Thomas Richard Gehrig, MD

• Associate Professor of Medicine

https://medicine.duke.edu/faculty/thomas-richard-gehrig-md

Patient positioning is one of the most important factors in a successful approach asthma short definition order singulair mastercard. Padding under the leg closest to the table is necessary to prevent peroneal palsy asthma definition 7 buy discount singulair 4 mg. Complications of Lateral Lumbar Interbody Fusion Cages to maintain a direct vertical approach to the lateral disc space and decrease the risk of inadvertently traversing posteriorly toward the spinal canal or anteriorly toward the retroperitoneal vasculature and other structures asthma treatment rajiv dixit order 10mg singulair with visa. With prolonged retractor placement asthma or bronchitis symptoms discount singulair line, the nerves of the lumbar plexus may experience prolonged compression between the retractor and the transverse process asthma treatment plan cheap singulair generic, and may become injured asthma grading purchase online singulair. This should prevent the cosmetic complications of a muscle hernia and may reduce bleeding and tissue injury. Blunt finger dissection into the retroperitoneal space is important to ensure that the peritoneum is not entered. Finger dissection also is helpful to palpate for any anomalous anatomy that may impede access, such as renal abnormalities. Injury to the retroperitoneal structures or entry into the peritoneum would require prompt vascular or general surgical consultation. The placement of the initial dilator should be just anterior to the center of the disc. Anterior bias may reduce the risk of nerve complications by decreasing direct injury to the nerves of the lumbar plexus9 as well as by decreasing risk of posterior placement of the cage. Careful placement of the dilators and the retractor directly affect the final position of the cage, given the portal of entry is just wide enough for discectomy and implant placement. While most postoperative weakness, numbness, and dysesthesia are transient,10 permanent nerve injury has been reported. The second mechanism of neurologic injury, which is more common, involves indirect and prolonged compression or tension of the nerves between the posterior retractor blade and the transverse process. Tape is then placed from the greater trochanter over the lateral femoral condyle to the edge of the table; another band of tape is placed from the lateral femoral condyle over the lateral malleolus to the other edge of the table. The table may be gently flexed to allow expansion of the space between the iliac crest and the rib cage. It is imperative that the table be moved and not the C-arm to obtain true anteroposterior and lateral imaging of the operative disc level, with the X-ray beam remaining orthogonal to the walls and floor of the operating room. Fluoroscopic control is imperative given that contralateral neurovascular injury has been reported with catastrophic consequences. Just as in the placement of any intervertebral device, compromise of the endplates may represent potential complications of subsidence and loss of reduction or height. In the setting of deformity, several surgeons will recommend medical treatment of osteoporosis with improvement in bone mineral density prior to surgical intervention. Although minimally invasive techniques may not provide as significant a magnitude of deformity correction as open techniques, they have demonstrated a 12% rate of major complication, which favors well against the overall Kim et al. Complications, though rare, can have catastrophic consequences associated with significant morbidity and mortality. The risk is to the (frequently calcified) vascular structures of the retroperitoneum, which are tethered to the vertebrae by segmental vessels. When lengthening the anterior aspect of the anterior column, these vessels may be injured, given that they may not be able to adequately lengthen in conjunction with the spine. The lengthening of the spine may cause significant bleeding that may be hard to control from the lateral approach. Defining the safe working zones using the minimally invasive lateral retroperitoneal transpsoas approach: an anatomical study. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Food and Drug Administration, Center for Devices and Radiological Health NuVasive CoRoent System K071795 Approval Letter, November 21, 2007 Kim et al. This plate is usually a metal alloy that spans the disc space and has a superior and inferior screw hole. Ex vivo studies have found that plates added to pedicle screw instrumentation result in greater rigidity than lateral plates alone. Another study by Le and colleagues8 specifically investigated complications from lateral plating during the minimally invasive lateral transpsoas approach. Kepler and colleagues reported postoperative atraumatic vertebral body fractures through the anterolateral plate screw holes in two patients with osteoporosis diagnosed by dual-energy X-ray absorptiometry. Both fractures occurred in the coronal plane within 6 weeks of surgery and one required a secondary procedure (kyphoplasty) due to pain. This could occur due to endplate preparation, overstuffing of the disc space, or endplate resorption perioperatively. The psoas muscle ensconced branches from the lumbar plexus and is bounded anteriorly by the femoral nerve, genitourinary nerve, iliac artery, and vein. In the study by Le and colleagues, three patients also sustained lateral plate failure by a dislodged lock nut and plate. These include lumbar plexus injury as well as injury to more superficial nerves 262 Kim et al. Complications of Lateral Lumbar Fusion Plates that run through and on the psoas muscle. Placing additional hardware, including screw fixation, has the potential to increase approach-related injury by widening the exposure corridor as well as placing screws with only partial visual guidance. Furthermore, it is widely held that retraction time on the plexus may be a factor in lumbar plexus injury during the lateral approach. Vertebral body fracture after anterolateral instrumentation and interbody fusion in two osteoporotic patients. Stand-alone lateral interbody fusion for the treatment of low-grade degenerative spondylolisthesis. Biomechanical stability of lateral interbody implants and supplemental fixation in a cadaveric degenerative spondylolisthesis model. Anatomy of the psoas muscle and lumbar plexus with respect to the surgical approach for lateral transpsoas interbody fusion. The complications associated with lateral plate fixation include vertebral fractures and hardware failure. The addition of a lateral plate to an interbody cage does increase the rigidity of the construct, however not as much as posterior pedicle screws. In addition, the increased exposure and dissection required for this approach and the use of the plate may place the patient at an increased risk for both neurological and vascular injury. A prospective study with a large number of patients and an appropriate matched control group (posterior pedicle screw fixation) is needed and would help determine the value of these devices. Unlike fusion surgery, which can be performed via an anterior, extreme lateral or posterior approach, disc arthroplasty is traditionally performed only via an anterior approach. Additionally, explanation