The mortality rate following resection of acoustic neuromas has dropped dramatically over the pas... more The mortality rate following resection of acoustic neuromas has dropped dramatically over the past three decades. Advanced microsurgical techniques and experience make life-threatening intraoperative complications rare. Postoperative deterioration of mental status, however, remains an occasionally encountered emergency that demands prompt, appropriate evaluation and treatment.
INTRODUCTION: Cervical Disc Replacement (CDR) is an increasingly utilized procedure to address ce... more INTRODUCTION: Cervical Disc Replacement (CDR) is an increasingly utilized procedure to address cervical degenerative conditions, as an alternative to discectomy and fusion, for the purpose of preserving natural segmental motion. METHODS: Using serial radiographs from patients, a panel of experts assembled for the purpose of creating a classification system to aid in reproducibly and consistently identifying boney changes and assessing CDR device radiographic appearance. Subdividing the superior and inferior vertebral bodies into 3 equal sections, observed bone loss such as endplate rounding, cystic erosion adjacent to the endplate, and cystic erosion not adjacent to the endplate, is recorded. Determining if bone loss is progressive and estimating severity of bone loss (measured by the percentage of end plate involved) is recorded. Additional relevant boney changes and device observations include radiolucent lines, heterotopic ossification, loss of core implant height, and presence of device migration, subsidence, and olisthesis. RESULTS: Serial radiographs from 26 patients implanted with a variety of CDR products were assessed by 6 investigators including clinicians and scientists experienced in CDR or appendicular skeleton joint replacement. After several iterations, a classification system emerged that had improved concordance among the participating investigators. Next steps include assessing reliability with a broad group of clinicians, using serial radiographs from a significant number of patients, to confirm the proposed classification scheme. CONCLUSIONS: A standardized nomenclature for boney changes following CDR will facilitate accurate and reproducible scientific communications regarding the clinical outcomes of this procedure. The novel system proposed demonstrated good concordance among experienced investigators in this field and represents an important advancement.
The concept of semi-rigid fixation (SRF) has driven the development of spinal implants that utili... more The concept of semi-rigid fixation (SRF) has driven the development of spinal implants that utilize nonmetallic materials and novel rod geometries in an effort to promote fusion via a balance of stability, intra- and inter-level load sharing, and durability. The purpose of this study was to characterize the mechanical and biomechanical properties of a pedicle screw-based polyetheretherketone (PEEK) SRF system for the lumbar spine to compare its kinematic, structural, and durability performance profile against that of traditional lumbar fusion systems. Performance of the SRF system was characterized using a validated spectrum of experimental, computational, and in vitro testing. Finite element models were first used to optimize the size and shape of the polymeric rods and bound their performance parameters. Subsequently, benchtop tests determined the static and dynamic performance threshold of PEEK rods in relevant loading modes (flexion-extension (F/E), axial rotation (AR), and lateral bending (LB)). Numerical analyses evaluated the amount of anteroposterior column load sharing provided by both metallic and PEEK rods. Finally, a cadaveric spine simulator was used to determine the level of stability that PEEK rods provide. Under physiological loading conditions, a 6.35 mm nominal diameter oval PEEK rod construct unloads the bone-screw interface and increases anterior column load (approx. 75% anterior, 25% posterior) when compared to titanium (Ti) rod constructs. The PEEK construct’s stiffness demonstrated a value lower than that of all the metallic rod systems, regardless of diameter or metallic composition (78% < 5.5 mm Ti; 66% < 4.5 mm Ti; 38% < 3.6 mm Ti). The endurance limit of the PEEK construct was comparable to that of clinically successful metallic rod systems (135N at 5 × 106 cycles). Compared to the intact state, cadaveric spines implanted with PEEK constructs demonstrated a significant reduction of range of motion in all three loading directions (> 80% reduction in F/E, p < 0.001; > 70% reduction in LB, p < 0.001; > 54% reduction in AR, p < 0.001). There was no statistically significant difference in the stability provided by the PEEK rods and titanium rods in any mode (p = 0.769 for F/E; p = 0.085 for LB; p = 0.633 for AR). The CD HORIZON® LEGACY™ PEEK Rod System provided intervertebral stability comparable to currently marketed titanium lumbar fusion constructs. PEEK rods also more closely approximated the physiologic anteroposterior column load sharing compared to results with titanium rods. The durability, stability, strength, and biomechanical profile of PEEK rods were demonstrated and the potential advantages of SRF were highlighted.
