Anterior Spine Surgery Research Articles

Proteome analysis of cartilage endplate in adolescent idiopathic scoliosis.

Objective To identify protein expression in asymmetrically developed intervertebral discs of adolescent idiopathic scoliosis (AIS) patients and try to find out factors that may originate or strengthen the deformity situation. Methods The apex intervertebral discs were harvested from 6 AIS patients during anterior spinal correction surgery procedure. Proteins in cartilage endplate were extracted and we used shotgun strategy to achieve proteomics investigation, the proteins were classified and their functions were investigated. Results Average protein consistency is 3.02 mg/ml, which was tested through Bradford procedure. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) shows that both species and consistency of the proteins from convex side were higher than that from the concave side. More than 100 proteins were identified from the convex sample, and over 60 proteins were identified from concave side, 58 proteins were found to only express in convex side and 10 in concave side. Conclusion Based on the physiological role, the identified proteins in cartilage endplate from AIS patients were classified preliminarily. Some proteins identified only in convex or concave side were strongly believed to play important roles in contribution to asymmetrically developed apex cartilage endplate and related intervertebral discs.

Pharyngocutaneous fistula after anterior cervical spine surgery

Pharyngocutaneous fistulae are rare complications of anterior spine surgery occurring in less than 0.1% of all anterior surgery cases. We report a case of a 19 year old female who sustained a C6 burst fracture with complete quadriplegia. She was treated urgently with a C6 corpectomy with anterior cage and plating followed by posterior cervical stabilization at another institution. Post operatively she developed a pharyngocutaneous fistula that failed to heal despite several attempts of closure and esophageal exclusion with a Jpeg tube. The patient was eventually successfully treated with a three-stage procedure consisting of firstly a posterior approach to reinforce the posterior stabilization of the cervical spine that was felt to be inadequate, secondly an anterior approach with removal of all the anterior instrumentation followed by iliac crest bone graft and thirdly a superior based sternocleidomastoid flap that was interposed between the esophagus and the anterior cervical spine. The patient's fistula healed successfully. However, yet asymptomatic, the anterior iliac crest bone graft resorbed almost completely at 16 months follow up. In light of this complication, we discuss the surgical options for the treatment of pharyngocutaneous fistulae and the closure of this fistula using a superiorly based sternocleidomastoid muscle flap.

Vascular Complications From Anterior Spine Surgery in Three Patients With Ehlers-Danlos Syndrome

A case report of vascular complications arising from anterior spine surgery in 3 patients with Ehlers-Danlos syndrome (EDS). The aim of the article is to describe complications of anterior spine surgery in 3 patients with EDS. Scoliosis can be a skeletal manifestation of EDS. Anterior approaches to the spine are sometimes used during scoliosis surgery to gain more correction than otherwise possible. A literature search revealed no published articles focusing on major vascular bleeding during anterior spine surgery in EDS patients as the specific topic. Review of records and radiographs. Three patients with EDS and severe scoliosis underwent an anterior and posterior release followed by posterior fusion. Major bleeding was encountered during anterior surgery in all 3 patients. Sources of bleeding included a torn external iliac artery, avulsed segmental arteries, and the abdominal aorta. Blood loss ranged from 600 mL to 6 L. All vessels were repaired with sutures and synthetic grafts. In all 3 patients, posterior fusion was met with no complications and their curves were stable at follow-up. These complications may be explained by the fragility of blood vessels secondary to the collagen defect in EDS. Though methods exist to decrease these complications, they may not be enough to prevent catastrophic bleeding. For EDS patients, risk of vascular complications during anterior surgery of the spine is high and surgeons should be aware of this when developing a surgical plan.