and fusion via a cage were performed in one stage with the implantation of a lateral fusion device. It also has its own approach-related complications that have been reported in the literature for lateral interbody fusions. The extreme lateral approach is most commonly performed with the patient in the lateral position. The nerves of the lumbar plexus lie within the posterior half of the psoas muscle belly with the exception of the genitofemoral nerve, which passes anteriorly through the muscle belly and exits anteriorly at the level of L3. Sympathetic nerves travel along the surface of the aorta and may be injured by aggressive dissection, retraction, or damage to the aorta. Complications of Lateral Lumbar Arthroplasty Devices proximity of the nearby lumbar plexus and nerves, which are located within the posterior substance of the psoas muscle. Alternatively, the surgeon can place his finger around the anterior aspect of the psoas muscle and sweep it posteriorly. Once an initial path is forged and confirmed with fluoroscopy, sequentially larger dilators are inserted to eventually make way for a tubular retractor. This can occur due to the blind docking of the initial dilator on the psoas muscle, at which point the bowel may be entrapped and injured. Treatment includes emergent exploration, bowel resection, and a diverting colostomy. Nerve injuries can be divided into those superficial to the psoas and those within the psoas. Superficial nerves include the ilioinguinal, iliohypogastric, and lateral femoral cutaneous nerves. Injury to these nerves typically results in numbness in their respective distributions without a significant motor disturbance. These deficits may be temporary or permanent, with some studies reporting transient weakness and others reporting persistent weakness at last follow-up. In 2009, Knight et al20 reported complications of 58 patients who underwent minimally invasive extreme lateral lumbar interbody fusions for treatment of degenerative conditions. Similarly, Tormenti et al21 reviewed eight patients who underwent similar procedures. Presumably, these transient complications were secondary to trauma to the psoas and injury to the lateral femoral cutaneous nerves. Prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of the ProDisc-L total disc replacement compared with circumferential arthrodesis for the treatment of two-level lumbar Kim et al. Biomechanical comparison of a two-level Maverick disc replacement with a hybrid one-level disc replacement and one-level anterior lumbar interbody fusion. Complications and radiographic correction in adult scoliosis following combined transpsoas extreme lateral interbody fusion and posterior pedicle screw instrumentation. Complications of Lumbar Interbody Fusion with Femoral Ring Allograft 41 Complications of Lumbar Interbody Fusion with Femoral Ring Allograft Adam J. Of the available allograft options, femoral ring allograft is the most common structural graft utilized for lumbar interbody fusions. They concluded that the femoral ring allograft was more cost-effective while also yielding greater quality of life improvements. In the case of lumbar interbody fusion with femoral ring allograft, pseudarthrosis is defined by a lack of bony integration between the graft and the lumbar vertebral endplates despite allowing a sufficient time for healing. Incorporation is initiated by a host inflammatory response that increases blood flow to the graft interface that is then followed by revascularization of the graft beginning when host capillary buds sprout into the graft. The next step that occurs is partial resorption, mediated by osteoclastic activity, of the allograft. Even when graft incorporation proceeds as anticipated, a substantial amount of necrotic allograft bone remains present within the allograft once remodeling, and thereby final healing, is complete. The remaining 3% still had the graft intact but not fully incorporated, and none of the grafts showed any resorption. On the other hand, not all results have been as encouraging as the previous two listed studies. The study found that freezedried femoral ring allograft was associated with higher rate of intraoperative fracture and a higher rate of pseudarthrosis requiring surgical revision. Another potential reason for the high pseudarthrosis rate in the Pradhan study is the fact that the femoral ring allografts in the study were used in a stand-alone fashion. Alternately, revision of posterior instrumentation with fusion may increase mechanical stability sufficiently to allow complete bony union. Femoral ring allograft is no different and likewise carries a risk of disease transmission. All femoral ring allografts undergo a rigorous screening process which begins at the time of tissue harvest. Bone allografts can be employed as a fresh allograft, a fresh-frozen graft, or a freeze-dried graft. Additionally, flexion/extension films may demonstrate continued motion across the spinal segment that is attempting to fuse. If an asymptomatic pseudarthrosis is identified during routine radiographic follow-up and the femoral ring allograft is maintaining its position within the interbody space, treatment is observation. In contradistinction, if a femoral ring allograft fails to heal and is resulting in clinical symptoms despite conservative measures, treatment is warranted. Prior to proceeding with surgical revision, the etiology of the pseudarthrosis should be established. In the hypothetical scenario of a disease being transmitted from a femoral ring allograft, an affected patient would most likely present with symptoms related to the specific disease that had been contracted. In the event of a bacterial contamination, acute symptoms such as fever, wound problems, and/or 268 Kim et al. Complications of Lumbar Interbody Fusion with Femoral Ring Allograft bacteremia may be predominant, and trigger a workup for a deep surgical infection. Finally, strong consideration should be made into removing the infected femoral ring allograft, as this represents the source of infection and removal will likely improve the chances of successful medical management. In the acute period, revision of the graft can be completed by removal of the fractured femoral ring allograft with re-preparation of the interbody space and replacement of a new graft. In this scenario, the morbidity of re-exposing and exploring the femoral ring allograft may outweigh the benefits. One study that documented the rate of fracture was a 2005 randomized controlled trial by McKenna et al1 comparing femoral ring allograft to titanium cages. A caveat to this statement is that processed femoral ring allograft, particularly that has been freeze-dried or irradiated, is more brittle and weaker than native cortical bone. When a femoral ring allograft fractures, it occurs in two different scenarios-at time of insertion or following implantation during incorporation. Femoral ring allograft is typically implanted by way of an inserter device along with a bone tamp and mallet. Intuitively, if the femoral ring allograft is oversized or the disc space is collapsed so that overly aggressive insertion techniques are required, fracture can occur. Other variables that are potentially linked to graft fracture include donor bone quality and, as mentioned above, graft processing techniques.