who subsequently underwent a Lumbar Discectomy (63030) over a three year time period from 2004-20... more who subsequently underwent a Lumbar Discectomy (63030) over a three year time period from 2004-2006. RESULTS: Within our population of 482,893 patients with the diagnosis of a disc herniation, 27,799(5.76%) underwent a lumbar discectomy. Of the 29,941 patients who received SNRB for a disc herniation, 3,235 (10.80%) later underwent a lumbar discectomy. CONCLUSIONS: The rate of lumbar discetomy after SNRB appears smaller than that reported in a previous randomized control trial. This may suggest that either SNRB is more beneficial than previously suspected or that patients are receiving SNRB earlier and more frequently in the conservative treatment of their disc herniation. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
T he current common practice for patients with cervical disc disease is initial conservative ther... more T he current common practice for patients with cervical disc disease is initial conservative therapy when appropriate, followed by anterior cervical discectomy and fusion (ACDF). Although the procedure is well tolerated, bony fusion often requires transient postoperative bracing and increases the risk of adjacent-level degeneration. 1 In young, active patients with cervical disc herniation and myelopathy or radiculopathy, disc arthroplasty or cervical disc replacement (CDR) has become a popular surgical alternative. Not only does CDR maintain postoperative neck mobility at the involved levels (Table 1), but also it allows for rapid return to activity and offers less risk of adjacent-level degeneration. 2,3 Despite the widespread adoption of arthroplasty by spine surgeons, the first FDA-approved cervical artificial disc, the PRESTIGE ST disc (Medtronic Inc.), was only approved in 2007. Few studies have examined long-term outcomes; however, two randomized clinical trials have reported lower failure rates at the index and adjacent levels for CDR than for ACDF for both one-level operations at 2 years' follow-up 4 and one-and two-level operations at 7 ABBREVIATIONS ACDF = anterior cervical discectomy and fusion; CDR = cervical disc replacement; SSK = symptomatic segmental kyphosis.
This continuing education activity is intended for orthopedic and neurologic surgeons and other p... more This continuing education activity is intended for orthopedic and neurologic surgeons and other physicians with an interest in spine surgery.
Study Design: Retrospective cohort Objective: Evaluate the safety profile of single and multileve... more Study Design: Retrospective cohort Objective: Evaluate the safety profile of single and multilevel cervical artificial disc replacement (ADR) performed in an outpatient setting. Summary of Background Data: As healthcare costs rise, attempts are made to perform an increasing proportion of spine surgery in ambulatory surgery centers (ASCs). ASCs are more efficient, economically and functionally. Few studies have published on the safety profile of multi-level cervical ADR. Methods: We have performed an analysis of all consecutive cervical ADR surgeries that we performed in an ASC over a 9-month period, including multi-level and revision surgery. The pre-, intra-and post-op data recorded included age, gender, BMI, tobacco use and the presence of diabetes; level and procedure, OR time, EBL, complications; discharge site, occurrence of re-operation, hospital admission or any medical complication or infection over a 90-day period. Results: 147 patients underwent 231 treated levels: 71 single-level, 76 multi-level: 69 two-level, 6 three-level, 1 four-level. Average age was 50 +/-10 years; 71 female, 76 males. None of the patients were insulin-dependent diabetics, 4 were current smokers, 16 were former smokers. Average BMI was 26.8 +/-4.6 (range 18-40). Average total anesthesia time was 88 minutes (range 39-168 minutes). Average EBL was 15 ml (range 5-100ml). 90.3% of patients were discharged directly home, 9.7% to an after-care facility. In the 90-day post-op period there were zero deaths, two hospital admissions (1.4%)-one for medical complication (0.7%) and one for a surgical site infection (0.7%). Conclusion: In this consecutive case series we performed 231 ADRs in 147 patients in the outpatient setting, including multi-level and revision procedures, with 2 minor post-operative complications resulting in hospital unplanned admissions within 90 days. We believe these procedures are safe to perform in an ASC. An efficient surgical team and careful patient selection criteria are critical in making this possible.
Background: As countries in COVID-19 pandemic lockdown begin relaxation of shelter-in-place mitig... more Background: As countries in COVID-19 pandemic lockdown begin relaxation of shelter-in-place mitigation strategies, the role of serology testing escalates in importance. However, there are no clear guidelines as to when to use qualitative rapid diagnostic serology tests (RDTs) vs. SARS-CoV-2 viral RNA load (PCR) tests as an aid in acute diagnosis of patients presenting with u-like symptoms, nor how to interpret serology test results in asymptomatic individuals or those with atypical COVID-19 symptomatology. Here we describe, in the context of the likely rst case of COVID-19 in California, with an atypical presentation and not tested acutely, who nearly 3 months later was found to be IgM-and IgG+ positive for SARS-CoV-2 antibodies, highlighting the role of RDT-based serology testing and interpretation in retrospective diagnosis. Case Presentation: A 62-year-old male practicing neurosurgeon had onset of u-like symptoms on January 20 with fatigue, slight cough only on deep inspiration, intermittent pleuritic chest pain unrelated to exertion, dyspnea, and night sweats but without fever, sore throat or rhinorrhea. He had recently traveled abroad but not to China. CT scan revealed right lower lobe in ltrate and effusion. Because of atypical symptoms, and low prevalence of COVID-19 in January, community acquired pneumonia was diagnosed and one week of doxycycline was prescribed without relief, followed by a second week of azithromycin with symptom remission. Three months later the physician-patient (author THL), tested positive for SARS-CoV-2 antibodies by a serology point-of-care rapid diagnostic test (RDT). Conclusions: Serology testing may be an aid in acute diagnosis of COVID-19, especially in patients with atypical presentations, as well as in assessment of asymptomatic higher-risk persons such as healthcare workers for prior infection. Recommendations for serology testing and interpretation are explicated.
