Multilevel Posterior Fusion Research Articles

450 Inflammatory Brachial Plexitis Mimics Postoperative Iatrogenic Neurological Deficits

INTRODUCTION: A common cause of neurosurgical malpractice cases is the misrepresentation of idiopathic brachial neuritis (incidence: 1/1000) as an iatrogenic neurological insult caused by a surgeon. METHODS: Confirmed postprocedural brachial neuritis patients from a single quaternary care institution were identified and analyzed. RESULTS: We identified 6 (3 female) postprocedural brachial neuritis patients with mean age 63.7 (range 50-75) years. Procedures included 5 cervical spine surgeries (3 multilevel ACDFs, 2 multilevel posterior fusions with laminectomies, 1 multilevel disc arthroplasty) and 1 intrajugular central venous catheter placement. Average time to symptom onset was 1 week post-procedure (range 1 day-2.5 weeks). Initial symptom was moderate-to-severe shoulder (5), arm (4), and/or neck (1) pain. Subsequently, all developed axillary/shoulder weakness; 3 distal arm/hand weakness, 2 winged scapula, and 2 dyspnea/orthopnea. For diagnosis, two patients had confirmatory EMG, 1 had MR neurography confirming plexus inflammation, and 3 had both (positive EMG findings and inflammation on MR Neurography). Average time to accurate diagnosis was 3.1 (range 1.5-5) months. Average number of clinicians seen prior to accurate diagnosis: 5. Treatments included opioids (5), steroids (1), and/or physical therapy (6). All experienced partial pain relief by 1-8 weeks; 2 had persistent pain requiring gabapentin past 6 months. All patients continued to experience motor deficits past 6 months: (4 patients had atrophy and 2-4/5 motor strength in proximal the proximal arm, 1 had distal arm 3/5 motor strength, and 1 had scapular winging). CONCLUSIONS: Postoperative idiopathic brachial plexitis mimics iatrogenic nerve damage following neurosurgical procedures. Recognition of this entity is difficult, and 6 patients at our institution saw on average 5 providers over 3 months prior to accurate diagnosis. Brachial plexitis has a prolonged course with typically only partial recovery at 6 months.

Bridging the Cervicothoracic Junction During Multi-Level Posterior Cervical Decompression and Fusion: A Systematic Review and Meta-Analysis.

Systematic review and Meta-analysis. This systematic review seeks to compare fusion, reoperation and complication rates, estimated blood loss (EBL), and surgical time between multi-level instrumented fusions with LIVs (lowest instrumented vertebra) in the cervical spine and those that extend into the thoracic spine. Several studies address the question of whether to extend a long-segment, posterior cervical fusions, performed for degenerative disease, into the upper thoracic spine. Recommendations for appropriate LIV continue to vary. A comprehensive computerized literature search through multiple electronic databases without date limits up until April 3rd, 2020 using combinations of key search terms and sets of inclusion/exclusion criteria was performed. Our comprehensive literature search yielded 3852 studies. Of these, 8 articles consisting of 1162 patients were included in the meta-analysis. In 61.2% of the patients, the fusion did not cross the cervicothoracic junction (CTJ) (cervical LIV, CLV). In the remaining 38.8%, the fusion extended into the upper thoracic spine (thoracic LIV, TLV). Overall, mean patient age was 62.5years (range: 58.8-66.1years). Our direct analysis showed that odds of fusion were not statistically different between the CLV and TLV groups (OR: .648, 95% CI: .336-1.252, P = .197). Similarly, odds of reoperation (OR: 0.726, 95% CI: 0.493-1.068, P = .104) and complication rates were similar between the 2 groups (OR: 1.214, 95% CI: 0.0.750-1.965, P = .430). Standardized mean difference (SMD) for the blood loss (SMD: .728, 95% CI: 0.554-.901, P = .000) and operative (SMD: 0.653, 95% CI: .479-.826, P = .000) differed significantly between the 2 groups. The indirect analysis showed similar fusion (Effect Size (ES)TLV: .892, 95% CI: .840-.928 vs ESCLV:0.894, 95% CI:0.849-.926); reoperation rate (ESTLV:0.112, 95% CI: 0.075-.164 vs ESCLV: .125, 95% CI: .071-.211) and complication rates (ESTLV: .108, 95% CI: .074-.154 vs ESCLV:0.081, 95% CI: .040-.156). Our meta-analysis showed that fusion, complication, and reoperation rates did not differ significantly between patients in whom multi-level posterior fusions ended in the cervical spine vs those of which was extended into the thoracic spine. The mean blood loss, operative time and length of stay were significantly lower in patients with CLV at C6 or C7, compared to their counterparts. These data suggest that, absent focal, C7-T1 pathology, extension of long, posterior cervical fusions into the thoracic spine may not be necessary.