Biomechanics of stand-alone cages and cages in combination with posterior fixation: a literature review asthmatic bronchitis icd 9 cm code order singulair without a prescription. Spondylolisthesis with a description of a new method of operative treatment and notes of ten cases asthma definition 4g discount singulair express. Lesions of the intervertebral disks and their treatment by interbody fusion methods asthma definition wikipedia discount singulair 5 mg free shipping. Subsidence after anterior lumbar interbody fusion using paired stand-alone rectangular cages asthma 504 plans order 4mg singulair with amex. Systematic review and meta-analysis of the retroperitoneal versus the transperitoneal approach to the abdominal aorta asthma treatment names purchase singulair overnight delivery. Anterior lumbar interbody fusion: indications for its use and notes on surgical technique asthma treatment names buy 4 mg singulair fast delivery. Circumferential fusion improves outcome in comparison with instrumented posterolateral fusion: long-term results of a randomized clinical trial. Outcome in relation to surgical methods, choice of implant and postoperative rehabilitation. Accuracy of pedicle screw placement in the lumbosacral spine using conventional technique: computed tomography postoperative assessment in 102 consecutive patients. Relaxation response of lumbar spine Segments Undergoing Annular Distraction: Implication to Anterior Lumbar Interbody Implant Stability. Augmentation of an anterior lumbar interbody fusion with an anterior plate or pedicle screw fixation: a comparative biomechanical in vitro study. Revision lumbar arthrodesis for the treatment of lumbar cage pseudoarthrosis: complications. A randomised controlled trial of a lowmolecular-weight heparin (Enoxaparin) to prevent deep-vein thrombosis in patients undergoing vascular surgery. Interspace distraction and graft subsidence after anterior lumbar fusion with femoral strut allograft. Additionally, a significant surgical learning curve and appropriate additional surgical training are keys to successful outcomes. However, long-term follow-up data and revision rates, whether due to polyethylene wear or adjacent segment disease, have not been well established yet. Complications with disc arthroplasty implantation can occur during the anterior surgical exposure of the spine, following the surgery, or can be related to the implant itself. This article will go over the most commonly reported complications as follows: Exposure-related complications: Vascular. In 10 of the patients who had lacerations to the left common iliac vein, the injury took place during the surgical exposure. The two patients with tears to the right lumbar veins required control of bleeding with thrombin-soaked sponges followed by aborting the planned procedure due to an inability to mobilize the vena cava without continued bleeding. The aforementioned injuries are not common and are minimized when the procedure is performed by a well-trained surgeon. The authors routinely monitored the SaO2 of the left lower extremity by placing a pulse oximeter on one of the toes of the foot. In addition to requiring a thrombectomy, one of the four patients developed a compartment syndrome of the left lower extremity and required fasciotomies. The authors did not feel that the chance of iliac artery thrombosis warranted a large, preoperative vascular evaluation beyond that of palpating the distal pulses of bilateral lower extremities unless the patient was known to have a complicated vascular history. Each of the patients with deep venous thrombosis was successfully treated without further operative intervention. Rajaraman et al stated that the incidence of deep venous thrombosis in patients undergoing an abdominal procedure is 7 to 8%. Use of a handheld retractor versus a Steinmann pin allows the periodic release of pressure on the vessel when work is not actively being done near the vein or artery. The incidence of durotomy during anterior procedures was not separated from those that occurred during all lumbar procedures. Bleeding was controlled with temporary cross-clamping of the aorta and packing of the abdomen and pelvis. If the wound becomes contaminated with the contents of the perforated bowel, the planned spinal procedure should be aborted, the bowel repaired, and the abdomen closed. However, after injury to this sympathetic chain, other more subtle signs may manifest such as temperature variation, dysesthesias, discoloration, and/or swelling of the lower limb. Although higher in incidence with the transperitoneal approach, postoperative ileus can still occur with the retroperitoneal approach even without defilement of the peritoneal tissue. The rate of ileus following placement of a lumbar total disc is not significantly different than the rate of ileus following other anterior lumbar surgical procedures. Prolonged ileus is often related to previous abdominal procedures, formation of a retroperitoneal hematoma, postoperative fluid shifts, extensive intraabdominal dissection, and increased narcotic usage. The goals of treatment are to prevent accumulation of the chylous ascites and the resulting complications from increased abdominal pressure as well as to provide adequate nutritional supplementation. If the ascites continues to recollect despite total parenteral nutrition, subcutaneous somatostatin is administered in an attempt to close the lymphatic fistula. Conservative treatment should be pursued for 6 to 8 weeks before concluding that it has failed and considering surgical intervention. Ideally, the implant should be positioned in the center of the vertebral body in both the coronal and sagittal plane. In a case report by Eskander et al, the posterior extrusion of the polyethylene core of a total disc arthroplasty device was found in a patient who presented with symptoms of radiculopathy. Likewise, implant migration is dependent on device fixation, which occurs through osteointegration with coated endplates or by fixation into the vertebral body, such as with the keel of the implant into the vertebral body. Additionally, confirming parallel placement of the implant onto the endplates safeguards against violation of the endplate, which aids in preventing implant subsidence. Furthermore, histology of the surgical specimens showed chronic inflammatory cells and reactive fibrosis of the vertebral tissue. Another mode of failure that has been reported in two patients by Shim et al is fracture of the vertebral body by the placement of a ProDisc arthroplasty. In these two patients, the only complaint was continued pain at the 3-month follow-up visit. Similarly, Cabraja et al, in a case report, noted the development