Interbody fusions have historically involved bone grafts to produce intervertebral arthrodesis in... more Interbody fusions have historically involved bone grafts to produce intervertebral arthrodesis in the treatment of degenerative disc disease. Cloward 9,10 pioneered this effort and was able to achieve notable success in his patients by performing PLIFs starting in the 1940s, and anterior cervical interbody fusions in the 1950s. The challenging surgical technique and the need for meticulous graft preparation, however, discouraged widespread adoption of these methodologies. Metallic spinal interbody devices were initially introduced in the setting of veterinary medicine with the Bagby stainless steel fenestrated device being used to treat equine spinal instability in the 1970s. 12 Subsequently, revived interest in human clinical applications sparked pursuit of designs for rectangular, cylindrical, ring, and threaded interbody geometries. 1,13,17,23 Such devices were commonly packed with morselized autologous bone chips. Surgical approaches included posterior, anterior, or transforaminal procedures. 22,23,26 Neurosurg Focus 16 (3):Article 9, 2004, Click here to return to Table of Contents
The International Journal of Spine Surgery, Oct 8, 2021
Background: Single and multilevel lumbar arthroplasty has had excellent results, but the L5-S1 le... more Background: Single and multilevel lumbar arthroplasty has had excellent results, but the L5-S1 level frequently has pathology that precludes arthroplasty. This study evaluated clinical outcomes and sagittal range of motion (ROM) of operated levels and adjacent motion segments in single-and multiple-level ProDisc-L above a simultaneous L5-S1 fusion (hybrid) after a 2-to 6-year follow-up. Methods: In this prospective cohort study, 46 patients underwent simultaneous lumbar total disc replacement (TDR) at one to three levels and anterior lumbar interbody fusion (ALIF) at L5-S1. Twenty-three patients had L5-S1 ALIF þ L4-5 TDR, 19 patients had L5-S1 ALIF þ two-level TDR, and 4 patients had L5-S1 ALIF þ three-level TDR. Oswestry disability index (ODI) and visual analog scores (VAS) of patient satisfaction (VAS-S) and pain (VAS-P) were recorded. Sagittal motion on pre-and postoperative lumbar radiographs at each operative segment and adjacent segment was acquired. Patients were evaluated preoperatively and at 6 weeks, 3 months, 6 months, and annually for 24 to 72 months postoperatively. Results: For clinical results, there were no differences among the groups for age, gender, body mass index, tobacco use, or worker's compensation status. At 2-6 years postoperation, all patients had significant reductions in ODI and VAS scores. For radiographic results, at the nonsurgical level adjacent to the TDR þ ALIF constructs, the mean preoperative ROM was 9.40 6 1.808 compared with 10.50 6 2.258 postoperatively. The mean preoperative ROM at levels undergoing TDR was 10.4 6 2.718 versus 12.6 6 2.258 postoperatively. There was no statistically significant difference in ROM at each prosthetic motion segment between patients receiving one-, two-, or three-level TDR. The mean preoperative ROM at the L5-S1 segment to undergo fusion was 2.4 6 2.448, with all patients having a postoperative ROM of 0.008. Conclusions: Multilevel TDR above an L5-S1 ALIF (hybrid procedure) preserves ROM at the individual TDR levels and does not reduce the fusion rate of the L5-S1 fused level. Most significantly, the nonoperative adjacent level maintains its preoperative ROM at 2-6 years postoperatively.
