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Shriver, Michael F Zeer, Valerie Alentado, Vincent J Mroz, Thomas E Benzel, Edward C Steinmetz, Michael POBJECT There are a variety of surgical positions that provide optimal exposure of the dorsal lumbar spine. These include the prone, kneeling, knee-chest, knee-elbow, and lateral decubitus positions. All are positions that facilitate exposure of the spine. Each position, however, is associated with an array of unique complications that result from excessive pressure applied to the torso or extremities. The authors reviewed clinical studies reporting complications that arose from positioning of the patient during dorsal exposures of the lumbar spine. METHODS MEDLINE, Scopus, and Web of Science database searches were performed to find clinical studies reporting complications associated with positioning during lumbar spine surgery. For articles meeting inclusion criteria, the following information was obtained: publication year, study design, sample size, age, operative time, type of surgery, surgical position, frame or table type, complications associated with positioning, time to first observed complication, long-term outcomes, and evidence-based recommendations for complication avoidance. RESULTS Of 3898 articles retrieved from MEDLINE, Scopus, and Web of Science, 34 met inclusion criteria. Twenty-four studies reported complications associated with use of the prone position, and 7 studies investigated complications after knee-chest positioning. Complications associated with the knee-elbow, lateral decubitus, and supine positions were each reported by a single study. Vision loss was the most commonly reported complication for both prone and knee-chest positioning. Several other complications were reported, including conjunctival swelling, Ischemic orbital compartment syndrome, nerve palsies, thromboembolic complications, pressure sores, lower extremity compartment syndrome, and shoulder dislocation, highlighting the assortment of possible complications following different surgical positions. For prone-position studies, there was a relationship between increased operation time and position complications. Only 3 prone-position studies reported complications following procedures of less than 120 minutes, 7 studies reported complications following mean operative times of 121-240 minutes, and 9 additional studies reported complications following mean operative times greater than 240 minutes. This relationship was not observed for knee-chest and other surgical positions. CONCLUSIONS This work presents a systematic review of positioning-related complications following prone, knee-chest, and other positions used for lumbar spine surgery. Numerous evidence-based recommendations for avoidance of these potentially severe complications associated with intraoperative positioning are discussed. This investigation may serve as a framework to educate the surgical team and decrease rates of intraoperative positioning complications. =20
Derakhshan, Adeeb Miller, Jacob Lubelski, Daniel Nowacki, Amy S Wells, Brian J Milinovich, Alex Benzel, Edward C Mroz, Thomas E Steinmetz, Michael PBACKGROUND: Few studies have examined the general correlation between socioeconomic status and imaging. This study is the first to analyze this relationship in the spine patient population.; OBJECTIVE: To assess the effect of socioeconomic status on the frequency with which imaging studies of the lumbar spine are ordered and completed.; METHODS: Patients that were diagnosed with lumbar radiculopathy and/or myelopathy and had at least 1 subsequent lumbar magnetic resonance imaging (MRI), computed tomography (CT), or X-ray ordered were retrospectively identified. Demographic information and the number of ordered and completed imaging studies were among the data collected. Patient insurance status and income level (estimated based on zip code) served as representations of socioeconomic status.; RESULTS: A total of 24,105 patients met the inclusion criteria for this study. Regression analyses demonstrated that uninsured patients were significantly less likely to have an MRI, CT, or X-ray study ordered (P < .001 for all modalities) and completed (P < .001 for MRI and X-ray, P =3D .03 for CT). Patients with lower income had higher rates of MRI, CT, and X-ray (P < .001 for all) imaging ordered but were less likely to have an ordered X-ray be completed (P =3D .009). There was no significant difference in the completion rate of ordered MRIs or CTs.; CONCLUSION: Disparities in image utilization based on socioeconomic characteristics such as insurance status and income level highlight a critical gap in access to health care. Physicians should work to mitigate the influence of such factors when deciding whether to order imaging studies, especially in light of the ongoing shift in health policy in the United States.=20