of a granulomatous necrotizing inflammatory mass, as identified on histopathological analysis, occurring 11 months after the placement of a lumbar total disc device. The effects of polyethylene wear particles appears to be similar to that seen in total knee and hip arthroplasties despite the intervertebral disc not being a synovial joint. In a randomized study of 276 patients, Tortolani et al reported the prevalence of heterotopic ossification was 4. Anhidrosis after anterior retroperitoneal approach for L4-L5 artificial disc replacement. Clinical results of Maverick lumbar total disc replacement: two-year prospective follow-up. Are periprosthetic tissue reactions observed after revision of total disc replacement comparable to the reactions observed after total hip or knee revision surgery The main indication for iliac screws is distal fixation to the pelvis after long spinal fusions to reduce failure rate. The most common complications arising from iliac screw placement are (1) screw prominence/pain, (2) rod breakage/screw loosening, (3) infection, and (4) neurologic injury. Intraoperative fluoroscopy or plain radiographs can be used during the procedure to confirm accurate screw placement. The "modified approach" does not use the adjunctive offset or slotted connector that the traditional approach requires. The pain may not significantly improve with narcotic or anti-inflammatory pain medication. Given the location of the screw, the most common complaint is screw prominence while sitting. Overall, the decision to electively remove iliac screws is patient and surgeon choice. The technique to allow for placement of the iliac screws requires extensive surgical exposure as described above. In a retrospective study comparing differing techniques of fixation after long fusion to the pelvis, 8 of 39 patients (20. The decision to remove the iliac screws is determined clinically on a patient-by-patient basis. Other complications after iliac screw placement can be related indirectly to the iliac screw. Although the techniques to enhance the reliability of iliac screws as well as long spinal fusion systems have progressed throughout the years, careful surgical technique and placement of all instrumentation is required to minimize the complications. Given the low incidence of neurologic injury in iliac screw placement, the exact incidence is unknown. In a 2014 study by Finger et al, 13% (3 of 23) of patients who had iliac screws placed experienced neurological deficits. No studies have demonstrated any symptomatic injuries to the structures of the greater sciatic notch; however, great care must be taken while placing iliac screws. A thorough understanding of the anatomy and experience with the surgical technique of placement of iliac screws is recommended to decrease the risk of injury to surrounding structures. The exact incidence of infection involving iliac screws is hard to ascertain from the literature given iliac screws are usually placed in conjunction with other hardware, as well as the diverse patient populations requiring the procedure. In a minimum 2-year follow-up study, an infection rate of 4% (3 of 81 patients) was found. Depending on the clinical picture, surgical irrigation and debridement can be used in conjunction with hardware removal. Few studies document the nature of the organisms involved in postoperative infections after instrumentation with iliac screws. As in all wound infections, cultures and local resistance patterns are recommended to guide the appropriate antibiotic therapy. Generally, acute infections are defined as infections occurring within 90 days (3 months) of the operation. Careful perioperative sterile technique should be followed to minimize the risk of infection given the extensive exposure during placement of iliac screws. Aggressive irrigation and debridement should be used liberally to minimize long-term complications. The internal iliac artery and vein, middle sacral artery and vein, sympathetic trunk, lumbosacral trunk, and 302 Complications of Iliac Screw Fixation the newest surgical technique described is freehand placement of iliac screws. At the end of the follow-up period (range of 24 to 40 months), there were no postoperative complications to be reported related to iliac screw placement. To truly determine the effectiveness and safety of the techniques described above for iliac screw placement, multiple larger scale studies demonstrating the same results seen in the small studies need to be undertaken. Evaluation of pelvic fixation in neuromuscular scoliosis: a retrospective study in 55 patients. Unilateral versus bilateral iliac screws for spinopelvic fixation: are two screws better than one Should symptomatic iliac screws be electively removed in adult spinal deformity patients fused to the sacrum A mid-term follow-up result of spinopelvic fixation using iliac screws for lumbosacral fusion. Correction of pelvic obliquity in neuromuscular spinal deformities using the "T construct": results and complications in a prospective series of 60 patients. Failure of lumbopelvic fixation after long construct fusions in patients with adult spinal deformity: clinical and radiographic risk factors: clinical article. Iliac screw fixation using computer-assisted computer tomographic image guidance: technical note. Biomechanical comparison of lumbosacral fixation techniques in a calf spine model. The pylon concept of pelvic anchorage for spinal instrumentation in the human cadaver. Biomechanical advantages of dual over single iliac screws in lumbo-iliac fixation construct. Biomechanical analysis of iliac screw fixation in spinal deformity instrumentation. Historical overview, indications, biomechanical relevance, and current techniques. Outcome and complications of long fusions to the sacrum in adult spine deformity: LuqueGalveston, combined iliac and sacral screws, and sacral fixation. Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. In this article, we describe the indications for pelvic fixation, review the current most commonly used techniques, and present the short-term clinical outcomes and complications of the sacral alar iliac screw technique. Posteroanterior (d) and lateral (e) radiographs after she underwent excision of hemivertebra with posterior instrumented fusion from L3 to S2. The first three ventral sacral roots contribute to the sacral plexus and innervate intrapelvic visceral structures. The dorsal rami provide sensory feedback from the skin overlying the sacrum and are often sacrificed during the dorsal sacral dissection. It travels along the midline over the fifth lumbar vertebra, sacrum, and coccyx and runs posterior to the venous system to anastomose with the lateral sacral arteries.