Rates of early complications and mortality in patients older than 80 years of age after surgical treatment of acute traumatic spinal fractures: ankylosing spondylitis versus osteoporosis.

The purpose of this retrospective cohort study was to analyze the early complications and mortality associated with multilevel spine surgery for unstable fractures in patients older than 80 years of age with ankylosing spondylitis and to compare the results with an age- and sex-matched cohort of patients with unstable osteoporotic fractures. A retrospective review of the electronic medical records at a single institution was conducted between January 2014 and December 2019. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were stratified using the age-adjusted Charlson Comorbidity Index (CCI). Among 11,361 surgically treated patients, 22 patients with ankylosing spondylitis (AS group) and 24 patients with osteoporosis (OS group) were identified. The mean ages were 83.1 ± 3.1 years and 83.2 ± 2.6 years, respectively. A significant difference in the mean CCI score was found (7.6 vs 5.6; p < 0.001). Multilevel posterior fusion procedures were conducted in all patients, with 6.7 ± 1.4 fused levels in the AS group and 7.1 ± 1.1 levels fused in the OS group (p > 0.05). Major complications developed in 10 patients (45%) in the AS group compared with 4 patients (17%) in the OS group (p < 0.05). The 90-day mortality was 36% in the AS group compared with 0% in the OS group (p < 0.001). Patients older than 80 years of age with AS bear a high risk of adverse events after multilevel spinal fusion procedures. The high morbidity and 90-day mortality should be clearly discussed and carefully weighed against surgical treatment.

Incidence of Chronic Periscapular Pain After Adult Thoracolumbar Deformity Correction and Impact on Outcomes.

ObjectiveExtension of the posterior upper-most instrumented vertebra (UIV) into the upper thoracic (UT) spine allows for greater deformity correction and reduced incidence of proximal junction kyphosis (PJK) in adult spinal deformity (ASD) patients. However, it may be associated with chronic postoperative scapular pain (POSP). The goal of this study was to assess the relationship between UT UIV and persistent POSP, describe the pain, and assess its impact on patient disability. MethodsASD patients who underwent multilevel posterior fusion were retrospectively identified then administered a survey regarding scapular pain and the Oswestry Disability Index (ODI), by telephone. Univariate and multivariate analysis were utilized. ResultsA total of 74 ASD patients were included in the study: 37 patients with chronic POSP and 37 without scapular pain. The mean age was 70.5 years, and 63.9% were women. There were no significant differences in clinical characteristics, including mechanical complications (PJK, pseudarthrosis, and rod fracture) or reoperation between groups. Patients with persistent POSP were more likely to have a UT than a lower thoracic UIV (p=0.018). UT UIV was independently associated with chronic POSP on multivariate analysis (p=0.022). ODI score was significantly higher in patients with scapular pain (p=0.001). Chronic POSP (p=0.001) and prior spine surgery (p=0.037) were independently associated with ODI on multivariate analysis. ConclusionA UT UIV is independently associated with increased odds of chronic POSP, and this pain is associated with significant increases in patient disability. It is a significant clinical problem despite solid radiographic fusion and the absence of PJK.

P109. Bridging the cervicothoracic junction during multi-level posterior cervical decompression and fusion -A systematic review and meta-analysis