Lubelski, Daniel Choma, Theodore J Steinmetz, Michael P Harrop, James S Mroz, Thomas EManagement of spine surgery patients with osteoporosis is challenging because of the difficulty of instrumenting and the potential complications, including nonunion and adjacent level fractures. Treatment of this patient population should involve a multidisciplinary approach including the spine surgeon, primary care physician, endocrinologist, and physical therapist. Indication for preoperative treatment before spinal fusion surgery is unclear. All patients should receive calcium and vitamin D. Hormone replacement therapy, including estrogen or selective estrogen receptor modulators, should be considered for elderly female patients with decreased bone mass. Bisphosphonates or intermittent parathyroid hormone are reserved for those with significant bone loss in the spine. Pretreatment with antiresorption medications affect bone remodeling, which is a vital part of graft incorporation and fusion. Although there have been numerous animal studies, there is limited clinical evidence. Accordingly, surgery should be delayed, if possible, to treat the osteoporosis before the intervention. Treatment may include bisphosphonates, as well as newer agents, such as recombinant parathyroid hormone. Further clinical data are needed to understand the relative advantages/disadvantage of antiresorptive vs anabolic agents, as well as the impact of administration of these medications before vs after fusion surgery. Future clinical studies will enable better understanding of the impact of current therapies on biomechanics and fusion outcomes in this unique and increasingly prevalent patient population.=20
Awad, Basem I Lubelski, Daniel Carmody, Margaret Mroz, Thomas E Anderson, James S Moore, Timothy A Steinmetz, Michael PBACKGROUND: Pedicle fractures in the cervical spine are common. They may occur in isolation or in combination with other concomitant fractures. Multiple classification systems have been introduced to provide a clinical framework when approaching these types of fractures; however, these systems do not provide guidelines for optimal treatment. Data regarding decision making are limited. Conservative treatment with orthoses may result in subluxation and instability requiring further treatment. Surgery may not be required in all instances because many of these injuries may heal without surgical intervention.; METHODS: All cases of cervical fractures treated at a single institution over a 5-year period were retrospectively reviewed. Cases with pedicle fractures were further evaluated, and 40 cases managed either with or without surgery were identified. Data on presenting history, neurologic examination, imaging findings, comorbidity, method of treatment, complication rate, and length of hospital stay were collected. Fractures were classified based on computed tomography scans. Data on associated injuries were also collected. Fusion rate and fracture displacement were assessed by plain radiographs and computed tomography scans at follow-up. Follow-up time points included 2, 6, and 12 weeks and 6 months after injury. Primary outcome was fracture healing regardless of modality in the absence of progressive deformity (i.e., listhesis, kyphosis) and need for further surgery.; RESULTS: Conservative therapy was administered to 26 patients, and 14 patients underwent surgery. There were no statistically significant differences between the 2 groups in terms of total levels injured (P =3D 0.9) or injury severity score (P =3D 0.5). Patients who presented with intact neurologic status were more likely to be treated conservatively (88% vs. 29%; P =3D 0.0004), whereas patients presenting with spinal cord injuries were more likely to undergo surgical fixation (35% vs. 0%; P =3D 0.0004). Length of hospital stay trended toward being significantly greater in patients who underwent surgery (10.6 days vs. 5.5 days; P =3D 0.07). According to our classification system, the most common fracture type was single line horizontal fracture occurring in 68% (27 of 40 cases). Vertical split pedicle fracture occurred in 28% (11 of 40 cases), and double line horizontal fracture occurred in 5% (2 of 40 cases). Posttreatment progressive listhesis was significantly higher in patients who were treated conservatively (31% vs. 0%; P =3D 0.03), especially when associated with comminuted lateral mass or subluxation or both.; CONCLUSIONS: This study describes and classifies unique cervical pedicle fractures and associated injuries. Our findings suggest that surgical treatment results in definitive stability for these injuries compared with conservative therapy, particularly for pedicle fractures associated with comminuted lateral mass or initially displaced fractures. However, nondisplaced vertical split pedicle fractures and isolated single line horizontal fractures may be treated nonsurgically without occurrence of further instability. A larger prospective study is required to confirm these findings. Copyright =C2=A9 2014 Elsevier Inc. All rights reserved.