They found no significant differences in fusion rates between the systems asthma zinc deficiency buy generic singulair from india, though individual studies showed improved fusion rates with the use of dynamic systems asthma definition zionism order singulair with amex. Standalone interbody cages with integrated screw fixation have recently been introduced with the goals of increasing fusion rates asthma treatment 5 steps buy singulair with paypal, maintaining sagittal correction asthma definition 6 steps order singulair amex, and providing a low profile to minimize implant prominence; however asthma symptoms night sweats purchase singulair master card, no long-term comparative studies exist comparing standalone interbody devices versus conventional graft and plate systems asthma 6 step management plan purchase 5mg singulair amex. They found lateral mass screw complications to be at worst, equivalent to those associated with wiring techniques. Furthermore, meticulous soft-tissue handling and closure of the posterior soft tissues is paramount to prevent further alterations to cervical biomechanics. Incidence of spinal column deformity after multilevel laminectomy in children and adults. Cervical alignment and range of motion after laminoplasty: radiographical data from more than 500 cases with cervical spondylotic myelopathy and a review of the literature. The long-term results of anterior surgical reconstruction in patients with postlaminectomy cervical kyphosis. Systematic review of the effect of dynamic fixation systems compared with rigid fixation in the anterior cervical spine. Extrusion of a screw into the gastrointestinal tract after anterior cervical spine plating. The use of an anterior plate and screw system when performing anterior discectomy or corpectomy with interbody fusion aides in preventing graft dislodgement and subsidence that would otherwise possibly lead to focal segmental kyphosis. Dynamic versus static anterior fixation requires additional research, though early research shows a benefit to static or constrained fixation in minimizing post anterior cervical fusion kyphosis. Analysis of cervical instability resulting from laminectomies for removal of spinal cord tumor. Pathogenesis and prophylaxis of postlaminectomy deformity of the spine after multiple level laminectomy: difference between children and adults. Delayed migration of a screw into the gastrointestinal tract after anterior cervical spine plating. Biomechanical analysis of an interbody cage with three integrated cancellous lag screws in a two-level cervical spine fusion construct: an in vitro study. Patients with a kyphosis ranging between 30 and 50 degrees should be assessed for surgery only if they have reached skeletal maturity and the rate of postural degeneration is advanced. Beyond 50 degrees, patients should be strongly considered for surgery because the rate of curvature progression is serious (1 degree or greater annually). Without treatment, the progression of the kyphosis can lead to pain, poor respiratory ability, and disability. Whereas this appearance is not always associated with pain, affected individuals may have persistent discomfort that classically ceases as the skeleton reaches maturity. The end plate may also have evidence of increased levels of mucopolysaccharides, reduced collagen, and disorganized endochondral ossification. Biological failures are the result of infection, osteoporosis, pseudarthrosis, and various comorbidities. Adequate bone quality is vital for the successful biomechanical integration of hardware within the thoracic spine. Osteoporotic vertebral endplates can contribute to failure of instrumentation fixation and loosening of implants. For example, the distal fixation point in posterior dual rod constructs can fail at a rate of 0 to 3%. This issue can lead to improper placement of instrumentation, risking damage to surrounding tissues. However, there is strong evidence to suggest that complication rates increase with more aggressive osteotomy procedures. Owing to the severity of these potential complications, three-column osteotomies are usually reserved for sharp, pointed deformities in rigid kyphotic 54. The surgeon should weigh the benefits of each method of surgical approach against the added risks associated with more complex procedures. Rate of complications in scoliosis surgery - a systematic review of the PubMed literature. Preventing distal pullout of posterior spine instrumentation in thoracic hyperkyphosis: a biomechanical analysis. Pedicle-sparing transforaminal thoracic spine wedge osteotomy for kyphosis correction. Rod fracture after long construct fusion for spinal deformity: clinical and radiographic risk factors. A lack of understanding of sagittal balance has resulted in numerous patients experiencing inadvertent outcomes after spine surgery. Spinopelvic balance is essentially an open linear chain in the sagittal plane, extending from the head cranially to the pelvis caudally. Any alteration of the anatomy at one level will have repercussions for subsequent adjacent levels. Within this cone, an individual can maintain standing balance; however, outside of this cone, the individual will require supportive devices to maintain balance. The normal sagittal balance in the adult spine is kyphotic from T1 to T12 with an average angulation of 10 to 40 degrees. Early attempts at spinal instrumentation included the use of facet screws, which, despite good initial results, demonstrated poor long-term outcomes related to catastrophic hardware failure when patients were mobilized prior to adequate fusion. In response to deformities associated with the polio epidemic, Harrington developed his instrumentation to provide correction and stabilization of spinal deformity. Distraction was provided through the rod and hook construct leading to correction of the deformity in the coronal plane. To compensate for this misalignment, the patient must then hyperextend any segments not included in the instrumentation and fusion mass, creating a loss of the normal thoracic kyphosis. Additional modifications included decreasing the number of fusion levels while not shortening the length of the instrumentation. Advancements in spinal implants have changed the way spinal instrumentation and fusion is performed. This technique has come into favor largely for the ability to achieve three-column fixation and therefore better rotational control. When compared with other modes of fixation, all pedicle screw constructs provide greater curve correction, rotational improvement, and improved sagittal alignment. If the patient is positioned in such a way that will make it difficult to restore lordosis, the spine will be fused in a suboptimal position. Alternatively, it is considered fixed if there is no correction, with some patients demonstrating partial correction. A closing wedge osteotomy is subsequently performed by applying compression of the instrumentation at the level of the osteotomy. The exiting nerve root will now share an enlarged foramen with the more cephalad exiting nerve root. The anterior and posterior columns are usually reconstructed using an anterior cage with posterior pedicle screw instrumentation. It is critical for the surgeon to take the appropriate steps intraoperatively to avoid the development of this complication. Appropriate positioning and minimizing the extent of the lumbar fusion are key in avoiding the loss of lumbar lordosis. In patients who do develop flatback, nonoperative techniques have shown poor results and corrective surgeries with various osteotomies are often