<h3>BACKGROUND CONTEXT</h3> Several studies address the question of whether to extend a long-segment, posterior cervical fusions into the upper thoracic spine. Recommendations for appropriate caudal "end level" continue to vary. <h3>PURPOSE</h3> This systematic review seeks to compare fusion, reoperation and complication rates, estimated blood loss (EBL) and surgical time between multilevel instrumented fusions ending in the cervical spine and those that extend into the thoracic spine. <h3>STUDY DESIGN/SETTING</h3> Systematic review and Meta-analysis. <h3>OUTCOME MEASURES</h3> Fusion, reoperation and complication rates, EBL and surgical time. <h3>METHODS</h3> A comprehensive computerized literature search through multiple electronic databases without date limits up until April Week 3 2020 using combinations of key search terms and inclusion/exclusion criteria was performed. <h3>RESULTS</h3> Our comprehensive literature search yielded 3,852 studies. Of these, 8 articles consisting of 1,162 patients were included in the meta-analysis. In 61.2% of the patients the fusion did not cross the CTJ (the cervical end level CEL). In the remaining 38.8%, fusion extended into the upper thoracic spine (thoracic end level, TEL). Mean age of CEL group ranged from 57 to 67.8 years, and for TEL group, it was 55 to 65.3 years. Our direct analysis showed that odds of fusion were not statistically different between CEL and TEL groups (OR: 0.648, 95% CI: 0.336-1.252, p=0.197). Similarly, odds of reoperation (OR:0.726, 95% CI:0.493-1.068, p=0.104) and complication rates were similar between the two groups (OR:1.299, 95% CI:0.536-3.149, p=0.563). Standardized mean difference (SMD) for the blood loss (SMD: 0.728, 95% CI:0.554-0.901, p=0.000) and operative (SMD:0.653, 95% CI: 0.479-0.826, p=0.000) differed significantly between the two groups. The indirect analysis showed similar fusion (Effect Size (ES)crossing: 0.892, 95% CI: 0.840-0.928 vs ES not crossing:0.894, 95% CI:0.849-0.926); reoperation rate (EScrossing:0.112, 95% CI:0.075-0.164 vs ES not crossing: 0.125, 95% CI: 0.071-0.211) and complication rates (EScrossing: 0.108, 95% CI: 0.074-0.154 vs ES not crossing:0.081, 95% CI: 0.040-0.156). <h3>CONCLUSIONS</h3> Our meta-analysis showed that fusion, complication and reoperation rates did not differ significantly between patients in whom multi-level posterior fusions ended in the cervical spine versus those of which was extended into the thoracic spine. The mean blood loss, operative time and length of stay were significantly lower in patients with caudal level as C7 or below, compared to their counterparts. These data suggest that, absent focal C7-T1 pathology, extension of long posterior cervical fusions into the thoracic spine may not be necessary. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P100. Upper instrumented vertebral pelvic angle and risk of proximal junctional kyphosis at 2- year follow-up

BACKGROUND CONTEXT There remains a need for practical radiographic parameters to help predict risk of proximal junctional kyphosis (PJK) in adult patients undergoing multilevel posterior fusion. The upper instrumented vertebral pelvic angle (UIVPA) is a novel measure of sagittal alignment that is easy to measure and can account for both spinal inclination and pelvic retroversion. We hypothesize that the further the UIV is from the center of gravity, the higher the risk of PJK. PURPOSE The purpose of this study is to evaluate the association between UIVPA and risk of PJK in adult patients undergoing 6-level fusion. STUDY DESIGN/SETTING Retrospective cohort study at single academic institution. PATIENT SAMPLE Adult patients with minimum two-year follow-up who underwent ≥6 level posterior spinal fusion. OUTCOME MEASURES PJK, proximal junctional failure (PJF). METHODS In this retrospective cohort study, adult patients with two-year follow-up and ≥6 levels of posterior fusion for spinal deformity were included. The UIVPA was measured between a line from the UIV centroid to the center of the femoral head to a line from the center of the sacrum to the center of the femoral head. PJK was defined as a >10° kyphotic angle between the UIV and the vertebra 2 levels above. Proximal junctional failure (PJF) was defined as PJK that required surgery. Patients who developed PJK and those who did not were compared with respect to UIVPA, T1 pelvic angle (T1PA), pelvic tilt, sagittal vertical axis and central sacral vertical line. RESULTS There were 291 patients with an average 3.0 years follow-up enrolled in the study. Fifty (17%) patients were diagnosed with PJK and 29 (10%) qualified for PJF. The average UIVPA for all patients was 19.5° preop. Patients with PJK had significantly higher preoperative UIVPA than those without PJK or PJF (25.6 vs 16.2 p CONCLUSIONS UIV pelvic angle correlates well with established measures of sagittal spinopelvic alignment, such as T1PA, SVA and pelvic tilt. Patients with PJK and PJF at least two years from surgery were more likely to have a significantly higher preoperative UIVPA than their counterparts. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Congenital cervicothoracic spondyloptosis in a 7-month-old patient

A 7-month-old patient presented with cervicothoracic bulge recognized by the parents. Cervicothoracic computed tomography and magnetic resonance imaging were performed to demonstrate the pathology. Distinct anterior displacement and inferior slippage of cervical vertebral block over subjacent thoracic vertebrae, impaction of the thoracic vertebral block into the enlarged cervical spinal canal, and multilevel posterior fusion defects throughout the cervical vertebrae were seen in his CT images (Fig. 1). Spinal cord was angulated and thickened at the level of impaction by the thoracic vertebral block, and there were irregularity and increased focal nodular signal intensity in the anterior part of the distal

Biomechanical Analysis of the Proximal Adjacent Segment after Multilevel Instrumentation of the Thoracic Spine: Do Hooks Ease the Transition?