Lubelski, Daniel Tharin, Suzanne Como, John J Steinmetz, Michael P Vallier, Heather Moore, TimothyOBJECTIVE Few studies have investigated the advantages of early spinal stabilization in the patient with polytrauma in terms of reduction of morbidity and mortality. Previous analyses have shown that early stabilization may reduce ICU stay, with no effect on complication rates. METHODS The authors prospectively observed 340 polytrauma patients with an Injury Severity Score (ISS) of greater than 16 at a single Level 1 trauma center who were treated in accordance with a protocol termed "early appropriate care," which emphasizes operative treatment of various fractures within 36 hours of injury. Of these patients, 46 had upper thoracic and/or cervical spine injuries. The authors retrospectively compared patients treated according to protocol versus those who were not. Continuous variables were compared using independent t-tests and categorical variables using Fisher's exact test. Logistic regression analysis was performed to account for baseline confounding factors. RESULTS Fourteen of 46 patients (30%) did not undergo surgery within 36 hours. These patients were significantly more likely to be older than those in the protocol group (53 vs 38 years, p =3D 0.008) and have greater body mass index (BMI; 33 vs 27, p =3D 0.02), and they were less likely to have a spinal cord injury (SCI) (82% did not have an SCI vs 44% in the protocol group, p =3D 0.04). In terms of outcomes, patients in the protocol-breach group had significantly more total ventilator days (13 vs 6 days, p =3D 0.02) and total ICU days (16 vs 9 days, p =3D 0.03). Infection rates were 14% in the protocol-breach group and 3% in the protocol group (p =3D 0.2) Total complications trended toward being statistically significantly more common in the protocol-breach group (57% vs 31%). After controlling for potential confounding variables by logistic regression (including age, sex, BMI, race, and SCI), total complications were significantly (p < 0.05) greater in the protocol-breach group (OR 29, 95% CI 1.9-1828). This indicates that the odds of developing "any complication" were 29 times greater if treatment was delayed more than 36 hours. CONCLUSIONS Early surgical stabilization in the polytrauma patient with a cervical or upper thoracic spine injury is associated with fewer complications and improved outcomes. Hospitals may consider the benefit of protocols that promote early stabilization in this patient population.=20
Whitmore, Robert G Curran, Jill N Ali, Zarina S Mummaneni, Praveen V Shaffrey, Christopher I Heary, Robert F Kaiser, Michael G Asher, Anthony L Malhotra, Neil R Cheng, Joseph S Hurlbert, John Smith, Justin S Magge, Subu N Steinmetz, Michael P Resnick, Daniel K Ghogawala, ZoherOBJECT: The authors have established a multicenter registry to assess the efficacy and costs of common lumbar spinal procedures using prospectively collected outcomes. Collection of these data requires an extensive commitment of resources from each site. The aim of this study was to determine whether outcomes data from shorter-interval follow-up could be used to accurately estimate long-term outcome following lumbar discectomy.; METHODS: An observational prospective cohort study was completed at 13 academic and community sites. Patients undergoing single-level lumbar discectomy for treatment of disc herniation were included. SF-36 and Oswestry Disability Index (ODI) data were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively. Quality-adjusted life year (QALY) data were calculated using SF-6D utility scores. Correlations among outcomes at each follow-up time point were tested using the Spearman rank correlation test.; RESULTS: One hundred forty-eight patients were enrolled over 1 year. Their mean age was 46 years (49% female). Eleven patients (7.4%) required a reoperation by 1 year postoperatively. The overall 1-year follow-up rate was 80.4%. Lumbar discectomy was associated with significant improvements in ODI and SF-36 scores (p < 0.0001) and with a gain of 0.246 QALYs over the 1-year study period. The greatest gain occurred between baseline and 3-month follow-up and was significantly greater than improvements obtained between 3 and 6 months or 6 months and 1 year(p < 0.001). Correlations between 3-month, 6-month, and 1-year outcomes were similar, suggesting that 3-month data may be used to accurately estimate 1-year outcomes for patients who do not require a reoperation. Patients who underwent reoperation had worse outcomes scores and nonsignificant correlations at all time points.; CONCLUSIONS: This national spine registry demonstrated successful collection of high-quality outcomes data for spinal procedures in actual practice. Three-month outcome data may be used to accurately estimate outcome at future time points and may lower costs associated with registry data collection. This registry effort provides a practical foundation for the acquisition of outcome data following lumbar discectomy.=20
Lubelski, Daniel Mihalovich, Kathryn E Skelly, Andrea C Fehlings, Michael G Harrop, James S Mummaneni, Praveen V Wang, Michael Y Steinmetz, Michael PSTUDY DESIGN: Systematic review.; OBJECTIVE: To summarize and critically review the economic literature evaluating the cost-effectiveness of minimal access surgery (MAS) compared with conventional open procedures for the cervical and lumbar spine.; SUMMARY OF BACKGROUND DATA: MAS techniques may improve perioperative parameters (length of hospital stay and extent of blood loss) compared with conventional open approaches. However, some have questioned the clinical efficacy of these differences and the associated cost-effectiveness implications. When considering the long-term outcomes, there seem to be no significant differences between MAS and open surgery.; METHODS: PubMed, EMBASE, the Cochrane Collaboration database, University of York, Centre for Reviews and Dissemination (NHS-EED and HTA), and the Tufts CEA Registry were reviewed to identify full economic studies comparing MAS with open techniques prior to December 24, 2013, based on the key questions established a priori. Only economic studies that evaluated and synthesized the costs and consequences of MAS compared with conventional open procedures (i.e., cost-minimization, cost-benefit, cost-effectiveness, or cost-utility) were considered for inclusion. Full text of the articles meeting inclusion criteria were reviewed by 2 independent investigators to obtain the final collection of included studies. The Quality of Health Economic Studies instrument was scored by 2 independent reviewers to provide an initial basis for critical appraisal of included economic studies.; RESULTS: The search strategy yielded 198 potentially relevant citations, and 6 studies met the inclusion criteria, evaluating the costs and consequences of MAS versus conventional open procedures performed for the lumbar spine; no studies for the cervical spine met the inclusion criteria. Studies compared MAS tubular discectomy with conventional microdiscectomy, minimal access transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion, and multilevel hemilaminectomy via MAS versus open approach.; CONCLUSION: Overall, the included cost-effectiveness studies generally supported no significant differences between open surgery and MAS lumbar approaches. However, these conclusions are preliminary because there was a paucity of high-quality evidence. Much of the evidence lacked details on methodology for modeling, related assumptions, justification of economic model chosen, and sources and types of included costs and consequences. The follow-up periods were highly variable, indirect costs were not frequently analyzed or reported, and many of the studies were conducted by a single group, thereby limiting generalizability. Prospective studies are needed to define differences and optimal treatment algorithms.; LEVEL OF EVIDENCE: 3.=20