Isolated long thoracic nerve paralysis - a rare complication of anterior spinal surgery: a case report

IntroductionIsolated long thoracic nerve injury causes paralysis of the serratus anterior muscle. Patients with serratus anterior palsy may present with periscapular pain, weakness, limitation of shoulder elevation and scapular winging.Case presentationWe present the case of a 23-year-old woman who sustained isolated long thoracic nerve palsy during anterior spinal surgery which caused external compressive force on the nerve.ConclusionDuring positioning of patients into the lateral decubitus position, the course of the long thoracic nerve must be attended to carefully and the nerve should be protected from any external pressure.

A Case of Difficult Endotracheal Intubation Due to Laryngeal and Upper Tracheal Frontal Protrusion Induced by Hard Abscess after Anterior Cervical Spinal Fusion Surgery

60歳, 男性. 頚椎椎弓形成・前方固定術後の頚部違和感のためプレート抜去術を行った際, 麻酔導入時に挿管困難をきたした. 頚椎前方にプレートと一塊になった硬い膿瘍が存在し, 気管を前方に偏移させたことが原因と思われた. 術前の頚部Ｘ線写真で気管の前後径は第6頚椎の高さで22mm, 横径20mmと太さは十分であったが気管の前方偏移が強かった. このような症例では挿管困難を念頭におき十分な準備を整えておくべきである.

Vulnerability of the Femoral Nerve During Complex Anterior and Posterior Spinal Surgery

Background: Femoral nerve palsy is not a common adverse effect of lumbar spinal surgery.Objective: To report 3 unique cases of femoral nerve neuropathy due to instrumentation and positioning during complex anterior and posterior spinal surgery.Methods: Case seriesResults: All 3 patients demonstrated femoral nerve neuropathy. The first patient presented postoperatively but after 6 months, the palsy resolved. Femoral nerve malfunctioning was documented in the second and third patients intraoperatively; however, with rapid patient repositioning and removal of offending instrumentation, postoperative palsy was avoided.Conclusions: Use of motor evoked potential monitoring of the femoral nerve during surgery is vital for the prevention of future neuropathies, an avoidable complication of spinal surgery.

Evaluation and Management of Abdominal Lymphoceles After Anterior Lumbar Spine Surgery

Case report. To examine the management of abdominal lymphoceles after anterior spine surgery and to review the existing literature on lymphoceles after access to the spine. Abdominal lymphoceles are a rare complication of anterior spinal approaches. Case report and review of the literature. In this article, we describe the management of 2 lymphoceles. In the first case, immediate operative drainage was required because of worsening abdominal pain and distention. In the second patient, conservative management was attempted, but the lymphocele ultimately persisted and required surgical intervention. Lymphoceles are often difficult to distinguish from ureteral injury, cerebrospinal fluid-leaks and hematomas using conventional imaging techniques. Although surgery remains the gold standard for the treatment of lymphoceles, expectant observation may be reasonable in some situations.

191. Video-assisted Thoracoscopic Surgery for Spinal Deformity Morbidity Indications and Results

BACKGROUND CONTEXT: Video-assisted thoracoscopic surgery (VATS), a technique developed to reduce the morbidities of open anterior spinal surgery is technically demanding with potential procedure-related complications.

Multislice Helical CT in the Diagnosis of Pharyngovertebral Fistula Due to Loosening of Anterior Screw-Plate Construct

Late dysphagia is a rare condition that results from hardware failure in anterior spine surgery patients. Dysphagia should be evaluated to find out the possible underlying causes. A barium swallow study and multislice helical computed tomography (CT) scan were used to evaluate a patient suffering from dysphagia 8 months after an anterior cervical fusion of C4-C7 vertebrae. A videofluoroscopic swallow study with a low-viscosity, high-density barium solution and different table tilt levels for obtaining slow passage of the barium meal revealed the existence of an esophagovertebral fistula with 2 ostia: one at the contact side of the screw and the other at a lower level with a pouch around the plate. A multislice helical CT scan provided volumetric data and multiplanar reconstruction that enabled us to delineate the extent of the abscess along the plate through the paravertebral space. It also showed the fistula location and relation of the fistula to the displaced screw, as well as the thickened retroesophageal soft tissue. Anterior spinal surgery patients should be followed carefully for progressive dysphagia. Videofluoroscopic swallow studies and multislice helical CT scans are efficient and complementary tools in the evaluation of late dysphagia.

