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1.  Collective commentaries regarding two articles disputing value of cervical disc arthroplasty vs. Anterior cervical diskectomy and fusion 
Surgical Neurology International  2014;5(Suppl 3):S79-S80.
PMCID: PMC4022998  PMID: 24843816
Anterior cervical diskectomy fusion; cervical spine surgery; disc replacement; outcomes
2.  Commentary: Utility of the O-Arm in spinal surgery 
Surgical Neurology International  2014;5(Suppl 15):S517-S519.
More studies report the intraoperative benefits vs. risks of utilizing the O-Arm in performing pedicle screw insertion in spinal surgery.
Several studies document the utility of CT-guided O-arm placement of pedicle/lateral mass screws. Singh et al. documented the efficacy of CT guided-O Arm placement of pedicle screws and lateral mass screws in the upper cervical spine.[4] Specifically, 10 patients with unstable hangman's fractures (ages 17-80) required 52 screws; C2 pedicle screws (20), C3 lateral mass screws (20), C4 lateral mass screws (12) and one C2 pedicle screw. Of these only 5% were misplaced, and none had new neuorlogical deficits. Kim et al. demonstrated the safety/efficacy of the CT/O-arm in minimally invasive spine surgery (MIS) (posterior percutaneous spinal fusions).[1] Of 290 pedicle screws, 280 (96.6%) were acceptably placed. Kotani et al. compared the placement of 222 pedicle screws (29 patients operated upon with CT-based navigation) vs. 416 screws (32 having surgery using O-arm-based navigation); postoperative CT studies confirmed the accuracy of screw placement, and no significant differences in the frequency of grade 2-3 perforations between the two groups. Nelson et al. analyzed the radiation exposure delivered to the operating room staff utilizing C-arm fluoroscopy (C-arm), portable X-ray (XR) radiography, and portable cone-beam computed tomography (O-arm); the surgeon and assistant were exposed to higher levels of scatter radiation from the C-arm, with a 7.7-fold increase in radiation exposure on the tube vs. detector sides.[3]
There are several pros and a few cons (radiation dosage) for the use of the O-arm in spine surgery.
PMCID: PMC4287897  PMID: 25593769
O Arm; radiation dosage; spinal surgery; utility
3.  Commentary: Bone morphogenetic protein's contribution to pulmonary artery hypertension: Should this raise concern for patients undergoing spinal fusions with bone morphogenetic protein? 
Surgical Neurology International  2014;5(Suppl 15):S570-S573.
Congenital pulmonary artery hypertension (PAH) has been clinically correlated in 70–80% of cases with mutations at the bone morphogenetic protein receptor 2 (BMPR2) genetic site. However, there is also clinical and basic science/laboratory literature indicating a dose–response relationship between BMP signaling and the evolution of PAH (e.g., increased endothelial, smooth muscle, and progenitor cell production, with calcifications).
Clinical PAH, characterized by pulmonary artery remodeling, elevated right ventricular pressures, increased vascular constriction, and inflammation, is largely due to congenital mutations at the BMPR2 site. Both clinical and laboratory studies have confirmed the correlation between dysfunction at the BMPR2 genetic site and PAH. However, additional basic science and clinical studies suggest a dose–response relationship between BMP signaling and the evolution of PAH.
Laboratory studies found that pulmonary artery smooth muscle cells (PASMCs) under hypoxic conditions proliferated in response to BMP-2 in a dose-dependent fashion. Others noted that PASMCs extracted from patients with Primary Pulmonary Hypertension (PPH) demonstrated abnormal growth responses to transforming growth factor-beta (TGF-β) in a dose-related manner.
The clinical/basic science literature appears to document a dose-dependent relationship between BMP and PAH (independent of the congenital lesions). Does this mean patients undergoing lumbar fusions with BMP are at risk for PAH?
PMCID: PMC4287904  PMID: 25593780
Bone morphogenetic protein; pulmonary hypertension; spinal surgery
4.  Intraoperative neuro-monitoring corner editorial: The need for preoperative sep and mep baselines in spinal surgery: Why can’t we and our monitoring colleagues get this right? 
Surgical Neurology International  2014;5(Suppl 15):S548-S551.
The majority of spinal surgeons now utilize intraoperative neurophysiological monitoring (IONM) during spinal procedures to limit the risk of inadvertent injury. Nevertheless, probably the most frequent error is the failure of the surgeon and IONM to obtain adequate preoperative baselines (e.g. before intubation or positioning).
Intraoperative neural monitoring should begin with the spinal surgeon, anesthesiologist, and monitoring technician/neurologist reviewing the patient's neurological deficits, the operative approach, the most anticipated risks and complications as well as the type of monitoring to be used (e.g. somatosensory evoked responses [SEP], motor evoked potential [MEP] monitoring, and electromyography [EMGs]). Baseline data should accurately reflect the preoperative status of the patient, and provide the appropriate data to be monitored and maintained throughout surgery.