Eccher, Matthew A Ghogawala, Zoher Steinmetz, Michael PThere is substantial controversy regarding the current evidence basis of practice for neurophysiologic intraoperative monitoring (NIOM). The randomized controlled trial is clearly the highest level of evidence of efficacy for intervention in health care. The low rate of new neurologic deficits in many types of surgeries for which NIOM is considered means that statistical power would require tremendous trial size; however, there are some surgeries with higher rates of new neurologic deficit for which this effect is not the case. For some surgeries, NIOM has clearly become the standard of care, and there would be no equipoise in randomization to NIOM versus no NIOM at all. For this situation, careful study design to permit comparison of different NIOM approaches or anesthesiological regimens might permit the achievement of equipoise. In oncological contexts, NIOM is often used to delimit the extent of resection to avoid motor new neurologic deficits, but this approach may lower complete resection rates; in this setting, a randomization to restrictive versus permissive NIOM parameters limiting resection could test the long-term advantages of motor versus oncological outcomes. Clearly, randomized controlled trial demonstration of NIOM efficacy for the prevention of new neurologic deficits would be difficult to accomplish. However, with careful choice of surgical population and randomization design, prospective trials would in fact not be impossible.=20
Tanenbaum, Joseph E Pelle, Dominic Benzel, Edward C Steinmetz, Michael P Mroz, Thomas
Grosso, Matthew J Matheus, Virgilio Clark, Megan van Rooijen, Nico Iannotti, Christopher A Steinmetz, Michael PBACKGROUND: Individually, immunomodulatory therapy and chondroitinases have demonstrated neuroprotective and potential neuroregenerative effects following spinal cord injury.; OBJECTIVE: To investigate the therapeutic potential of combined immunomodulatory and chondroitin sulfate-glycosaminoglycan degradation therapy in spinal cord injury.; METHODS: A combined immunomodulatory treatment using (1) liposome-encapsulated clodronate (selectively depletes peripheral macrophages), and (2) rolipram (a selective type 4 phosphodiesterase inhibitor), along with the chondroitin sulfate proteoglycan-glycosaminoglycan-degrading enzyme, chondroitinase ABC (ChABC), was assessed for its potential to promote axonal regrowth and improve locomotor recovery following midthoracic spinal cord hemisection injury in adult rats.; RESULTS: We demonstrate that combined treatment with liposomal clodronate, rolipram, and ChABC attenuates macrophage accumulation at the site of injury, reduces axonal die-back of injured dorsal column axons, and produces the greatest improvement in locomotor recovery at 6 weeks postinjury compared with controls and noncombined therapy. Anterograde and retrograde tracing revealed that delivery of clodronate, rolipram, and ChABC did not promote substantial axonal regeneration through the site of injury, although the treatment did limit the extent of axonal die-back. Histological assessments revealed that combined treatment with clodronate/rolipram and/or ChABC resulted in a significant reduction in lesion size and cystic cavitation in comparison with injured controls. Combined clodronate, rolipram, and ChABC treatment reduced the accumulation of macrophages within the injured spinal cord 7 weeks after injury.; CONCLUSION: The present data suggest that delivery of an immunomodulatory therapy consisting of clodronate and rolipram, in combination with ChABC, reduces axonal injury and enhances neuroprotection, plasticity, and hindlimb functional recovery after hemisection spinal cord injury in adult rats.=20
Steinmetz, Michael P Benzel, Edward C Apfelbaum, Ronald IOBJECTIVE: Subsidence is a naturally occurring process that is observed during aging and after spine surgery. Rigid cervical spine instrumentation is excellent for stabilizing the spine. These devices, however, also retard subsidence after surgery. Thus, the implant carries much of the axial load, rather than sharing the axial load with the bone graft. This results in an increased incidence of construct failures, pseudoarthrosis, or both, which often occur late in the postoperative course.METHODS: In contrast, dynamic implants allow normal (natural) subsidence to occur, while effectively stabilizing the spine by preventing translation, rotation, and angular deformation. Load sharing, which works with, instead of against, the normal biology of bone healing, occurs with axially dynamic implants, resulting in more robust and earlier fusions.RESULTS: Diminished incidences of construct failures have been reported with dynamic implants.CONCLUSION: Dynamic implants seem to be the system of choice for ventral cervical stabilization in selected patients.