Pregnancy after anterior spinal surgery: fertility, cesarean-section rate, and the use of neuraxial anesthesia

Background context Previous publications have reported results with respect to functional outcome and sexual function in young women after traumatic injuries to the pelvis. It is well known that anterior spinal surgery has the possibility of causing reproductive dysfunction in men. Little has been described concerning deleterious effects of anterior spinal surgery in women of childbearing age. Purpose The purpose of the study was to determine the fertility, cesarean section rate, and the use of neuraxial anesthesia in a population of women of childbearing age who have undergone anterior spinal surgery. Study design/setting This was a retrospective chart review combined with a telephone questionnaire of the patients who had undergone anterior spinal surgery by a single orthopedic surgeon. Methods Demographic data were collected from hospital and office records. Patients were asked if they had tried to become pregnant, if their pregnancy had come to term, the use of spinal or epidural anesthesia for that labor and delivery, and the type of delivery. Results Seventy-nine potential subjects were identified and 67 patients were contacted to determine their fertility status. Ninteen patients had tried to become pregnant after their anterior spinal surgery. All patients who reported that they tried to become pregnant were successful at having a child. Seven of the 19 women had children who were born by cesarean section (37%). Only two patients received an epidural as analgesia for their delivery. Conclusions Although the cesarean-section rate appears high, it is consistent with the current obstetrical trends. Anesthesiologists appear less inclined to offer neuraxial anesthesia to a population which has undergone anterior spinal surgery.

Is return to professional rugby union likely after anterior cervical spinal surgery?

We have examined the outcome in 19 professional rugby union players who underwent anterior cervical discectomy and fusion between 1998 and 2003. Through a retrospective review of the medical records and telephone interviews of all 19 players, we have attempted to determine the likelihood of improvement, return to professional sport and the long-term consequences. We have also attempted to relate the probability of symptoms in the neck and radicular pain in the arm to the position of play. Neck and radicular pain were improved in 17 patients, with 13 returning to rugby, the majority by six months after operation. Of these, 13 returned to their pre-operative standard of play, one to a lower level and five have not played rugby again. Two of those who returned to the game have subsequently suffered further symptoms in the neck, one of whom was obliged to retire. The majority of the players with problems in the neck were front row forwards. A return to playing rugby union after surgery and fusion of the anterior cervical spine is both likely and safe and need not end a career in the game.

Perioperative Outcomes and Complications Related to Teaching Residents and Fellows in Scoliosis Surgery

Single-surgeon retrospective case series of 303 consecutive operative patients with idiopathic scoliosis (IS). The purpose of this study is to evaluate the perioperative outcomes in patients undergoing surgery for IS as a function of the experience level of the surgical assistant. The experience level of the surgical assistant, who is often a resident or fellow, has never before been evaluated as an independent factor in predicting perioperative outcomes and morbidity in scoliosis surgery. We hypothesize that there is no difference in perioperative outcomes with varying experience level of the surgical assistant. We evaluated the clinical, radiographic, and operative records from 303 consecutive operative patients from consecutive patients with IS. Group I was comprised of residents or spine fellows as assistants (teaching service, n = 175), and Group II consisted of junior or senior attendings as assistants (private practice service, n = 128). Multivariable linear regression was used to evaluate the relationship between experience level of the assistant and curve correction, operative time, estimated blood loss (EBL), complications, transfusions, and length of stay. In the posterior spinal fusion group (PSF, n = 164), there were no statistically significant differences in operative times between Groups I and II. Group I operative time was significantly increased, however, in patients undergoing anterior spinal surgery (ASF, P = 0.01), video-assisted thoracoscopic surgery (P = 0.0004), and combined anterior/posterior surgeries (ASF/PSF, P = 0.0063). There were no differences in EBL in ASF, video-assisted thoracoscopic surgery, or PSF surgeries, however, Group I had significantly higher EBL in the ASF/PSF group (P = 0.0016). No group differences were detected with respect to curve correction, transfusion rates, length of stay, or early complication rates. The experience level of surgical assistant had little bearing on perioperative morbidity or radiographic outcomes in scoliosis surgery. Marginally increased operative times and EBL, without an increase in transfusions or complications, is an acceptably safe tradeoff for educating orthopedic residents and fellows.