Background: Patients may occasionally have persistent or recurrent radicular symptoms after cervi... more Background: Patients may occasionally have persistent or recurrent radicular symptoms after cervical artificial disc replacement (ADR) for cervical spondylotic radiculopathy. We describe our approach using anterior cervical foraminotomy (ACF) to provide symptom relief in such patients without the need to convert to a fusion or remove the ADR implant. Methods: Our operative technique for ACF after cervical ADR begins by starting at the lateral edge of the ADR at the superior end plate of the inferior vertebral body. The ipsilateral uncovertebral joint is drilled with a combination of a high-speed burr and diamond-coated burr to minimize the risk of injury to the vertebral artery. The neuroforamen is entered after drilling through the posterior aspect of the uncinate process. The exiting cervical nerve root should be directly visualized, and a Kerrison rongeur may be used to trace along the nerve root laterally to remove any remaining uncinate osteophyte or process. We queried our internal database for patients with recurrent or new radicular pain following cervical ADR who underwent ACF. Clinical characteristics and outcomes were reported. Results: Five patients with recurrent radicular symptoms after ADR were reviewed. Two ACFs were performed at C5-6, and 2 were performed at C6-7. Four patients developed ipsilateral recurrent radicular symptoms, and only 1 patient developed contralateral new radicular symptoms. Three patients reported complete resolution of their new or recurrent radicular symptoms following ACF, and 2 patients reported only partial resolution. No patients required conversion to a fusion. Conclusions: In patients with recurrent symptoms of cervical spondylotic radiculopathy following ADR, ACF with uncovertebral joint resection can be used to provide direct foraminal decompression without the need for implant removal. This approach also preserves motion at the affected level, preserves cervical spinal stability, and prevents the need for spinal fusion. Clinical Relevance: Patients with persistent or recurrent radicular symptoms after cervical ADR may achieve resolution of symptoms through a modified ACF technique. Level of Evidence: 4.
Background: Given the increased attention to functional improvement in spine surgery as it relate... more Background: Given the increased attention to functional improvement in spine surgery as it relates to motion preservation, activities of daily living, and cost, it is critical to fully understand the healthcare economic impact of new devices being tested in large FDA randomized controlled trials (RCT). The purpose of this analysis was to comprehensively evaluate the cost-effectiveness of the novel Total Posterior Spine (TOPS™) System investigational device compared with the trial control group, standard transforaminal lumbar interbody fusion (TLIF). Objective: To evaluate the cost-effectiveness of TOPS™ compared with TLIF. Methods: The study patient population was extracted from a multicenter RCT with current enrollment at n=121 with complete 1-year follow-up. The primary outcome was cost-effectiveness, expressed as the incremental cost-effectiveness ratio. Secondary outcomes were health-related utility, presented as quality-adjusted life-years (QALYs), and cost, calculated in US do...
Background: Driving an automobile requires the ability to turn the neck laterally. Anecdotally, p... more Background: Driving an automobile requires the ability to turn the neck laterally. Anecdotally, patients with multilevel fusions often complain about restricted turning motion. The purpose of this study was to compare the effectiveness of cervical disc arthroplasty (CDA) with anterior cervical discectomy and fusion (ACDF) on driving disability improvement at 10-year follow-up after a 2-level procedure. Methods: In the original randomized controlled trial, patients with cervical radiculopathy or myelopathy at 2 levels underwent CDA or ACDF. The driving disability question from the Neck Disability Index was rated from 0 to 5 years preoperatively and up to 10 years postoperatively. Severity of driving disability was categorized into "none" (score 0), "mild" (1 or 2), and "severe" (3, 4, or 5). Score and severity were compared between groups. Results: Out of 397 patients, 148 CDA and 118 ACDF patients had 10-year follow-up. Driving disability scores were not different between the groups preoperatively (CDA: 2.65; ACDF: 2.71, P = 0.699). Postoperatively, the scores in the CDA group were significantly lower than those in the ACDF group at 5 (0.60 vs 1.08, P ≤ 0.001) and 10 years (0.66 vs 1.07, P = 0.001). Mean score improvement in the CDA group was significantly greater than the ACDF group at 10-year follow-up (−1.94 vs −1.63, P = 0.003). The majority of patients reported severe driving disability (CDA: 56.9%, ACDF: 58.0%, P = 0.968) before surgery. After surgery, a greater proportion of patients in the CDA group had neck pain-free driving compared with the ACDF group at 5 (63.3% vs 41.8%, P < 0.001) and 10 years (61.8% vs 41.2%, P = 0.003). Conclusion: In patients with cervical radiculopathy/myelopathy and 2-level disease, CDA provided greater improvements in driving disability as compared with ACDF at 10-year follow-up. This is the first report of its kind. This finding may be attributable to preservation of motion associated with CDA. Clinical Relevence: This study provides valuable information regarding the improvement of driving disability after both CDA and ACDF. It demonstrates that both procedures result in significant improvements, with CDA resulting in even better improvements than ACDF, up to 10 year follow-up. Level of Evidence: 3.