Steinmetz, Michael P Resnick, Daniel KLaminoplasty was developed to treat multilevel pathology of the cervical spine, namely ossification of the posterior longitudinal ligament and cervical spondylotic myelopathy. Laminoplasty was popularized in the 1980s, and since then many variations on the theme have been developed. All are similar in that they expand the cervical canal while leaving the protective dorsal elements in place. Advocates claim that this prevents the formation of the "postlaminectomy" membrane, maintains spinal alignment, and should aid in maintaining cervical range of motion. The aforementioned are all potential shortcomings of laminectomy or laminectomy and fusion. The procedure has proven to be essentially equal to other cervical decompressive procedures in the neutral or lordotic spine, and outcome has been shown to be durable.
Progression free survival and functional outcome after surgical resection of intramedullary ependymomas.
Abdullah, Kalil G Lubelski, Daniel Miller, Jacob Steinmetz, Michael P Shin, John H Krishnaney, Ajit Mroz, Thomas E Benzel, Edward CWe present a 15 year institutional analysis of the factors affecting progression free survival (PFS) and overall survival (OS) in patients undergoing attempted resection of adult intramedullary spinal cord ependymomas. Intramedullary spinal cord tumors are rare but important clinical entities, and ependymomas are the most commonly encountered intramedullary tumor. In total, 53 adult patients over the span of 15 years were analyzed for OS, PFS, and the effects of plane of dissection (POD) and gross total resection (GTR) on functional and long term outcomes. The mean age was 45 years and median follow-up was 54 months. The follow-up neurological outcome and modified McCormick scale were used to determine the functional outcome. Kaplan-Meier curves were used to calculate progression and survival. The overall ability to achieve GTR was significantly correlated to identification of an intraoperative POD (p<0.001). There was a trend towards increased PFS with the ability to achieve a GTR. There was no significant difference in the pre- and postoperative functional outcome scores. The ability to achieve a GTR is strongly correlated to the identification of a POD in ependymomas. There is a trend towards an increased probability of PFS in intramedullary spinal cord tumors when GTR is achieved. The resection of these tumors is likely to halt, but not reverse, neurological deterioration. Copyright =C2=A9 2015 Elsevier Ltd. All rights reserved.
Teamwork in Trauma: System Adjustment to a Protocol for the Management of Multiply Injured Patients.
Vallier, Heather A Moore, Timothy A Como, John J Dolenc, Andrea J Steinmetz, Michael P Wagner, Karl G Smith, Charles E Wilczewski, Patricia AOBJECTIVES: We developed a protocol to determine the timing of definitive fracture care based on the adequacy of resuscitation. Inception of this project required a multidisciplinary group, including physicians from anesthesiology, general trauma and critical care, neurosurgery, orthopaedic spine, and orthopaedic trauma. The purposes of this study were to review our initial experience with adherence to protocol recommendations and to assess barriers to implementation.; DESIGN: Prospective.; SETTING: Level 1 trauma center.; INTERVENTION: Definitive fixation of pelvis, acetabulum, spine, and femur fractures within 36 hours of injury, based on laboratory parameters for acidosis.; MAIN OUTCOME MEASUREMENTS: Three hundred five consecutive skeletally mature patients with Injury Severity Score =E2=89=A5 16 (mean, 26.4) and 346 fractures of the proximal or diaphyseal femur (n =3D 152), pelvic ring (n =3D 56), acetabulum (n =3D 44), and/or spine (n =3D 94) were treated surgically. Adherence to the protocol was defined as definitive fixation within 36 hours of injury in resuscitated patients. All patients were adequately resuscitated within that time. Patient demographic and injury characteristics, date and time of presentation, and reasons for delay were recorded.; RESULTS: Two hundred fifty-one patients (82%) with 287 fractures were treated according to the protocol, whereas 54 patients (18%) with 59 fractures were definitively stabilized on a delayed basis (mean, 90 hours). Delay was not related to patient age, Injury Severity Score, day of week, or time of presentation. Before implementation of this protocol, 76% were treated on a delayed basis, demonstrating