Segmental vessel ligation in patients undergoing surgery for anterior spinal deformity

Segmental vessel ligation during anterior spinal surgery has been associated with paraplegia. However, the incidence and risk factors for this devastating complication are debated. We reviewed 346 consecutive paediatric and adolescent patients ranging in age from three to 18 years who underwent surgery for anterior spinal deformity through a thoracic or thoracoabdominal approach, during which 2651 segmental vessels were ligated. There were 173 patients with idiopathic scoliosis, 80 with congenital scoliosis or kyphosis, 43 with neuromuscular and 31 with syndromic scoliosis, 12 with a scoliosis associated with intraspinal abnormalities, and seven with a kyphosis. There was only one neurological complication, which occurred in a patient with a 127 degrees congenital thoracic scoliosis due to a unilateral unsegmented bar with contralateral hemivertebrae at the same level associated with a thoracic diastematomyelia and tethered cord. This patient was operated upon early in the series, when intra-operative spinal cord monitoring was not available. Intra-operative spinal cord monitoring with the use of somatosensory evoked potentials alone or with motor evoked potentials was performed in 331 patients. This showed no evidence of signal change after ligation of the segmental vessels. In our experience, unilateral segmental vessel ligation carries no risk of neurological damage to the spinal cord unless performed in patients with complex congenital spinal deformities occurring primarily in the thoracic spine and associated with intraspinal anomalies at the same level, where the vascular supply to the cord may be abnormal.

Mini-open anterior spine surgery for anterior lumbar diseases

Minimally invasive surgeries including endoscopic surgery and mini-open surgery are current trend of spine surgery, and its main advantages are shorter recovery time and cosmetic benefits, etc. However, mini-open surgery is easier and less technique demanding than endoscopic surgery. Besides, anterior spinal fusion is better than posterior spinal fusion while considering the physiological loading, back muscle function, etc. Therefore, we aimed to introduce the modified “mini-open anterior spine surgery” (MOASS) and to evaluate the feasibility, effectiveness and safety in the treatment of various anterior lumbar diseases with this technique. A total of 61 consecutive patients (46 female, 15 male; mean age 58.2 years) from 1997 to 2004 were included in this study, with an average follow-up of 24–52 (mean 43) months. The disease entities included vertebral fracture (20), failed back surgery (13), segmental instability or spondylolisthesis (10), infection (8), herniated disc (5), undetermined lesion for biopsy (4), and hemivertebra (1). Lesions involved 13 cases at T12–L1, 18 at L1–L2, 18 at L2–L3, 22 at L3–L4 and 11 at L4–L5 levels. All patients received a single stage anterior-only procedure for their anterior lumbar disease. We used the subjective clinical results, Oswestry disability index, fusion rate, and complications to evaluate our clinical outcome. Most patients (91.8%) were subjectively satisfied with the surgery and had good-to-excellent outcomes. Mean operation time was 85 (62–124) minutes, and mean blood loss was 136 (minimal-250) ml in the past 6 years. Hospital stay ranged from 4–26 (mean 10.6) days. Nearly all cases had improved back pain (87%), physical function (90%) and life quality (85%). Most cases (95%) achieved solid or probable solid bony fusion. There were no major complications. Therefore, MOASS is feasible, effective and safe for patients with various anterior lumbar diseases.