The mortality rate following resection of acoustic neuromas has dropped dramatically over the pas... more The mortality rate following resection of acoustic neuromas has dropped dramatically over the past three decades. Advanced microsurgical techniques and experience make life-threatening intraoperative complications rare. Postoperative deterioration of mental status, however, remains an occasionally encountered emergency that demands prompt, appropriate evaluation and treatment.
INTRODUCTION: Cervical Disc Replacement (CDR) is an increasingly utilized procedure to address ce... more INTRODUCTION: Cervical Disc Replacement (CDR) is an increasingly utilized procedure to address cervical degenerative conditions, as an alternative to discectomy and fusion, for the purpose of preserving natural segmental motion. METHODS: Using serial radiographs from patients, a panel of experts assembled for the purpose of creating a classification system to aid in reproducibly and consistently identifying boney changes and assessing CDR device radiographic appearance. Subdividing the superior and inferior vertebral bodies into 3 equal sections, observed bone loss such as endplate rounding, cystic erosion adjacent to the endplate, and cystic erosion not adjacent to the endplate, is recorded. Determining if bone loss is progressive and estimating severity of bone loss (measured by the percentage of end plate involved) is recorded. Additional relevant boney changes and device observations include radiolucent lines, heterotopic ossification, loss of core implant height, and presence of device migration, subsidence, and olisthesis. RESULTS: Serial radiographs from 26 patients implanted with a variety of CDR products were assessed by 6 investigators including clinicians and scientists experienced in CDR or appendicular skeleton joint replacement. After several iterations, a classification system emerged that had improved concordance among the participating investigators. Next steps include assessing reliability with a broad group of clinicians, using serial radiographs from a significant number of patients, to confirm the proposed classification scheme. CONCLUSIONS: A standardized nomenclature for boney changes following CDR will facilitate accurate and reproducible scientific communications regarding the clinical outcomes of this procedure. The novel system proposed demonstrated good concordance among experienced investigators in this field and represents an important advancement.
The concept of semi-rigid fixation (SRF) has driven the development of spinal implants that utili... more The concept of semi-rigid fixation (SRF) has driven the development of spinal implants that utilize nonmetallic materials and novel rod geometries in an effort to promote fusion via a balance of stability, intra- and inter-level load sharing, and durability. The purpose of this study was to characterize the mechanical and biomechanical properties of a pedicle screw-based polyetheretherketone (PEEK) SRF system for the lumbar spine to compare its kinematic, structural, and durability performance profile against that of traditional lumbar fusion systems. Performance of the SRF system was characterized using a validated spectrum of experimental, computational, and in vitro testing. Finite element models were first used to optimize the size and shape of the polymeric rods and bound their performance parameters. Subsequently, benchtop tests determined the static and dynamic performance threshold of PEEK rods in relevant loading modes (flexion-extension (F/E), axial rotation (AR), and lateral bending (LB)). Numerical analyses evaluated the amount of anteroposterior column load sharing provided by both metallic and PEEK rods. Finally, a cadaveric spine simulator was used to determine the level of stability that PEEK rods provide. Under physiological loading conditions, a 6.35 mm nominal diameter oval PEEK rod construct unloads the bone-screw interface and increases anterior column load (approx. 75% anterior, 25% posterior) when compared to titanium (Ti) rod constructs. The PEEK construct’s stiffness demonstrated a value lower than that of all the metallic rod systems, regardless of diameter or metallic composition (78% &lt; 5.5 mm Ti; 66% &lt; 4.5 mm Ti; 38% &lt; 3.6 mm Ti). The endurance limit of the PEEK construct was comparable to that of clinically successful metallic rod systems (135N at 5 × 106 cycles). Compared to the intact state, cadaveric spines implanted with PEEK constructs demonstrated a significant reduction of range of motion in all three loading directions (&gt; 80% reduction in F/E, p &lt; 0.001; &gt; 70% reduction in LB, p &lt; 0.001; &gt; 54% reduction in AR, p &lt; 0.001). There was no statistically significant difference in the stability provided by the PEEK rods and titanium rods in any mode (p = 0.769 for F/E; p = 0.085 for LB; p = 0.633 for AR). The CD HORIZON® LEGACY™ PEEK Rod System provided intervertebral stability comparable to currently marketed titanium lumbar fusion constructs. PEEK rods also more closely approximated the physiologic anteroposterior column load sharing compared to results with titanium rods. The durability, stability, strength, and biomechanical profile of PEEK rods were demonstrated and the potential advantages of SRF were highlighted.