Significant but transient changes from the established preoperative baseline SEP and MEP often reflect alterations in the anesthetic technique (e.g. hypotension/hypoperfusion). However, when these changes persist, and resuscitative maneuvers have been exhausted (e.g. removing an oversized graft to avoid ischemia, utilizing total intravenous anesthesia [TIVA] correctly, reversing hypotension, changing the patient's cervical position, checking the electrode placement, checking the position of the limbs, and other factors), significant MEP/SEP changes may signal a major impending neural injury.
IONM is only as good as how competently it is implemented by the technologist/neurologist, and understood by the surgeon and anesthesiologist. If any team member does not understand what and how the monitoring should be performed, then it becomes a useless adjunct to spinal surgery.
PMCID: PMC4287905  PMID: 25593775
EMG; intraoperative neural monitoring; MEP; preoperative baselines; SEP; spinal surgery
5.  Basic science and spine literature document bone morphogenetic protein increases cancer risk 
Surgical Neurology International  2014;5(Suppl 15):S552-S560.
Increasingly, clinical articles document that bone morphogenetic protein (BMP/INFUSE: Medtronic, Memphis, TN, USA) and its derivatives utilized in spinal surgery increase the risk of developing cancer. However, there is also a large body of basic science articles that also document that various types of BMP and other members of the TGF-Beta (transforming growth factor beta) family promote the growth of different types of cancers.
This review looks at many clinical articles citing BMP/INFUSE's role, largely “off-label”, in contributing to complications encountered during spinal surgery. Next, however, specific attention is given to the clinical and basic science literature regarding how BMP and its derivatives (e.g. members of the TGF-beta family) may also impact the development of breast and other cancers.
Utilizing BMP/INFUSE in spine surgery increased the risk of cancers/new malignancy as documented in several studies. For example, Carragee et al. found that for single-level instrumented posterolateral fusions (PLF) using high-dose rhBMP-2 (239 patients) vs. autograft (control group; n = 224), the risks of new cancers at 2 and 5 years postoperatively were increased. In laboratory studies, BMP's along with other members of the TGF-Beta family also modulated/contributed to the proliferation/differentiation of breast cancer (e.g. bone formation/turnover, breast cancer-related solid tumors, and metastases), lung, adrenal, and colon cancer.
BMP/INFUSE when utilized clinically in spinal fusion surgery appears to promote cancer at higher rates than observed in the overall population. Furthermore, BMP and TGF-beta are correlated with increased cancer growth both in the clinic and the laboratory.
PMCID: PMC4287907  PMID: 25593776
Bone morphogenetic protein; Pulmonary hypertension; Spinal surgery
6.  Commentary: Unnecessary preoperative epidural steroid injections lead to cerebrospinal fluid leaks confirmed during spinal stenosis surgery 
Surgical Neurology International  2014;5(Suppl 7):S325-S328.
Increasingly, older patients with severe spinal stenosis/instability undergo multiple unnecessary preoperative epidural spinal injections (ESI), despite their risks and lack of long-term benefits. Here we add to the list of risks by showing how often preoperative ESI lead to punctate cerebrospinal fluid (CSF) fistulas documented during subsequent surgery (e.g. multilevel laminectomies with non-instrumented fusions).
A series of 39 patients with spinal stenosis/instability prospectively underwent multilevel laminectomy/non-instrumented fusion utilizing lamina autograft and NanOss Bioactive. We asked how often preoperative ESI were performed in this population and how frequently they contributed to operatively confirmed punctate cerebrospinal fluid (CSF) fistulas. Notably, CSF leaks were clearly attributed to ESI, as they were located centrally/paracentrally at the L4-L5 level, just below hypertrophied/ossified yellow ligament (OYL), and were the exact size of a Tuohy needle with clean edges.
An average of 4.1 (range 2-12) preoperative ESI were performed in 33 of 39 patients undergoing average 4.3 level laminectomies and 1.3 level non-instrumented fusions; 6 (18.2%) patients exhibited operatively confirmed, punctate CSF fistulas attributed to these ESI. The most recent injections were administered between 2 and 5 weeks prior to surgery (average 3.9 weeks). Fistulas were primarily repaired with 7-0 GORE-TEX sutures and fibrin Sealant (Tisseel).
Of 33 patients undergoing multilevel laminectomies with non-instrumented fusions receiving preoperative ESI, 6 (18.2%) had operatively confirmed punctate CSF fistulas due to preoperative ESI performed an average of 4.1 times per patient.
PMCID: PMC4173206  PMID: 25289153
Epidural steroid injections; fistulas; operative confirmation; punctate cerebrospinal fluid leaks; spinal surgery
7.  Multidisciplinary in-hospital teams improve patient outcomes: A review 
Surgical Neurology International  2014;5(Suppl 7):S295-S303.
The use of multidisciplinary in-hospital teams limits adverse events (AE), improves outcomes, and adds to patient and employee satisfaction.
Acting like “well-oiled machines,” multidisciplinary in-hospital teams include “staff” from different levels of the treatment pyramid (e.g. staff including nurses’ aids, surgical technicians, nurses, anesthesiologists, attending physicians, and others). Their enhanced teamwork counters the “silo effect” by enhancing communication between the different levels of healthcare workers and thus reduces AE (e.g. morbidity/mortality) while improving patient and healthcare worker satisfaction.
