Abstract:

Introduction: Spine surgeons are embracing advanced biologic technologies in an attempt to help millions of people achieve a better outcome in spine surgery. These new technologies may be complicated to understand, partly because the contribution of different types of cells has not been definitively identified. This paper describes the characteristics of the stem cells used in spine surgery, including their actions and possible complications. The description necessitates an overview of all studies to date on the use of stem cells in spine surgery, as well as other cells used in cellular therapy. Materials and Methods: The paper summarizes the results of major studies to date on the use of stem cells in spine surgery. Cells were harvested from the posterior superior iliac spine, vertebral bodies in surgery, fat tissue, or from the posterior spine of cadavers. Results: This paper reports on three studies involving 37 patients treated with stem cells for regenerative spine surgery, 14 studies involving 533 patients treated with stem cells in spinal fusion surgery, and one study in which stem cells were used for the treatment of anterior cervical discectomy and fusion. Discussion: Indications, techniques, and calibration of results were different in each study. Results are available for cellular augmentation of demineralized bone sponges, OsteoSponge® (Bacterin, Belgrade, Montana) and concentrated bone marrow (Terumo BCT®, Lakewood, CO); cancellous allograft bone and BMA; mineralized collagen and BMA; Osteocel® Plus (OC+) (Nuvasive®, San Diego, California); b-Tricalcium phosphate (b-TCP) (SYNTHES® Dento, West Chester, Pennsylvania; a silicate-substituted calcium phosphate (Si-CaP) with bone marrow aspirate (BMA), and HEALOS® graft carrier (DePuy Synthes, West Chester, Pennsylvania) with bone marrow aspirate. Conclusion: Stem cell augmentation of spinal fusion surgery is equivalent to the gold standard for iliac crest bone graft in posterolateral fusion models. There is evidence of safety and feasibility in the injectable treatment of DDD with autologous BMC that indicates a favorable outcome of mesenchymal cell concentration on discogenic pain reduction. The use of adult stem cells is an innovation that promises fewer complications and improved function in patients who are demographically suitable for stem cell therapy.

Authors:

Kenneth K. Hansraj, MD, Chief of Spine Surgery, New York Spine Surgery & Rehabilitation Medicine, New York, New York, Attending Spine Surgeon, MidHudson Regional Hospital Of Westchester Medical Center Health Network, Poughkeepsie, New York

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Abstract:

The introduction of modern endoscopy in neurosurgery brought light to one of the darkest areas: the skull base. In particular, the trans-nasal route allowed skull base surgeons to visualize and dominate the entire midline skull base. We analyzed our surgical series of 199 patients that were affected by several pathologies (pituitary adenomas, clivalchordomas, craniopharyngioma, Rathke's cleft cysts, tuberculum sellaemeningiomas, and craniovertebral junction pathologies with bulbar compression) and treated each by using a 3D-HD endoscope between December 2012 and December 2015 and reviewed the literature. We present our results in terms of tumor resections and decompression inpatients affected by craniovertebral junction pathologies. Analyzing our direct experience, as well as the literature, we can assert that the amount and accuracy of necessary movements in order to achieve a determined target are affected by the screen clarity and image resolution of the device. Additionally, the experience of the surgeon has an important role in the surgical outcome. Moreover, depth perception is critical in order to obtain precise and accurate movements. Our observations and the experts' opinion indicate that this modality provides improved surgical dexterity by affording the surgeon with depth perception while manipulating tissue and maneuvering the endoscope in the endonasal corridor, which is especially crucial in reducing the learning curve of young neurosurgeons.

Authors:

Roberto Altieri, MD, Resident, Division of Neurosurgery, Valentina Tardivo, MD, Resident, Division of Neurosurgery, Paolo Pacca, MD, Resident, Division of Neurosurgery, Valentina Pennacchietti, MD, Resident, Division of Neurosurgery, Federica Penner, MD, Resident, Division of Neurosurgery, Diego Garbossa, MD, Neurosurgeon, Division of Neurosurgery, Alessandro Ducati, MD, Professor of Neurosurgery, Director of Division of Neurosurgery, , Massimiliano Garzaro, MD, Ear, Nose, and Throat Specialist, 1st ENT Division, Francesco Zenga, MD, Neurosurgeon, Division of Neurosurgery, Department of Neuroscience, University School of Medicine, Turin, Italy

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Abstract:

Objective: A novel motion-preserving technique to directly repair pars defects. Moreover, the indications for repair are expanded to include those with disc disease and associated spondylolisthesis. Summary of Background Data: The challenge in treating pars defects has been that there are few techniques available to stabilize them adequately. Treatment has focused on fusion across the inter-space versus grafting and instrumentation of the defect itself. We hypothesize that direct repair of the defect favors maintenance of normal motion characteristics by preserving the functional unit of the disc. This paper describes a motion-preserving technique to repair bilateral pars defects and its early clinical outcomes. Materials and Methods: A retrospective review of 20 patients with symptomatic bilateral pars defects treated with either intra-segmental or intra-intersegmental motion-preserving repair with two years of follow-up. Fifteen patients met the criteria for single level fixation. Five patients required additional fixation of flexible posterolateral fusion involving the inferior segment. Rh-BMP and autologous bone graft were placed within the defect. Plain film X-rays were used to determine stability, and thin-section CT was used to assess healing of the defect. Results: The procedure arrested any further slippage in 100% of cases, with bony healing in 95% of cases as demonstrated by CT scan. Clinical outcomes for the entire series were: excellent n=14, good n=3, no significant help n=3. For all cases there was a 5% rate of non-union. Conclusion: Further study and development of the technique via biomechanical testing is ongoing; however, the initial results are encouraging. Bone formation appears to be linked to decreasing symptoms in patients with bilateral pars fractures who have failed conservative treatment.