required. Gravity line analysis in adult volunteers: age-related correlation with spinal parameters, pelvic parameters, and foot position. Long-term anatomic and functional changes in patients with adolescent idiopathic scoliosis treated by Harrington rod fusion. Sagittal plane analysis in idiopathic scoliosis patients treated with Cotrel-Dubousset instrumentation. Adult idiopathic scoliosis treated by posterior spinal fusion and Harrington instrumentation. A comparison of intraoperative results of patient positioning on two different operative table frame types. Osteotomy of the lumbar spine for correction of kyphosis in a case of ankylosing spondylarthritis. She noted that the pain began 7 to 8 years ago and had gradually worsened over the past year; it now prevents her from participating in sports activities. She was most comfortable lying down, whereas her pain increased with standing, sitting, and walking. On physical exam, the patient was a well-appearing young woman; when standing erect, she exhibited a slight forward tilt of her trunk relative to her pelvis. These compromises to structural integrity of the spine may lead to a propensity for the development of a high-grade slip, which can lead to increased loads being placed on implants placed to treat the condition. Degenerative occurs with increasing age and is the result of disk degeneration and resultant facet degeneration. Traumatic implies a bilateral fracture of the posterior column that leads to spondylolisthesis. Developmental is defined as having anatomic abnormalities that predispose the patient to development of a spondylolisthesis and is divided into high and low dysplastic, whereas acquired includes the subclassifications of traumatic, surgical, pathologic, and degenerative. Interbody fusion devices are generally approved for spinal fusion at one or two continuous levels from L2 to S1 for the diagnosis of degenerative disc disease and/or Grade I spondylolisthesis, and to be packed with autograft. Several other authors2,3,4,45 have further contributed to the study of this anatomic parameter and its role in spondylolisthesis. The same has been demonstrated2,44 for the relationship between increasing pelvic incidence and lumbar lordosis. Among these is the demonstration of an underdeveloped or elongated pars, as well as dysplastic facets, underdeveloped transverse processes,10 a defective neural arch, wedging of the L5 vertebral body, and sacral doming. However, as Ikata et al51 suggested, some of these anatomic aberrations, namely, sacral doming and wedging of the L5 vertebral body, may develop as a response or adaptation to the forces at work in the listhesed segment. Sansur et al,54 in their review of reported Scoliosis Research Society Morbidity and Mortality database complications associated with more than 10,000 adult patients treated for spondylolisthesis, showed a 22. A note of importance is that the literature has been inconsistent in the reporting of patient functional outcomes based on choice of instrumentation. Whereas the most attractive method of instrumentation would be the one which provides the best patient outcome while minimizing complications risks, the method that provides that is not entirely clear. Instrumented posterolateral fusion was found to have a statistically higher rate of postoperative blood transfusion than either in situ fusion or 360-degree fusion; the authors attributed this to the lower number of operated levels in the 360-degree fusion group. A crucial element to keep in mind about this study, however, was that the grade of spondylolisthesis was not reported in the results, as well as the fact that this study dealt with the treatment of degenerative spondylolisthesis rather than developmental/ 379 Thoracolumbar dysplastic spondylolisthesis, and which tends to be of a lower grade slip. Molinari et al10 demonstrated a higher level of patient function, satisfaction, and fusion rate in the treatment of patients with high-grade spondylolisthesis when utilizing partial reduction of the listhesed segment and an interbody fusion device (circumferential fusion) versus instrumented posterolateral fusion without a reduction maneuver. In patients without instrumentation and a grade 1 listhesis, 4 of 25 patients demonstrated migration; in patients without instrumentation and grade 2 listhesis, 3 of 14 patients had evidence of migration. A similar rate of migration (17%) has been demonstrated when lateral approach stand-alone interbody cages were used to treat low-grade lumbar spondylolisthesis. All six patients in their series achieved fusion as well as a good functional outcome according to the Scoliosis Research Society outcomes measure, and at an average of 42 months of follow-up, none demonstrated any instrumentationrelated complications. The fibula is harvested, split longitudinally, and placed into the reamed passages for fixation across the segment. All patients achieved fusion, and they did not encounter any implant-related complications. Another modification was described by Jones et al,39 in which the approach for placement of the fibula strut was anterior. Sasso et al42 also described their results, with eight patients having bilateral fibular struts placed from a posterior 56. Hu et al13 showed a 25% (4 patients) instrumentation failure rate performing complete reduction with the Edwards Modular Spinal System, with each patient requiring a revision procedure. Boos et al11 also demonstrated the need for an interbody device in the reporting of their results, in which they noted that five out of six patients treated for high-grade spondylolisthesis with instrumented posterolateral fusion without interbody support had a loss of reduction and instrumentation failure. As further illustration of this point, DeWald et al12 demonstrated 100% fusion rate in patients with high-grade spondylolisthesis undergoing circumferential fusion utilizing pedicle screws, with one case of implant pullout (7. Therefore, it has become the recommendation by many authors11,12,13,56,57 that surgical treatment for high-grade spondylolisthesis include the use of an interbody fusion device for anterior column support. One patient had late implant removal because of subcutaneous prominence; they did not report any implant failures. Nevertheless, reduction maneuvers are often included in the treatment for high-grade spondylolisthesis when significant sagittal imbalance is present. The authors noted that the procedure produced a significant reduction in slip angle without a significant reduction in slip grade, but that they had no neural injuries, no progression of slip, restoration of sagittal balance, and good functional outcome in all patients at an average of 2 years of follow-up. Though the advantages of reduction are many, the neurologic risks often include nerve root palsies (overwhelmingly the L5 root),7,9,10,54 most of which are temporary. Ilharreborde et al have as of yet not reported their outcomes with the use of this technique for treatment of high-grade spondylolisthesis, but did later36 describe their experience with the technique when employed for the original indication, neuromuscular scoliosis. Molinari et al,10 in their report on 32 patients undergoing one of three procedures (in situ fusion, instrumented posterolateral fusion, or reduction and circumferential fusion), showed a 29% implant complication rate (including loosening, breakage, or pullout which caused partial loss of reduction) in the instrumented posterolateral fusion group, and 11% of those in the reduction and interbody fusion group had partial loss of reduction.