Anaesthetic Management of a Child with Freeman-Sheldon Syndrome Undergoing Spinal Surgery

Freeman-Sheldon syndrome, or distal arthrogryposis type 2A, is a rare congenital myopathy and dysplasia characterised by multiple contractures, abnormalities of the head and face, defective development of the hands and feet and skeletal malformations. The facial muscle contracture produces the typical 'whistling face' appearance. Anaesthetic issues include difficult intravenous access, difficult airway and postoperative pulmonary complications. Although an association with malignant hyperthermia has been suggested, this has not been confirmed. We report the management of a seven-year-old girl with Freeman-Sheldon syndrome undergoing anterior and posterior spinal surgery and describe a successful anaesthetic regimen based on a total intravenous anaesthesia technique with remifentanil and propofol without neuromuscular blocking agents. The child had an uneventful anaesthetic and postoperative course. We believe the presence of the myopathy warranted the use of a 'non-triggering' anaesthetic, as suxamethonium and volatile agents may be associated with significant complications such as muscle rigidity and rhabdomyolysis in myopathic patients, even in the absence of malignant hyperthermia.

Pulmonary Embolism After Adult Spinal Deformity Surgery

Retrospective review. To determine the incidence and identify the associated risk factors of pulmonary embolism (PE) in patients who receive pharmacologic thromboprophylaxis after adult spinal deformity surgery. The risk of PE after adult spinal deformity surgery is reported to be as high as 2.2%. However, the incidence and associated risks of PE in the same patient population who receive postoperative pharmacologic thromboprophylaxis is unknown. The study included 361 adult patients with spinal deformity who underwent 407 corrective spinal procedures for scoliosis, kyphosis, or kyphoscoliosis. The incidence of PE was determined and compared with a study (historical control) of similar patients undergoing similar surgery but without postoperative pharmacologic thromboprophylaxis. Their demographic information, American Society of Anesthesiologists score, operative time, surgical approach, surgical complexity, and intraoperative blood loss were also analyzed to determine the presence of associated risk factors. Despite universal pharmacologic thromboprophylaxis, 10 pulmonary emboli (2.4%) were diagnosed. Patients undergoing anterior spinal surgery were at a significantly higher risk than those undergoing posterior spinal surgery (P = 0.024). The right-side anterior approach was also associated with a significantly higher incidence of PE compared with the left-sided anterior approach (P = 0.018). Although the rate of PE after posterior spinal surgery did not differ from the historical control, the rate of PE after anterior surgery was reduced by 50% compared with the historical control. Age, gender, estimated blood loss, operative time, revision status, and the number of fusion levels were not significant variables for PE. There were 2 epidural hematomas requiring decompression (0.48%) and 1 wound hematoma (0.24%). Although pharmacologic thromboprophylaxis probably does not have a role after posterior spinal surgery, the data in this study suggest that it does lower the incidence of PE after anterior spinal surgery.

Major Vascular Injury During Anterior Lumbar Spinal Surgery

Retrospective chart review. To examine the incidence of major vascular injury during anterior lumbar spinal surgery, attempt to identify predisposing risk factors, and to discuss management techniques. Major vascular injury can be a catastrophic complication of anterior lumbar spinal surgery. Current procedural terminology codes were used to identify the occurrence of major vascular injury, defined as injury to the iliac vessels, vena cava, and aorta. Once identified, the office record, hospital chart, operative note, and diagnostic test results were reviewed in detail. Three hundred forty-five operations were performed on 338 patients. Incidence of major vascular complication was 2.9% (10 of 345). There were 9 injuries of the common iliac vein and a single aortic injury. Risk factors identified in patients with major vascular injury were current or previous osteomyelitis or discogenic infection (n = 3), previous anterior spinal surgery (n = 2), spondylolisthesis (n = 2; 1 isthmic Grade II, 1 iatrogenic Grade II), large anterior osteophyte (n = 2), transitional lumbosacral vertebra (n = 1), and anterior migration of interbody device (n = 1). Lateral venorrhaphy by suture (n = 6) and hemoclip application (n = 2) was augmented by topical agents, which constituted the sole method of repair on 1 occasion. Magnetic resonance venography demonstrated iliac vein thrombosis in 1 patient. Current or previous osteomyelitis or discogenic infection, previous anterior spinal surgery, spondylolisthesis, osteophyte formation, transitional lumbosacral vertebra and anterior migration of interbody device point to an increased risk of vascular injury during anterior lumbar spinal surgery. Careful handling of the vascular structures and liberal use of topical hemostatic agents can lead to control of hemorrhage and preservation of vascular patency. Routine postoperative surveillance for proximal deep vein thrombosis, by magnetic resonance venography of the pelvic veins and inferior vena cava, should be performed after venorrhaphy.