Multiple articles across diverse disciplines incorporate a variety of concepts of “teamwork” for staff covering emergency rooms (ERs), hospital wards, intensive care units (ICUs), and most critically, operating rooms (ORs). Cohesive teamwork improved communication between different levels of healthcare workers, and limited adverse events, improved outcomes, decreased the length of stay (LOS), and yielded greater patient “staff” satisfaction.
Within hospitals, delivering the best medical/surgical care is a “team sport.” The goals include: Maximizing patient safety (e.g. limiting AE) and satisfaction, decreasing the LOS, and increasing the quality of outcomes. Added benefits include optimizing healthcare workers’ performance, reducing hospital costs/complications, and increasing job satisfaction. This review should remind hospital administrators of the critical need to keep multidisciplinary teams together, so that they can continue to operate their “well-oiled machines” enhancing the quality/safety of patient care, while enabling “staff” to optimize their performance and enhance their job satisfaction.
PMCID: PMC4173201  PMID: 25289149
Improved outcomes; medicine; multidisciplinary approaches; patient safety; quality of care; spine; surgery; teamwork
8.  Tisseel utilized as hemostatic in spine surgery impacts time to drain removal and length of stay 
Surgical Neurology International  2014;5(Suppl 7):S354-S361.
Although fibrin sealants (FSs) and fibrin glues (FGs) are predominantly utilized to strengthen repairs of cerebrospinal fluid (CSF) fistulas (deliberate/traumatic) during spinal surgery, they are also increasingly utilized to achieve hemostasis. Here, we investigated whether adding Tisseel (Baxter International Inc., Westlake Village, CA, USA), utilized to address increased bleeding during multilevel lumbar laminectomies with non-instrumented fusions, would reduce or equalize the time to drain removal and length of stay (LOS) without contributing to infections or prolonging time to fusion.
Prospectively, 39 patients underwent multilevel laminectomies and 1-2 level non-instrumented (in situ) fusions to address stenosis/olisthesis; 22 who demonstrated increased intraoperative bleeding received Tisseel, while 17 without such bleeding did not.
The 22 receiving versus 17 not receiving Tisseel, with similar clinical parameters, underwent comparable average multilevel laminectomies (4.36 and 4.25) and 1-2 level fusions (1.4 vs. 1.29 levels). As anticipated, for those receiving Tisseel, the average intraoperative estimated blood loss (EBL), total postoperative blood loss, and total perioperative transfusion requirements [red blood cells (RBC), fresh frozen plasma (FFP), platelets] were higher. However, Tisseel had the added benefit of equalizing the time to postoperative drain removal [e.g. 3.41 days (with) vs. 3.38 days (without)] and LOS [e.g. 5.86 days (with) vs. 5.82 days (without)] without increasing the infection rates (e.g. one superficial infection per group) or average times to fusion (e.g. 5.9 vs. 5.5 months).
Adding Tisseel for increased bleeding during multilevel laminectomies/in situ fusions contributed to hemostasis by equalizing the average times to drain removal/LOS compared to patients without increased bleeding and not requiring Tisseel.
PMCID: PMC4173204  PMID: 25289160
CSF fistulas: Epidural steroid injections; Fibrin sealant: Hemostasis; Lumbar laminectomy; Non-instrumented fusions; Punctate CSF Fistulas; Tisseel
9.  Hemostasis and other benefits of fibrin sealants/glues in spine surgery beyond cerebrospinal fluid leak repairs 
Surgical Neurology International  2014;5(Suppl 7):S304-S314.
Fibrin sealants (FS)/glues (FG) are primarily utilized in spinal surgery to either strengthen repairs of elective (e.g., intradural tumors/pathology) or traumatic cerebrospinal fluid (CSF) fistulas. Here, additional roles/benefits of FS/FG in spine surgery are explored; these include increased hemostasis, reduction of scar, reduction of the risk of infection if impregnated with antibiotics, and its application to restrict diffusion and limit some of the major complications attributed to the controversial “off-label” use of bone morphogeneitc protein (rhBMP-2/INFUSE).
We reviewed multiple studies, focusing not just on the utility of FS/FG in the treatment of CSF fistulas, but on its other applications.
FS/FG have been primarily used to supplement elective/traumatic dural closure in spinal surgery. However, FS/FG also contribute to; hemostasis, reducing intraoperative/postoperative bleeding/transfusion requirements, length of stay (LOS)/costs, reduced postoperative scar/radiculitis, and infection when impregnated with antibiotics. Nevertheless, one should seriously question whether FS/FG should be applied to prevent diffusion and limit major complications attributed to the “off-label” use of BMP/INFUSE (e.g., limit/prevent heterotopic ossification, dysphagia/respiratory decompensation, and new neurological deficits).
FS/FG successfully supplement watertight dural closure following elective (e.g., intradural tumor) or traumatic CSF fistulas occurring during spinal surgery. Additional benefits include: intraoperative hemostasis with reduced postoperative drainage, reduced transfusion requirements, reduced LOS, cost, scar, and prophylaxis against infection (e.g., impregnated with antibiotics). However, one should seriously question whether FS/FG should be used to contain the diffusion of BMP/INFUSE and limit its complications when utilized “off-label”.