who subsequently underwent a Lumbar Discectomy (63030) over a three year time period from 2004-20... more who subsequently underwent a Lumbar Discectomy (63030) over a three year time period from 2004-2006. RESULTS: Within our population of 482,893 patients with the diagnosis of a disc herniation, 27,799(5.76%) underwent a lumbar discectomy. Of the 29,941 patients who received SNRB for a disc herniation, 3,235 (10.80%) later underwent a lumbar discectomy. CONCLUSIONS: The rate of lumbar discetomy after SNRB appears smaller than that reported in a previous randomized control trial. This may suggest that either SNRB is more beneficial than previously suspected or that patients are receiving SNRB earlier and more frequently in the conservative treatment of their disc herniation. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
T he current common practice for patients with cervical disc disease is initial conservative ther... more T he current common practice for patients with cervical disc disease is initial conservative therapy when appropriate, followed by anterior cervical discectomy and fusion (ACDF). Although the procedure is well tolerated, bony fusion often requires transient postoperative bracing and increases the risk of adjacent-level degeneration. 1 In young, active patients with cervical disc herniation and myelopathy or radiculopathy, disc arthroplasty or cervical disc replacement (CDR) has become a popular surgical alternative. Not only does CDR maintain postoperative neck mobility at the involved levels (Table 1), but also it allows for rapid return to activity and offers less risk of adjacent-level degeneration. 2,3 Despite the widespread adoption of arthroplasty by spine surgeons, the first FDA-approved cervical artificial disc, the PRESTIGE ST disc (Medtronic Inc.), was only approved in 2007. Few studies have examined long-term outcomes; however, two randomized clinical trials have reported lower failure rates at the index and adjacent levels for CDR than for ACDF for both one-level operations at 2 years' follow-up 4 and one-and two-level operations at 7 ABBREVIATIONS ACDF = anterior cervical discectomy and fusion; CDR = cervical disc replacement; SSK = symptomatic segmental kyphosis.
This continuing education activity is intended for orthopedic and neurologic surgeons and other p... more This continuing education activity is intended for orthopedic and neurologic surgeons and other physicians with an interest in spine surgery.
Study Design: Retrospective cohort Objective: Evaluate the safety profile of single and multileve... more Study Design: Retrospective cohort Objective: Evaluate the safety profile of single and multilevel cervical artificial disc replacement (ADR) performed in an outpatient setting. Summary of Background Data: As healthcare costs rise, attempts are made to perform an increasing proportion of spine surgery in ambulatory surgery centers (ASCs). ASCs are more efficient, economically and functionally. Few studies have published on the safety profile of multi-level cervical ADR. Methods: We have performed an analysis of all consecutive cervical ADR surgeries that we performed in an ASC over a 9-month period, including multi-level and revision surgery. The pre-, intra-and post-op data recorded included age, gender, BMI, tobacco use and the presence of diabetes; level and procedure, OR time, EBL, complications; discharge site, occurrence of re-operation, hospital admission or any medical complication or infection over a 90-day period. Results: 147 patients underwent 231 treated levels: 71 single-level, 76 multi-level: 69 two-level, 6 three-level, 1 four-level. Average age was 50 +/-10 years; 71 female, 76 males. None of the patients were insulin-dependent diabetics, 4 were current smokers, 16 were former smokers. Average BMI was 26.8 +/-4.6 (range 18-40). Average total anesthesia time was 88 minutes (range 39-168 minutes). Average EBL was 15 ml (range 5-100ml). 90.3% of patients were discharged directly home, 9.7% to an after-care facility. In the 90-day post-op period there were zero deaths, two hospital admissions (1.4%)-one for medical complication (0.7%) and one for a surgical site infection (0.7%). Conclusion: In this consecutive case series we performed 231 ADRs in 147 patients in the outpatient setting, including multi-level and revision procedures, with 2 minor post-operative complications resulting in hospital unplanned admissions within 90 days. We believe these procedures are safe to perform in an ASC. An efficient surgical team and careful patient selection criteria are critical in making this possible.