Incidence asthmatic bronchitis back pain buy singulair 10mg, prevalence asthma 504 form cheap singulair 10 mg with mastercard, and analysis of risk factors for surgical site infection following adult spinal surgery asthmatic bronchitis icd-9 code purchase 4 mg singulair visa. Surgical site infection in spinal surgery: description of surgical and patient-based risk factors for postoperative infection using administrative claims data asthmatic bronchitis 4 times generic 10mg singulair free shipping. Management of infection after instrumented posterior spine fusion in pediatric scoliosis asthma symptoms early singulair 10mg mastercard. Infections after spinal correction and fusion for spinal deformities in childhood and adolescence asthma treatment list singulair 10 mg sale. Infection after spinal fusion for pediatric spinal deformity: thirty years of experience at a single institution. The post-operative changes in the level of inflammatory markers after posterior lumbar interbody fusion. Quantitation of C-reactive protein levels and erythrocyte sedimentation rate after spinal surgery. Usefulness of white blood cell differential for early diagnosis of surgical wound infection following spinal instrumentation surgery. Factors associated with increased rate of infection included revision surgery, performance of spinal fusion, and use of implants. Clinical outcome of deep wound infection after instrumented posterior spinal fusion: a matched cohort analysis. At the completion of treatment, patients can expect a mediumterm clinical outcome similar to patients in whom the complication did not occur. Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Predisposing factors for infection in spine surgery: a survey of 850 spinal procedures. Effects of nonsteroidal anti-inflammatory drugs on bone formation and soft-tissue healing. One-stage versus two-stage anterior and posterior spinal reconstruction in adults. Predisposing factors for surgical site infection of spinal instrumentation surgery for diabetes patients. Relationship of blood transfusion, post-operative infections and immunoreactivity in patients undergoing surgery for gastrointestinal cancer. Rates and causes of mortality associated with spine surgery based on 108,419 procedures: a review of the Scoliosis Research Society Morbidity and Mortality Database. Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Decreased risk of wound infection after posterior cervical fusion with routine local application of vancomycin powder. Postoperative deep wound infections in adults after spinal fusion: management with vacuum-assisted wound closure. Therapy of spinal wound infections using vacuum-assisted wound closure: risk factors leading to resistance to treatment. Primary spinal tumors are rare and isolated malignant osseous tumor cases are candidates for en bloc resections. Anterior body support must be taken into consideration during surgical planning because posterior-only instrumentation in the setting of vertebral body collapse may lead to instrumentation failure. Direct extension or invasion of the tumor from adjacent organs is another means of metastatic spread. Prognostic scores assist in the surgical planning process and in determining whether or not to operate. In addition to neurological compromise, spinal instability is a common indication for surgical management. A score of 0 to 6 is a stable spine, 7 to 12 is impending instability, and 13 to 18 is an unstable spine. Nonmetastatic malignant lesions in the spine include lymphoma and multiple myeloma. These are radiosensitive tumors and can be managed primarily with radiation and chemotherapy. In the cervical spine, lateral mass screws and pedicle screws at C2 and C7 are commonly used. Posterior-based approaches allow for decompression of metastatic epidural compression. In the thoracic and lumbar spine, transpedicular decompression can provide adequate decompression depending on the extent of compression. If a wider decompression or anterior body support is needed in the thoracic spine, a costotransversectomy or a lateral extracavitary approach can also be used. In the cervical spine, posterior-based approaches usually supplement anterior-based instrumentation. Depending on the location of the chordoma and extent of resection, lumbo-sacro-pelvic fixation is usually needed. In the sacrum depending on the extent of presacral tumors, a colorectal surgeon is used to help with mobilization of the rectum and sigmoid. Especially in the thoracic spine, there is a learning curve associated with this technique. If extensive posterior decompression and fusion is performed, there is risk of pseudarthrosis and rod failure. However, the majority of spine tumor surgeries are palliative and pseudarthrosis may not be a significant concern as in other types of spine surgeries. This technique has been described for spinal deformity cases with three-column osteotomies. Instrumenting across junctional levels such as the cervicothoracic, thoracolumbar, and lumbosacral spine can lead to instrumentation failure. In the thoracolumbar region, osteoporosis or lytic lesions can lead to proximal junction kyphosis and end-plate subsidence. If proximal junction kyphosis is greater than 20 degrees and the patient is symptomatic, then revision and extension of the construct can be considered. It is advisable to supplement anterior fixation with posterior-based instrumentation if poor bone quality is encountered. If using expandable cages, it would be ideal to use the largest footprint available. The patient opted nonoperative management as his renal cell had progressed and was seeking hospice care. The benefit of iliac fixation is the option of putting up to three iliac screws if necessary. Magnetic resonance imaging of spine tumors: classification, differential diagnosis, and spectrum of disease. Single-stage posterolateral transpedicle approach for spondylectomy, epidural decompression, and circumferential fusion of spinal metastases. The route of metastatic vertebral tumors extending to the adjacent vertebral body: a histological study. Current posterior-based approaches in the thoracic spine allow for resection of the vertebral body and anterior column support. As more vertebral decompressions are being performed from posteriorbased