glenohumeral injections: A cadaveric study
Background: Intra-articular glenohumeral (GH) injections are important for diagnostic and therapeutic purposes. It has been suggested that ultrasound guided injections are more accurate than blind or freehand injections. This study assessed the accuracy of ultrasound-guided GH injections compared with freehand injections in fresh cadavers. Methods: The study used 80 shoulder specimens from fresh cadavers. Ultrasound guidance was used to inject radiopaque contrast in 40 shoulders, and freehand technique was used in the remaining 40. All injections were performed by 2 surgeons (A and B) through a posterior approach. After the injections, radiographs were obtained of the specimens to assess the accuracy of the injections.
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Glenoid Bone Loss: Correlation of MR Imaging and CT 3D Using a Cadaveric Study Model
PURPOSE The purpose of this study is to evaluate the correlation of MR and CT3D measurements of glenoid bone loss. METHOD AND MATERIALS 18 cadaveric shoulders from skeletally mature individuals underwent soft tissue removal producing a bare glenoid. Specimens with pre-existent anterior glenoid loss were excluded. A bone saw was used to create a defect along the anterior/anteroinferior margin of the glenoid at a predetermined distance from the glenoid bare spot. Post-osteotomy sagittal digital images were then taken of the glenoid. CT3D reconstruction and 3TMR images of the glenoids were then obtained. 2 readers in a blinded fashion using Philips iSite analyzed the data from the MR and CT3D studies independently.
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Complications Using Bioabsorbable Cross-Pin Femoral Fixation: A Case Report and Review of the Literature
The use of bioabsorbable cross-pin transcondylar fixation has remained a viable option for femoral fixation in anterior cruciate ligament reconstruction. Although numerous biomechanical studies have demonstrated high fixation strength and minimal slippage with use of this method of fixation, there have been increasing reports of a variety of clinical complications associated with these implants. We reviewed the literature for all complications associated with the Bio-TransFix implant and present a case report of a patient status after ACL reconstruction using Bio-TransFix cross-pin femoral fixation with iliotibial band friction syndrome from a broken cross-pin four month post-operatively.
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Rupture of the Distal Biceps Tendon Combined with a Supinator Muscle Tear in a 51-Year-Old Woman: A Case Report
Distal biceps tendon rupture is a relatively uncommon occurrence in the general female population, and to our knowledge, has not been reported in association with a supinator muscle tear. We report a case of 51-year-old woman who experienced sharp pain in her forearm and elbow after lifting a heavy object. History and physical examination raised suspicion for a distal biceps tendon rupture. MRI imaging determined a combined distal biceps tendon tear with a supinator muscle tear with subsequent confirmation at surgery. Surgical repair was performed for the distal biceps tendon only through a single incision approach using the Endobutton technique.