PMCID: PMC4173211  PMID: 25289150
Benefits; complications; fibrin sealant; hemostasis; length of stay; lumbar surgery; reduced spread BMP/INFUSE; Tisseel
10.  Medicolegal Corner: When minimally invasive thoracic surgery leads to paraplegia 
Surgical Neurology International  2014;5(Suppl 3):S55-S58.
A patient with mild cervical myelopathy due to multilevel ossification of the posterior longitudinal ligament (OPLL) initially underwent a cervical C3-T1 laminectomy with C2-T2 fusion utilizing lateral mass screws. The patient's new postoperative right upper extremity paresis largely resolved within several postoperative months. However, approximately 6 months later, the patient developed increased paraparesis attributed to thoracic OPLL and Ossification of the yellow ligament (OYL) at the T2-T5 and T10-T11 levels. The patient underwent simultaneous minimally invasive (MIS) unilateral MetRx approaches to both regions. Postoperatively, the patient was paraplegic and never recovered function. Multiple mistakes led to permanent paraplegia due to MIS MetRx decompressions for T2-T5 and T10-11 OPLL/OYL in this patient. First, both thoracic procedures should have been performed “open” utilizing a full laminectomy rather than MIS; adequate visualization would have likely averted inadvertent cord injury, and the resultant CSF leak. Second, the surgeon should have used an operating microscope. Third, the operation should have been monitored with somatosensory evoked potentials (SEP), motor evoked potentials (MEP), and EMG (electromyography). Fourth, preoperatively the patient should have received a 1-gram dose of Solumedrol for cord “protection”. Fifth, applying Gelfoam as part of the CSF leak repair is contraindicated (e.g. due to swelling in confined spaces- see insert). Sixth, if the patient had not stopped Excedrin prior to the surgery, the surgery should have been delayed to avoid the increased perioperative risk of bleeding/hematoma.
PMCID: PMC4023002  PMID: 24843811
Contraindications; minimally invasive surgery; ossification posterior longitudinal ligament; ossification of yellow ligament; paraplegia; spine surgery; thoracic stenosis
11.  Cervical surgery for ossification of the posterior longitudinal ligament: One spine surgeon's perspective 
Surgical Neurology International  2014;5(Suppl 3):S88-S92.
The selection, neurodiagnostic evaluation, and surgical management of patients with cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. Whether for prophylaxis or treatment, the decision to perform anterior vs. posterior vs. circumferential cervical OPLL surgery is complex.
MR and CT Documentation of OPLL:
Together, MR and CT cervical studies best document the full extent of OPLL. While MR provides the optimal soft-tissue overview (e.g. hyperintense signals reflecting edema/myelomalacia in the cord), CT's directly demonstrate the ossification of OPLL often “missed” by MR (e.g. documents the single or double layer signs of dural penetration.
Patient Selection:
Patients with mild myelopathy/cord compression rarely require surgery, while those with moderate/severe myelopathy/cord compression often warrant anterior, posterior, or circumferential approaches.
Operative Approaches:
Anterior corpectomies/fusions, warranted in patients with OPLL and kyphosis/loss of lordosis, also increase the risks of cerebrospinal fluid (CSF) leaks (e.g. single/double layer sign), and vascular injuries (e.g. carotid, vertebral). Alternatively, with an adequate lordosis, posterior procedures (e.g. often with fusions), may provide adequate multilevel decompression while minimizing risk of anterior surgery. Occasionally, combined pathologies may warrant circumferential approaches.
Anesthetic and Intraoperative Monitoring Protocols:
The utility of awake nasotracheal fiberoptic intubation/awake positioning, intraoperative somatosensory/motor evoked potential, and electromyographic monitoring, and the requirement for total intravenous anesthesia (TIVA) for OPLL surgery is also discussed.
Anterior, posterior, or circumferential surgery may be warranted to treat patients with cervical OPLL, and must be based on careful patient selection, and both MR and CT documentation of the full extent of OPLL.
PMCID: PMC4023004  PMID: 24843818
Cervical spine; neurodiagnostic testing; ossification posterior longitudinal ligament; surgery; patient selection
12.  Few patients with neurodegenerative disorders require spinal surgery 
Surgical Neurology International  2014;5(Suppl 3):S81-S87.
Few patients with neurodegenerative disorders (ND) (e.g., Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS), and Postpolio Syndrome (PPS)) require spinal surgery. Typically, their neurological symptoms and signs reflect their underlying neurologic disorders rather than structural spinal pathology reported on magnetic resonance images (MR) or computed tomographic scans (CT).
The first author, a neurosurgeon, reviewed 437 spinal consultations performed over a 20-month period. Of 254 patients seen in first opinion (e.g., had not been seen by a spinal surgeon), 9 had MS, while 2 had ALS. Of 183 patients seen in second opinion (e.g., prior spinal surgeons recommended surgery), 4 had MS, 2 had ALS, and 1 had PPS. We performed this study to establish how often patients with ND, seen in first or second opinion, require spinal surgery. We focused on whether second opinions from spinal surgeons would limit the number of operations offered to these patients.