Non-Neurologic Complications Following Surgery for Adolescent Idiopathic Scoliosis

The reported prevalence of non-neurologic complications following corrective surgery for adolescent idiopathic scoliosis ranges from 0% to 10%. However, most studies were retrospective evaluations of treatment techniques and did not focus solely on complications. The purpose of this study was to determine the prevalence of non-neurologic complications following surgery for adolescent idiopathic scoliosis and to identify preoperative and operative factors that can increase this risk. The demographic data, medical and surgical histories, and prevalence of non-neurologic complications were reviewed in a prospective cohort of 702 patients who had undergone corrective surgery for adolescent idiopathic scoliosis and were consecutively enrolled in a multicenter database. There were 556 female and 146 male patients. The mean age at the time of surgery was 14.25 years (range, eight to eighteen years). Five hundred and twenty-three patients had only posterior spinal surgery, 105 had only anterior spinal surgery, and seventy-four had a combined anterior and posterior procedure. There was a total of 108 complications in eighty-one patients, for an overall prevalence of 15.4%. There were ten respiratory complications (1.42%), six cases of excessive bleeding (0.85%), five wound infections (0.71%), and five cases of wound hematoma, seroma, or dehiscence (0.71%). Five patients, two with an early infection and three with late failure of the implant, required a reoperation. Factors that did not correlate with an increased prevalence of complications were age, body mass index, presence of cardiac or respiratory disease, previous surgery, pulmonary function, surgical approach, number of levels fused, graft material, use of a diaphragmatic incision, Lenke curve type, or region of the major curve. Although the number of patients with renal disease was small, these patients were 7.90 times more likely to have a non-neurologic complication. Increased blood loss as well as prolonged operative and anesthesia times were associated with a higher prevalence of non-neurologic complications. The prevalence of non-neurologic postoperative complications following surgery for correction of adolescent idiopathic scoliosis in this study was 15.4%. The few factors noted to significantly increase the rate of complications include a history of renal disease, increased operative blood loss, prolonged posterior surgery time, and prolonged anesthesia time.

Chyloretroperitoneum following anterior spinal deformity correction

Chyloretroperitoneum is an uncommon complication following spinal surgery. The authors present the case of a patient in whom conservative treatment and initial surgical measures failed to relieve varied symptoms of postsurgical chyloretroperitoneum. Following attempts at conservative management, a peritoneal window was surgically created to divert lymphatic flow from the retroperitoneal space into the peritoneal space, where it was resorbed. This unique surgical technique provides yet another option in the treatment of refractory chyloretroperitoneum following anterior lumbar spinal surgery. The authors describe their technique and review retroperitoneal lymphatic anatomy along with similar case reports in the literature.

Chyloretroperitoneum following anterior spinal deformity correction

✓ Chyloretroperitoneum is an uncommon complication following spinal surgery. The authors present the case of a patient in whom conservative treatment and initial surgical measures failed to relieve varied symptoms of postsurgical chyloretroperitoneum. Following attempts at conservative management, a peritoneal window was surgically created to divert lymphatic flow from the retroperitoneal space into the peritoneal space, where it was resorbed. This unique surgical technique provides yet another option in the treatment of refractory chyloretroperitoneum following anterior lumbar spinal surgery. The authors describe their technique and review retroperitoneal lymphatic anatomy along with similar case reports in the literature.