Background: As countries in COVID-19 pandemic lockdown begin relaxation of shelter-in-place mitig... more Background: As countries in COVID-19 pandemic lockdown begin relaxation of shelter-in-place mitigation strategies, the role of serology testing escalates in importance. However, there are no clear guidelines as to when to use qualitative rapid diagnostic serology tests (RDTs) vs. SARS-CoV-2 viral RNA load (PCR) tests as an aid in acute diagnosis of patients presenting with u-like symptoms, nor how to interpret serology test results in asymptomatic individuals or those with atypical COVID-19 symptomatology. Here we describe, in the context of the likely rst case of COVID-19 in California, with an atypical presentation and not tested acutely, who nearly 3 months later was found to be IgM-and IgG+ positive for SARS-CoV-2 antibodies, highlighting the role of RDT-based serology testing and interpretation in retrospective diagnosis. Case Presentation: A 62-year-old male practicing neurosurgeon had onset of u-like symptoms on January 20 with fatigue, slight cough only on deep inspiration, intermittent pleuritic chest pain unrelated to exertion, dyspnea, and night sweats but without fever, sore throat or rhinorrhea. He had recently traveled abroad but not to China. CT scan revealed right lower lobe in ltrate and effusion. Because of atypical symptoms, and low prevalence of COVID-19 in January, community acquired pneumonia was diagnosed and one week of doxycycline was prescribed without relief, followed by a second week of azithromycin with symptom remission. Three months later the physician-patient (author THL), tested positive for SARS-CoV-2 antibodies by a serology point-of-care rapid diagnostic test (RDT). Conclusions: Serology testing may be an aid in acute diagnosis of COVID-19, especially in patients with atypical presentations, as well as in assessment of asymptomatic higher-risk persons such as healthcare workers for prior infection. Recommendations for serology testing and interpretation are explicated.
Interbody fusions have historically involved bone grafts to produce intervertebral arthrodesis in... more Interbody fusions have historically involved bone grafts to produce intervertebral arthrodesis in the treatment of degenerative disc disease. Cloward 9,10 pioneered this effort and was able to achieve notable success in his patients by performing PLIFs starting in the 1940s, and anterior cervical interbody fusions in the 1950s. The challenging surgical technique and the need for meticulous graft preparation, however, discouraged widespread adoption of these methodologies. Metallic spinal interbody devices were initially introduced in the setting of veterinary medicine with the Bagby stainless steel fenestrated device being used to treat equine spinal instability in the 1970s. 12 Subsequently, revived interest in human clinical applications sparked pursuit of designs for rectangular, cylindrical, ring, and threaded interbody geometries. 1,13,17,23 Such devices were commonly packed with morselized autologous bone chips. Surgical approaches included posterior, anterior, or transforaminal procedures. 22,23,26 Neurosurg Focus 16 (3):Article 9, 2004, Click here to return to Table of Contents
The International Journal of Spine Surgery, Oct 8, 2021
Background: Single and multilevel lumbar arthroplasty has had excellent results, but the L5-S1 le... more Background: Single and multilevel lumbar arthroplasty has had excellent results, but the L5-S1 level frequently has pathology that precludes arthroplasty. This study evaluated clinical outcomes and sagittal range of motion (ROM) of operated levels and adjacent motion segments in single-and multiple-level ProDisc-L above a simultaneous L5-S1 fusion (hybrid) after a 2-to 6-year follow-up. Methods: In this prospective cohort study, 46 patients underwent simultaneous lumbar total disc replacement (TDR) at one to three levels and anterior lumbar interbody fusion (ALIF) at L5-S1. Twenty-three patients had L5-S1 ALIF þ L4-5 TDR, 19 patients had L5-S1 ALIF þ two-level TDR, and 4 patients had L5-S1 ALIF þ three-level TDR. Oswestry disability index (ODI) and visual analog scores (VAS) of patient satisfaction (VAS-S) and pain (VAS-P) were recorded. Sagittal motion on pre-and postoperative lumbar radiographs at each operative segment and adjacent segment was acquired. Patients were evaluated preoperatively and at 6 weeks, 3 months, 6 months, and annually for 24 to 72 months postoperatively. Results: For clinical results, there were no differences among the groups for age, gender, body mass index, tobacco use, or worker's compensation status. At 2-6 years postoperation, all patients had significant reductions in ODI and VAS scores. For radiographic results, at the nonsurgical level adjacent to the TDR þ ALIF constructs, the mean preoperative ROM was 9.40 6 1.808 compared with 10.50 6 2.258 postoperatively. The mean preoperative ROM at levels undergoing TDR was 10.4 6 2.718 versus 12.6 6 2.258 postoperatively. There was no statistically significant difference in ROM at each prosthetic motion segment between patients receiving one-, two-, or three-level TDR. The mean preoperative ROM at the L5-S1 segment to undergo fusion was 2.4 6 2.448, with all patients having a postoperative ROM of 0.008. Conclusions: Multilevel TDR above an L5-S1 ALIF (hybrid procedure) preserves ROM at the individual TDR levels and does not reduce the fusion rate of the L5-S1 fused level. Most significantly, the nonoperative adjacent level maintains its preoperative ROM at 2-6 years postoperatively.