Two of 11 patients with ND seen in first opinion required surgery. The first patient required a C5-7 laminectomy/C2-T2 fusion, followed by a L2-S1 laminectomy/L5S1 fusion. The second patient required a L2-L3 laminectomy/diskectomy/fusion. However, none of the seven patients seen in second opinion, who were previously told by outside surgeons they needed spinal surgery, required operations.
Few patients with neurodegenerative syndromes (MS, ALS, PPS) and reported “significant” spondyloitic spinal disease interpreted on MR/CT studies required surgery. Great caution should be exercised in offering patients with ND spinal surgery, and second opinions should be encouraged to limit “unnecessary” procedures.
PMCID: PMC4023008  PMID: 24843817
Amyotrophic lateral sclerosis; first opinions; multiple sclerosis; postpolio syndrome; second opinions: Limiting spinal surgery; spinal surgery
13.  A review article on the benefits of early mobilization following spinal surgery and other medical/surgical procedures 
Surgical Neurology International  2014;5(Suppl 3):S66-S73.
The impact of early mobilization on perioperative comorbidities and length of stay (LOS) has shown benefits in other medical/surgical subspecialties. However, few spinal series have specifically focused on the “pros” of early mobilization for spinal surgery, other than in acute spinal cord injury. Here we reviewed how early mobilization and other adjunctive measures reduced morbidity and LOS in both medical and/or surgical series, and focused on how their treatment strategies could be applied to spinal patients.
We reviewed studies citing protocols for early mobilization of hospitalized patients (day of surgery, first postoperative day/other) in various subspecialties, and correlated these with patients’ perioperative morbidity and LOS. As anticipated, multiple comorbid factors (e.g. hypertension, high cholesterol, diabetes, hypothyroidism, obesity/elevated body mass index hypothyroidism, osteoporosis, chronic obstructive pulmonary disease, coronary artery disease and other factors) contribute to the risks and complications of immobilization for any medical/surgical patient, including those undergoing spinal procedures. Some studies additionally offered useful suggestions specific for spinal patients, including prehabilitation (e.g. rehabilitation that starts prior to surgery), preoperative and postoperative high protein supplements/drinks, better preoperative pain control, and early tracheostomy, while others cited more generalized recommendations.
In many studies, early mobilization protocols reduced the rate of complications/morbidity (e.g. respiratory decompensation/pneumonias, deep venous thrombosis/pulmonary embolism, urinary tract infections, sepsis or infection), along with the average LOS.
A review of multiple medical/surgical protocols promoting early mobilization of hospitalized patients including those undergoing spinal surgery reduced morbidity and LOS.
PMCID: PMC4023009  PMID: 24843814
Decreased cost; early mobilization; length of stay; prehabilitation; reduced morbidity; rehabilitation; spinal surgery
14.  What you need to know about ossification of the posterior longitudinal ligament to optimize cervical spine surgery: A review 
Surgical Neurology International  2014;5(Suppl 3):S93-S118.
What are the risks, benefits, alternatives, and pitfalls for operating on cervical ossification of the posterior longitudinal ligament (OPLL)? To successfully diagnose OPLL, it is important to obtain Magnetic Resonance Images (MR). These studies, particularly the T2 weighted images, provide the best soft-tissue documentation of cord/root compression and intrinsic cord abnormalities (e.g. edema vs. myelomalacia) on sagittal, axial, and coronal views. Obtaining Computed Tomographic (CT) scans is also critical as they best demonstrate early OPLL, or hypertrophied posterior longitudinal ligament (HPLL: hypo-isodense with punctate ossification) or classic (frankly ossified) OPLL (hyperdense). Furthermore, CT scans reveal the “single layer” and “double layer” signs indicative of OPLL penetrating the dura. Documenting the full extent of OPLL with both MR and CT dictates whether anterior, posterior, or circumferential surgery is warranted. An adequate cervical lordosis allows for posterior cervical approaches (e.g. lamionplasty, laminectomy/fusion), which may facilitate addressing multiple levels while avoiding the risks of anterior procedures. However, without lordosis and with significant kyphosis, anterior surgery may be indicated. Rarely, this requires single/multilevel anterior cervical diskectomy/fusion (ACDF), as this approach typically fails to address retrovertebral OPLL; single or multilevel corpectomies are usually warranted. In short, successful OPLL surgery relies on careful patient selection (e.g. assess comorbidities), accurate MR/CT documentation of OPLL, and limiting the pros, cons, and complications of these complex procedures by choosing the optimal surgical approach. Performing OPLL surgery requires stringent anesthetic (awake intubation/positioning) and also the following intraoperative monitoring protocols: Somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), and electromyography (EMG).
PMCID: PMC4023010  PMID: 24843819
Anesthesia; cervical surgery; diagnosis; intraoperative monitoring; ossification posterior longitudinal ligament; surgical management
15.  Are recommended spine operations either unnecessary or too complex? Evidence from second opinions 
Surgical Neurology International  2013;4(Suppl 5):S353-S358.