Study Design Biomechanical cadaveric study. Objective Clinical studies indicate that using less-rigid fixation techniques in place of the standard all-pedicle screw construct when correcting for scoliosis may reduce the incidence of proximal junctional kyphosis and improve patient outcomes. The purpose of this study is to investigate whether there is a biomechanical advantage to using supralaminar hooks in place of pedicle screws at the upper-instrumented vertebrae in a multilevel thoracic construct. Methods T7–T12 spines were biomechanically tested: (1) intact; (2) following a two-level pedicles screw fusion from T9 to T11; and after proximal extension of the fusion to T8–T9 with (3) bilateral supra-laminar hooks, (4) a unilateral hook + unilateral screw hybrid, or (5) bilateral pedicle screws. Specimens were nondestructively loaded while three-dimensional kinematics and intradiscal pressure at the supra-adjacent level were recorded. Results Supra-adjacent hypermobility was reduced when bilateral hooks were used in place of pedicle screws at the upper-instrumented level, with statistically significant differences in lateral bending and torsion (p < 0.05 and p < 0.001, respectively). Disk pressures in the supra-adjacent segment were not statistically different among top-off techniques. Conclusions The use of supralaminar hooks at the top of a multilevel posterior fusion construct reduces the stress at the proximal uninstrumented motion segment. Although further data is needed to provide a definitive link to the clinical occurrence of PJK, this in vitro study demonstrates the potential benefit of “easing” the transition between the stiff instrumented spine and the flexible native spine and is the first to demonstrate these results with laminar hooks.

Mid-Thoracic Spinal Injuries during Horse Racing: Report of 3 Cases and Review of Causative Factors and Prevention Measurements

We report three cases of a rare pattern of mid-thoracic spine injuries after horse racing falls and discuss possible causative factors and prevention measurements to reduce injury rates in professional riding and racing. Three patients, 2 male and 1 female with a mean age of 28 years old, underwent surgical treatment for mid-thoracic fractures after professional equestrian activities. The ASIA scale was E in one patient, B in the other one and A in the third. Multilevel posterior fusion was used in two patients and somatectomy plus fusion in the other. Follow up evaluation included changing of the ASIA scale, functional outcome and participation in equestrian activities. One patient fully recovered after surgery. Two patients remained paraplegic despite early surgical treatment and prolonged rehabilitation therapy. All patients had ended their professional equestrian career. This report analyzes possible mechanisms of injury and the pattern of mid-thoracic spine fractures after professional horse riding injuries. Despite skill improvements and continued safety education for horse riding, prophylactic measures for both the head and the spine should be refined. According to our study, additional mid-thoracic spinal protection should be added.

An argument for traditional posterior cervical fusion techniques: evidence from 35 cases

Background For patients with adequate preservation of the cervical lordotic curvature, focal laminectomy (1-3 levels), and multilevel posterior fusion offer decompression with immediate stabilization. For lateral mass/pedicle screw techniques, CT-guided cadaveric studies document a 13.4% incidence of noncritical, and 10.6% frequency of critical pedicle breaches. Without CT guidance, fewer critical breaches (1.4%-9%) occur in patients who exhibit even fewer neurovascular injuries. Alternatively, for 35 patients undergoing focal laminectomy with posterior fusions using spinous process-based wiring techniques, no screw-related neurovascular injuries occurred, whereas 100% of patients fused. Methods Patients averaged 65 years of age (22 men and 13 women) and exhibited severe myelopathy (Nurick grade 4.1). Dynamic x-ray and MR/CT studies documented preserved cervical lordotic curvatures and cord compression (stenosis, OPLL, OYL, olisthy). Patients required, on average, 2 level laminectomies (range, 1-3) and 7 level posterior fusions. Fusions used spinous process-based wiring techniques with iliac autograft/bone graft expanders. One-year SF-36 and 2-year fusion (dynamic x-rays/2D-CT) rates and Odom's criteria were assessed. Results Two years postoperatively, patients exhibited mild radiculopathy (Nurick grade 0.3). Complications included 2 transient root injuries (diabetic patients), 2 wound infections, 1 wound breakdown, no cord injuries, and no mortalities. Fusion occurred in 100% of patients an average of 5.2 months postoperatively. Odom's criteria revealed 29 good/excellent and 6 fair/poor outcomes, whereas SF-36 data revealed improvement on all 8 health scales. Conclusions Focal cervical laminectomies using multilevel posterior fusions, based on spinous process wiring techniques, resulted in high fusion rates with limited morbidity.