approaches, smaller cages are being developed. This concept of "separation surgery" has been introduced by Laufer and colleagues. Tube-based tumor decompression and percutaneous stabilization have also been described. Lateral interbody fusion technique also allows for minimally invasive corpectomies of the thoracic and lumbar spine. If blood loss and patient outcomes are better with the minimally invasive techniques, more adoptions of these techniques may occur. Minimally invasive surgery treatment for thoracic spine tumor removal: a mini-open, lateral approach. Biomechanical analysis of revision strategies for rod fracture in pedicle subtraction osteotomy. Biomechanical testing of a novel four-rod technique for lumbo-pelvic reconstruction. The incidence and patterns of hardware failure after separation surgery in patients with spinal metastatic tumors. Spine instrumentation failure after spine tumor resection and radiation: comparing conventional radiotherapy with stereotactic radiosurgery outcomes. Minimally invasive decompression and stabilization for the management of thoracolumbar spine metastasis. They demonstrated that 36% of the load was transmitted to the vertebral bodies and 64% to the posterior elements. The facet joints have a limited gliding motion, with the plane of articulation being more horizontally oriented to allow a greater range of motion in the cervical spine. Flexion and extension of the cervical spine provides a wide arc of motion, averaging 90 degrees. As the center of gravity moves anterior to the bodies, the posterior spinal musculature must continually contract to keep the head upright, causing fatigue, neck pain, and further decompensation and kyphosis. This "chin-on-chest" deformity can be debilitating for the patient, and difficult to treat for the surgeon. Ask pertinent questions about symptoms, past surgical history, and prior 358 Cervical Kyphosis treatments. Dynamic flexion and extension X-rays evaluate flexibility and may reveal instability. Preoperative cervical traction with cranial tongs may result in slow, gentle, controlled correction of the deformity in an awake patient that can be serially monitored for any neurologic changes. Each strategy must be individualized for the patient, depending on symptoms, previous surgery, and the indication for surgery. Vocal cord function should be analyzed by direct laryngoscopy prior to revision anterior cervical surgery. Reported incidence of pseudarthrosis after anterior cervical discectomy and interbody fusion ranges from 0 to 50%, and up to 30% of these are asymptomatic and may be treated nonoperatively. The symptomatic patient in this scenario is best treated with revision anterior surgery, removal of hardware, and exploration of fusion, followed by repeat endplate preparation, correction of kyphosis with anterior interbody placement, and anterior cervical plating. In addition, decompression of the spinal cord for myelopathy versus root decompression for radiculopathy changes the surgical management in revision anterior surgery. Treatment algorithm of postlaminectomy kyphosis centers on fixed versus flexible deformity, area of stenosis, and symptoms. Conservative treatments used for the management of symptoms secondary to kyphosis include physical therapy, traction, nonsteroidal anti-inflammatory medicines, steroid injections, and other modalities. Indications for further surgical intervention include intractable pain, neurologic deficits, progressive deformity, or disability, such as dysphagia or difficulty with forward gaze. The first anterior cervical plate and screw system was developed by Orozco Delclos and Llovet Tapies in 1972 for use in cervical trauma. Complications related to the use of anterior cervical instrumentation are vast and can be related to implant limitations, application, and surgical technique. In a systematic review, Campos and Botelho assessed the differences in outcomes and complications between dynamic and rigid fixation systems for anterior cervical instrumentation. The authors noted that all complications occurred with intrasacral rods (2 of 32 or 6. Though there have been numerous reports of minimally invasive surgical techniques employed for the treatment of low-grade spondylolisthesis,24,80,81,82 at the time of this writing there are few83,84 reports published regarding minimally invasive treatment for high-grade spondylolisthesis. This study demonstrated that a partial slip reduction was effective in helping to achieve a satisfactory clinical result, and established the benefit of circumferential fusion. One-stage decompression and posterolateral and interbody fusion for lumbosacral spondyloptosis through a posterior approach. Most authors advocate the use of instrumentation as a part of the treatment algorithm and the choices of implants are many; this presents several methods of achieving secure fixation with a relatively low rate of implant-related complications. The use of minimally invasive surgical techniques has been described; though only a few reports exist, it is likely that this will be a focus of future research relating to high-grade spondylolisthesis. Correlation of pelvic incidence with low- and high-grade isthmic spondylolisthesis. The sagittal pelvic tilt index as a criterion in the evaluation of spondylolisthesis. Short-term complications associated with surgery for high-grade spondylolisthesis in adults and pediatric patients: a report from the scoliosis research society morbidity and mortality database. Clinical outcome of trans-sacral interbody fusion after partial reduction for high-grade l5-s1 spondylolisthesis. Pedicular transvertebral screw fixation of the lumbosacral spine in spondylolisthesis. Long-term results of pediculo-body fixation and posterolateral fusion for lumbar spondylolisthesis. A comparison of in situ arthrodesis only with in situ arthrodesis and reduction followed by immobilization in a cast. Intrasacral rod fixation for pediatric long spinal fusion: results of a prospective study with a minimum 5-year follow-up. Transvertebral transsacral strut grafting for high-grade isthmic spondylolisthesis L5-S1 with fibular allograft. Spondylolisthesis, pelvic incidence, and spinopelvic balance: a correlation study.

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