In 2011, Epstein and Hood documented that 17.2% of 274 patients with cervical/lumbar complaints seen in first or second opinion over one year were told they needed “unnecessary” spine surgery (e.g., defined as for pain alone, without neurological deficits, or significant radiographic abnormalities). Subsequently, in 2012 Gamache found that 69 (44.5%) of the 155 second opinion patients seen over a 14-month period were told by outside spine surgeons that they needed surgery; the second opinion surgeon (Gamache) found those operations to be unnecessary. Increasingly, patients, spine surgeons, hospitals, and insurance carriers should not only be questioning whether spinal operations are “unnecessary”, but also whether they are “wrong” (e.g., overly extensive, anterior vs. posterior operations), or “right” (appropriate).
Prospectively, 437 patients with cervical or lumbar complaints were seen in spinal consultation over a 20-month period. Of the 254 (58.1%) patients coming in for first opinions those with surgical vs. non-surgical lesions were identified. Of the 183 (41.9%) patients coming in for second opinions, who were previously told by outside surgeons that they needed spine operations, the second opinion surgeon documented the number of “unnecessary”, “wrong”, or “right” operations previously recommended.
Surgical pathology was identified in 138 (54.3%) patients presenting for first opinions. For patients seen in second opinion, 111 (60.7%) were told by outside surgeons that they required “unnecessary”, 61 (33.3%) the “wrong”, or 11 (6%) the “right” operations.
Of 183 second opinions seen over 20 months, the second opinion surgeon documented that previous spine surgeons recommended “unnecessary” (60.7%), the “wrong” (33.3%), or the “right” (6%) operations.
PMCID: PMC3841934  PMID: 24340231
First opinions; right; spine surgery; second opinions; unnecessary; wrong
16.  The need to add motor evoked potential monitoring to somatosensory and electromyographic monitoring in cervical spine surgery 
Surgical Neurology International  2013;4(Suppl 5):S383-S391.
Intraoperative neural monitoring (IONM), utilizing somatosensory evoked potentials (SEP) and electromyography (EMG), was introduced to cervical spine surgery in the late 1980's. However, as SEP only provided physiological data regarding the posterior cord, new motor deficits were observed utilizing SEP alone. This prompted the development of motor evoked potential monitoring (MEP) which facilitated real-time assessment of the anterior/anterolateral spinal cord. Although all three modalities, SEP, EMG, and MEP, are routinely available for IONM of cervical spine procedures, MEP are not yet routinely employed. The purpose of this review is to emphasize that MEP should now routinely accompany SEP and EMG when performing IONM of cervical spine surgery. Interestingly, one of the most common reasons for malpractice suits involving the cervical spine, is quadriparesis/quadriplegia following a single level anterior cervical diskectomy and fusion (ACDF). Previously, typical allegations in these suits included; negligent surgery, lack of informed consent, failure to diagnose/treat, and failure to brace. Added to this list, perhaps, as the 5th most reason for a suit will be failure to monitor with MEP. This review documents the value of MEP monitoring in addition to SEP and EMG monitoring in cervical spine surgery. The addition of MEP0 should minimize major motor injuries, and more accurately and reliably detect impending anterior cord deterioration that may be missed with SEP monitoring alone.
PMCID: PMC3842003  PMID: 24340237
Cervical surgery; electromyography; intraoperative monitoring; motor evoked potentials; neurological; somatosensory evoked potentials; spine surgery
17.  Complications due to the use of BMP/INFUSE in spine surgery: The evidence continues to mount 
Surgical Neurology International  2013;4(Suppl 5):S343-S352.
Increasingly, adverse events (AE) attributed to utilizing BMP/INFUSE (Bone Morphogenetic Protein, Medtronic, Memphis, TN, USA) “off-label” in spine surgery are being reported. In 2008, the Food and Drug Administration (FDA) issued a warning that in anterior cervical spine surgery, the “off-label” use of BMP/INFUSE contributed to marked dysphagia, hematoma, seroma, swelling, and/or the need for intubation/tracheostomy. Subsequent studies have cited the following AE; heterotopic ossification (HO), osteolysis, infection, arachnoiditis, increased neurological deficits, retrograde ejaculation, and cancer. Furthermore, in 2011, Carragee et al. noted that 13 of the original industry-sponsored BMP/INFUSE spinal surgery studies failed to acknowledge multiple AE. Additionally, in 2012, Comer et al. observed that the frequency of retrograde ejaculation reported for BMP/INFUSE used “on-label” to perform Anterior Lumbar Interbody Fusion/Lumbar Tapered Fusion-Cage Device (ALIF/LT-Cage) was also largely “under-reported.” To summarize, there is mounting evidence in the spinal literature that utilizing BMP/INFUSE in spinal fusions contributes to major perioperative and postoperative morbidity.
PMCID: PMC3717531  PMID: 23878769
Adverse events; BMP/INFUSE; fusions; morbidity; “off-label”; spinal surgery
18.  Medicolegal corner: Quadriplegia following chiropractic manipulation 
Surgical Neurology International  2013;4(Suppl 5):S327-S329.