improvement for each fracture type: spine (79% of previous patients with delay), pelvis (57%), acetabulum (72%), and femur (22%); all P < 0.0001 for more frequently delayed surgery before the protocol. Surgeon choice to delay the procedure accounted for 67% of reasons for delay. Other reasons included intensivist choice (13%), operating room availability (7.4%), patient choice (3.7%), severe head injury (5.6%), or cardiac issues (3.7%). Our trauma center and surgeons became more accustomed to the protocol and had fewer delays over time; 10% were delayed 2 years after implementation.; CONCLUSIONS: Management of trauma patients with injury to multiple systems requires teamwork among providers from related specialties and hospital support, in terms of operating room access, with appropriate ancillary personnel and equipment. Our system adjusted quickly to the protocol. Surgeon preference was the most common reason for delayed fixation, but within 24 months, only 10% of fractures were treated on a delayed basis, as long as patients were resuscitated.=20
Steinmetz, Michael P Claybrooks, Roderick Krishnaney, Ajit Prayson, Richard A Benzel, Edward COBJECTIVE AND IMPORTANCE: Spinal hemangioblastomas usually occur as isolated, intramedullary, central nervous system masses, often as a component of von Hippel-Lindau syndrome. They may occasionally occur extradurally and give the appearance of vertebral hemangioma. Rarely, they may be purely osseous lesions. The surgical management of these lesions has not been elaborated. We present a case and discuss the management of multilevel osseous hemangioblastoma of the thoracic spine.CLINICAL PRESENTATION: A 50-year-old woman with a history of thoracic hemangioblastoma 3 years earlier presented with progressive paraparesis. Imaging revealed circumferential tumor involvement of T7 to T9, inclusive. There was severe spinal cord compression.INTERVENTION: The patient underwent surgery via a bilateral lateral extracavitary approach to the tumor. This permitted a complete spondylectomy of T7, T8, and T9; complete tumor removal; and decompression of the spinal cord. Pathological analysis confirmed hemangioblastoma. The spine was reconstructed with an interbody expandable cage and pedicle screw fixation, all placed via the dorsal approach. The patient improved neurologically after the operation.CONCLUSION: Although extremely rare, hemangioblastomas may occur in a purely osseous location. They may resemble vertebral hemangioma. Treatment should include aggressive surgical removal, although arduous, if appropriate. A bilateral lateral extracavitary approach is ideal for complete spondylectomy. With this technique, ventral and dorsal reconstruction of the spine through the same incision is possible.
The Utility of Preoperative Magnetic Resonance Imaging for Determining the Flexibility of Sagittal Imbalance.
Sharma, Akshay Pourtaheri, Sina Savage, Jason Kalfas, Iain Mroz, Thomas E Benzel, Edward C Steinmetz, Michael PBACKGROUND: Scoliosis X-rays are the gold standard for assessing preoperative lumbar lordosis; however, particularly for flexible lumbar deformities, it is difficult to predict from these images the extent of correction required, as standing radiographs cannot predict the thoracolumbar alignment after intraoperative positioning.; OBJECTIVE: To determine the utility of preoperative MRI in surgical planning for patients with flexible sagittal imbalance.; METHODS: We identified 138 patients with sagittal imbalance. Radiographic parameters including pelvic incidence and lumbar lordosis were obtained from images preoperatively.; RESULTS: The mean difference was 2.9=C2=B0 between the lumbar lordosis measured on supine MRI as compared to the intraoperative X-rays, as opposed to 5.53=C2=B0 between standing X-rays and intraoperative X-ray. In patients with flexible deformities (n =3D24), the lumbar lordosis on MRI measured a discrepancy of 3.08=C2=B0, as compared to a discrepancy of 11.46=C2=B0 when measured with standing X-ray.; CONCLUSION: MRI adequately determined which sagittal deformities were flexible. Furthermore, with flexible sagittal deformities, lumbar lordosis measured on MRI more accurately predicted the intraoperative lumbar lordosis than that measured on standing X-ray. The ability to preoperatively predict intraoperative lumbar lordosis with positioning helps with surgical planning and patient counseling regarding expectations and risks of surgery.=20