Background: Patients may occasionally have persistent or recurrent radicular symptoms after cervi... more Background: Patients may occasionally have persistent or recurrent radicular symptoms after cervical artificial disc replacement (ADR) for cervical spondylotic radiculopathy. We describe our approach using anterior cervical foraminotomy (ACF) to provide symptom relief in such patients without the need to convert to a fusion or remove the ADR implant. Methods: Our operative technique for ACF after cervical ADR begins by starting at the lateral edge of the ADR at the superior end plate of the inferior vertebral body. The ipsilateral uncovertebral joint is drilled with a combination of a high-speed burr and diamond-coated burr to minimize the risk of injury to the vertebral artery. The neuroforamen is entered after drilling through the posterior aspect of the uncinate process. The exiting cervical nerve root should be directly visualized, and a Kerrison rongeur may be used to trace along the nerve root laterally to remove any remaining uncinate osteophyte or process. We queried our internal database for patients with recurrent or new radicular pain following cervical ADR who underwent ACF. Clinical characteristics and outcomes were reported. Results: Five patients with recurrent radicular symptoms after ADR were reviewed. Two ACFs were performed at C5-6, and 2 were performed at C6-7. Four patients developed ipsilateral recurrent radicular symptoms, and only 1 patient developed contralateral new radicular symptoms. Three patients reported complete resolution of their new or recurrent radicular symptoms following ACF, and 2 patients reported only partial resolution. No patients required conversion to a fusion. Conclusions: In patients with recurrent symptoms of cervical spondylotic radiculopathy following ADR, ACF with uncovertebral joint resection can be used to provide direct foraminal decompression without the need for implant removal. This approach also preserves motion at the affected level, preserves cervical spinal stability, and prevents the need for spinal fusion. Clinical Relevance: Patients with persistent or recurrent radicular symptoms after cervical ADR may achieve resolution of symptoms through a modified ACF technique. Level of Evidence: 4.
Background: Given the increased attention to functional improvement in spine surgery as it relate... more Background: Given the increased attention to functional improvement in spine surgery as it relates to motion preservation, activities of daily living, and cost, it is critical to fully understand the healthcare economic impact of new devices being tested in large FDA randomized controlled trials (RCT). The purpose of this analysis was to comprehensively evaluate the cost-effectiveness of the novel Total Posterior Spine (TOPS™) System investigational device compared with the trial control group, standard transforaminal lumbar interbody fusion (TLIF). Objective: To evaluate the cost-effectiveness of TOPS™ compared with TLIF. Methods: The study patient population was extracted from a multicenter RCT with current enrollment at n=121 with complete 1-year follow-up. The primary outcome was cost-effectiveness, expressed as the incremental cost-effectiveness ratio. Secondary outcomes were health-related utility, presented as quality-adjusted life-years (QALYs), and cost, calculated in US do...
Background: Driving an automobile requires the ability to turn the neck laterally. Anecdotally, p... more Background: Driving an automobile requires the ability to turn the neck laterally. Anecdotally, patients with multilevel fusions often complain about restricted turning motion. The purpose of this study was to compare the effectiveness of cervical disc arthroplasty (CDA) with anterior cervical discectomy and fusion (ACDF) on driving disability improvement at 10-year follow-up after a 2-level procedure. Methods: In the original randomized controlled trial, patients with cervical radiculopathy or myelopathy at 2 levels underwent CDA or ACDF. The driving disability question from the Neck Disability Index was rated from 0 to 5 years preoperatively and up to 10 years postoperatively. Severity of driving disability was categorized into "none" (score 0), "mild" (1 or 2), and "severe" (3, 4, or 5). Score and severity were compared between groups. Results: Out of 397 patients, 148 CDA and 118 ACDF patients had 10-year follow-up. Driving disability scores were not different between the groups preoperatively (CDA: 2.65; ACDF: 2.71, P = 0.699). Postoperatively, the scores in the CDA group were significantly lower than those in the ACDF group at 5 (0.60 vs 1.08, P ≤ 0.001) and 10 years (0.66 vs 1.07, P = 0.001). Mean score improvement in the CDA group was significantly greater than the ACDF group at 10-year follow-up (−1.94 vs −1.63, P = 0.003). The majority of patients reported severe driving disability (CDA: 56.9%, ACDF: 58.0%, P = 0.968) before surgery. After surgery, a greater proportion of patients in the CDA group had neck pain-free driving compared with the ACDF group at 5 (63.3% vs 41.8%, P < 0.001) and 10 years (61.8% vs 41.2%, P = 0.003). Conclusion: In patients with cervical radiculopathy/myelopathy and 2-level disease, CDA provided greater improvements in driving disability as compared with ACDF at 10-year follow-up. This is the first report of its kind. This finding may be attributable to preservation of motion associated with CDA. Clinical Relevence: This study provides valuable information regarding the improvement of driving disability after both CDA and ACDF. It demonstrates that both procedures result in significant improvements, with CDA resulting in even better improvements than ACDF, up to 10 year follow-up. Level of Evidence: 3.
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Papers by Todd Lanman