A 45 year old male with multiple comorbidities presented to his internist with a 2 week history of right sided neck pain and tenderness, accompanied by tingling in the hand. The internists’ neurological examination was normal, except for decreased range of motion of the right arm. He referred the patient to a chiropractor; he performed plain X rays which revealed mild spasm, but never ordered a magnetic resonance imaging study. The chiropractor manipulated the patient's neck on two successive days. By the morning of the third visit, the patient reported extreme pain and difficulty walking. Without performing a new neurological examination or obtaining an MR scan, the chiropractor again manipulated the patient's neck. He immediately became quadriplegic. Despite undergoing an emergency C5 C6 anterior cervical diskectomy/fusion to address a massive disc found on the MR scan (CT was negative), the patient remained quadriplegic (e.g., C4 sensory, C6 motor levels). A major point of negligence in this case was the failure of both the referring internist and chiropractor to order an MR of the cervical spine prior to the chiropractic manipulation. The internist claimed that there was no known report of permanent quadriplegia resulting from neck manipulation in any medical journal, article or book, or in any literature of any kind or on the internet and that the risk of this injury must be vanishingly small given the large numbers of manipulations performed annually. The total amount of the verdict was $14,596,000.00 the internist's liability was 5% ($759,181.65).
PMCID: PMC3717529  PMID: 23878767
Cervical manipulation; cervical disc; chiropractic treatment; quadriplegia
19.  When does a spinal surgeon need a plastic surgeon? 
Surgical Neurology International  2013;4(Suppl 5):S299-S300.
PMCID: PMC3716009  PMID: 23878764
20.  A review article on the diagnosis and treatment of cerebrospinal fluid fistulas and dural tears occurring during spinal surgery 
Surgical Neurology International  2013;4(Suppl 5):S301-S317.
In spinal surgery, cerebrospinal fluid (CSF) fistulas attributed to deliberate dural opening (e.g., for tumors, shunts, marsupialization of cysts) or inadvertent/traumatic dural tears (DTs) need to be readily recognized, and appropriately treated.
During spinal surgery, the dura may be deliberately opened to resect intradural lesions/tumors, to perform shunts, or to open/marsupialize cysts. DTs, however, may inadvertently occur during primary, but are seen more frequently during revision spinal surgery often attributed to epidural scarring. Other etiologies of CSF fistulas/DTs include; epidural steroid injections, and resection of ossification of the posterior longitudinal ligament (OPLL) or ossification of the yellow ligament (OYL). Whatever the etiology of CSF fistulas or DTs, they must be diagnosed utilizing radioisotope cisternography (RIC), magnetic resonance imaging (MRI), computed axial tomography (CT) studies, and expeditiously repaired.
DTs should be repaired utilizing interrupted 7-0 Gore-Tex (W.L. Gore and Associates Inc., Elkton, MD, USA) sutures, as the suture itself is larger than the needle; the larger suture occludes the dural puncture site. Closure may also include muscle patch grafts, dural patches/substitutes (bovine pericardium), microfibrillar collagen (Duragen: Integra Life Sciences Holdings Corporation, Plainsboro, NJ), and fibrin glues or dural sealants (Tisseel: Baxter Healthcare Corporation, Deerfield, IL, USA). Only rarely are lumbar drains and wound-peritoneal and/or lumboperitoneal shunts warranted.
DTs or CSF fistulas attributed to primary/secondary spinal surgery, trauma, epidural injections, OPLL, OYL, and other factors, require timely diagnosis (MRI/CT/Cisternography), and appropriate reconstruction.
PMCID: PMC3801173  PMID: 24163783
Cerebrospinal fluid; dural sealants; fibrin sealants; fistulas; muscle grafts; reconstruction methods; spinal surgery; suture techniques
21.  How much medicine do spine surgeons need to know to better select and care for patients? 
Surgical Neurology International  2012;3(Suppl 5):S329-S349.
Although we routinely utilize medical consultants for preoperative clearance and postoperative patient follow-up, we as spine surgeons need to know more medicine to better select and care for our patients.
This study provides additional medical knowledge to facilitate surgeons’ “cross-talk” with medical colleagues who are concerned about how multiple comorbid risk factors affect their preoperative clearance, and impact patients’ postoperative outcomes.
Within 6 months of an acute myocardial infarction (MI), patients undergoing urological surgery encountered a 40% mortality rate: similar rates may likely apply to patients undergoing spinal surgery. Within 6 weeks to 2 months of placing uncoated cardiac, carotid, or other stents, endothelialization is typically complete; as anti-platelet therapy may often be discontinued, spinal surgery can then be more safely performed. Coated stents, however, usually require 6 months to 1 year for endothelialization to occur; thus spinal surgery is often delayed as anti-platelet therapy must typically be continued to avoid thrombotic complications (e.g., stroke/MI). Diabetes and morbid obesity both increase the risk of postoperative infection, and poor wound healing, while the latter increases the risk of phlebitis/pulmonary embolism. Both hypercoagluation and hypocoagulation syndromes may require special preoperative testing/medications and/or transfusions of specific hematological factors. Pulmonary disease, neurological disorders, and major psychiatric pathology may also require further evaluations/therapy, and may even preclude successful surgical intervention.
Although we as spinal surgeons utilize medical consultants for preoperative clearance and postoperative care, we need to know more medicine to better select and care for our patients.
PMCID: PMC3520072  PMID: 23248752
Hematology; medical comorbidities; neurological/psychiatric -disorders; obesity; pulmonary; spinal surgery: cardiac disease; stroke
22.  Morbidity and mortality conferences: Their educational role and why we should be there 
Surgical Neurology International  2012;3(Suppl 5):S377-S388.
This article examines the value of morbidity and mortality (M&M) conferences, and the multiple factors that contribute to their efficacy. Physicians’ morbidity and mortality conferences (M&MCs) focus on education by reviewing individual adverse events (AE), M&M. Alternatively, Quality Assurance (QA) conferences better examine system-wide issues (e.g., the role institutions play) in attaining or maintaining acceptable levels of patient care. Other issues examined in this review include: whether prospective vs. retrospective M&M data collection are more accurate, and how most states offer ‘nondiscovery’ of M&M proceedings.
Most studies emphasize the educational role of M&MCs, and differentiate their role from QA. Studies comparing the accuracy of prospective vs. retrospective collection of M&M data were reviewed along with the medicolegal issues surrounding the protection of M&M data (‘nondiscovery’).
Multiple review articles emphasized that QA conferences typically identify system-wide failures (e.g., hospital policies) while M&MCs focus on physicians’ AE/morbidity/mortality. Additionally, the prospective collection of M&M data proved to be more accurate than retrospective analysis. Finally, most states protect M&M confidentiality (‘nondisclosure’); a glaring exception is Florida, ‘The Sunshine State,’ that allows ‘full disclosure.’
This study reviews how M&MCs, differentiated from QA meetings, and educate physicians. It also documents how prospective collection of M&M data is more accurate than retrospective analysis. Additionally, it documents how in most states, medicolegal protections against discovery are in place, with Florida, the ‘Sunshine State’ remaining a glaring exception.
PMCID: PMC3520073  PMID: 23248758
Attendance revival; conferences; medicolegal requirements; morbidity; mortality; spinal surgery
23.  How to reduce hospital-acquired pressure ulcers on a neuroscience unit with a skin and wound assessment team 
In 2008, the incidence of hospital acquired pressure ulcers (HAPUs) continued to increase on a neuroscience unit that included both neurosurgical and neurological patients in a 14-bed intensive care unit, and in a 18-bed floor unit.
To reduce HAPUs, several changes were instituted in 2008; (1) turning patients every 1–2 h/repositioning, (2) specialty beds, and (3) a “skin and wound assessment team (SWAT)” that included one (or two) “expert” nurses/nursing assistants who made rounds on all the patients in the unit at least once a week. They would examine patients from “head to toe”, document/measure all pressure ulcers, and educate primary nurses/nurse assistants on the plan/products needed for the patients wound care based on their assessments. In 2010, further measures included: (1) adding eight Stryker beds, (2) adding pressure relieving heel protector boots, and (3) requiring that all new hospital orientees work one shift (7.5 h) shadowing the SWAT team.
The SWAT team initially decreased HAPUs by 48% in 2009; this reduction was further increased in 2010 (57%), and 2011 (61%). Additionally, in 2010, the SWAT team was required to educate nurses in all other units. By 2011, all nurses had to complete the hospital acquired pressure ulcer prevention tutorial.
Since instituting a specialized SWAT team for our neuroscience unit, the incidence of HAPUs (cost estimated for grade IV, US $129,248) was decreased by 48% in 2009, by 57% in 2010, and by 61% in 2011. The SWAT program is now hospital-wide.
PMCID: PMC3515926  PMID: 23230519
Hospital-acquired pressure ulcers; Neuroscience unit; Skin and wound assessment teams
25.  The diagnosis and management of synovial cysts: Efficacy of surgery versus cyst aspiration 
Surgical Neurology International  2012;3(Suppl 3):S157-S166.
The surgical management of lumbar synovial cysts that have extruded into the spinal canal remains controversial (e.g. decompression with/without fusion).
The neurological presentation, anatomy, pathophysiology, and surgical challenges posed by synovial cysts in the lumbar spine are well known. Neurological complaints typically include unilateral or, more rarely, bilateral radicular complaints, and/or cauda equina syndromes. Anatomically, synovial cysts constitute cystic dilatations of synovial sheaths that directly extrude from facet joints into the spinal canal. Pathophysiologically, these cysts reflect disruption of the facet joints often with accompanying instability, and potentially compromise both the cephalad and caudad nerve roots.
Aspiration of lumbar synovial cysts, which are typically gelatinous and non-aspirable, and typically performed by “pain specialists” (e.g. pain management, rehabilitation, radiologists, others) utilizing fluoroscopy or CT-guided aspiration, is associated with 50–100% failure rates. Surgical decompression with/without fusion (as the issue regarding fusion remains unsettled) results in the resolution of back and radicular pain in 91.6–92.5% and 91.1–91.9% of cases, respectively.
After a thorough review of the literature, it appears that the treatment with the best outcome for patients with synovial cysts is cyst removal utilizing surgical decompression; the need for attendant fusion remains unsettled. The use of an alternative treatment, percutaneous aspiration of cysts, appears to have a much higher recurrence and failure rate, but may be followed by surgery if warranted.
PMCID: PMC3422091  PMID: 22905322
Decompression; extruded lumbar synovial cysts; failed aspiration; failed techniques; fusion

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