Authors:

James T. Bennett, MD, Orthopaedic Surgery Resident, Department of Orthopaedic Surgery, Temple University Hospital, Philadelphia, Pennsylvania, Kenneth J. Zook, PA-C, Physician Assistant, Department of Orthopaedic Surgery, SUN Orthopaedics of Evangelical, Lewisburg, Pennsylvania, Peter M. Eyvazzadeh, MD, Orthopaedic Surgery Resident, Department of Orthopaedic Surgery, Temple University Hospital, Philadelphia, Pennsylvania, Paul S. Lin, MD, Medical Director Orthopaedics, Department of Orthopaedic Surgery, SUN Orthopaedics of Evangelical, Lewisburg, Pennsylvania

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Abstract:

Background: How the relative volume of an epidural abscess on MRI affects outcomes with antibiotics alone has limited literature. The purpose of this study was to identify which infected epidural collections will reabsorb with antibiotics alone. Specifically, what is the critical size and enhancement on contrast MRIs to require a drainage procedure? Materials and Methods: A retrospective review of all spinal osteomyelitis patients from 2001–2012 was performed. Inclusion criteria included appropriate initial imaging, lab results, no drainage procedures of collections, and no treatment prior to admission at an outside institution. Large size epidural abscess was defined as abscesses with a volume greater than 1400 mm3. Clearance and mortality rates were evaluated. Results: The cohort consisted of 128 patients including 76 men and 52 women who had a mean age of 62 years (range, 21 to 90 years) and had a mean follow-up of 38 months (range, 24 to 72 months). Patients with a large epidural abscess had a greater clearance rate of the infection and decreased mortality rate when treated with surgery or drainage compared to patients treated with antibiotics alone [clearance: p=0.048; mortality: p=0.048]. Those small epidural abscesses had similar clearance and mortality rates when treated with surgery or drainage compared to antibiotics alone [clearance: p=0.75; mortality: p=0.13]. Patients with non-enhancing epidural abscesses had similar clearance rates—but increased mortality rates—when treated with antibiotics alone compared to surgery or drainage [clearance: p>0.9; mortality: p=0.03]. Those with enhancing epidural collections had similar clearance and mortality rates when treated with antibiotics alone compared to surgery or drainage [clearance: p=0.08, mortality: p=0.10]. Conclusion: Large epidural infected collections require surgery or a percutaneous drainage procedure. Clearance rates are higher and mortality rates are lower compared to non-operative management in these instances. Neurologically intact patients with a small epidural collection can be treated with antibiotics alone with good expected outcomes.

Authors:

Sina Pourtaheri, MD, Associate Professor, Kimona Issa, MD, PGY3 Resident, Tyler Stewart, MD, PGY2 Resident, Yashika Patel, MD, Research Assistant, Kumar Sinha, MD, Associate Professor, Ki Hwang, MD, Associate Professor, Arash Emami, MD, Chairman, Department of Orthopaedic Surgery, Seton Hall University, St Joseph's Regional Medical Center, Paterson, NJ

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Abstract:

Introduction: Obtaining blood or tissue cultures prior to administration of antibiotics has been the standard of care in the treatment of osteomyelitis of the spine. A delay in diagnosis of vertebral osteomyelitis is the primary culprit for the inaccuracy of blood cultures and biopsies. The purpose of this study was to evaluate the outcomes of spinal osteomyelitis in patients where the infecting organism was identified through cultures in contrast to cases where the cultures continued to be negative. Materials and Methods: We retrospectively reviewed the database of spinal osteomyelitis cases presented at a high-volume institution from 2001–2011. This resulted in 91 patients (51 men and 40 women) who had a mean age of 59 years with a mean follow-up of four years. Delay in diagnosis was defined as greater than 2.5 months from first ER visit for non-specific back pain to diagnosis of osteomyelitis without antibiotic treatment in the interim. Nineteen patients had a delay in diagnosis (DD) and 72 were diagnosed early (ED). Outcomes evaluated include clearance of infection, clinical outcomes measured by Oswestry disability index scores (ODIs), and the efficacy of blood cultures and biopsies. Results: The ED group had a higher odds ratio of osteomyelitis clearance compared to the delay in diagnosis group and this trended toward significance [p=0.08]. The mean improvements in ODIs were significantly greater in the ED group compared to the DD group. Positive blood cultures were more positive when drawn within one month compared to after one month [p=.001]. Percutaneous biopsy cultures were more positive when drawn within 2.5 months compared to after 2.5 months [p=.025]. Open biopsy cultures were more positive when drawn within 4.5 months compared to after that [p< 0.001]. Discussion: We found that delayed diagnosis may negatively affect the treatment outcome as evidenced by the greater improvements in ODI scores among those diagnosed early. Although we were unable to show a difference in clearance between early and delayed diagnosis, it is quite possible that larger cohorts may have shown this given the trend toward significance. Conclusion: Hence, an early diagnosis has improved vertebral osteomyelitis clearance and clinical outcomes, and blood cultures and biopsies may have a low yield if delayed.

Authors:

Kimona Issa, MD, PGY-3 Resident, Seton Hall University, St Joseph's Regional Medical Center, Paterson, NJ, Sina Pourtaheri, MD, Assistant Professor, Department of Orthopaedics, University of California, Los Angeles, Los Angeles, California, Anita Vijapura, MD, Resident PGY2, Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, Tyler Stewart, MD, Resident PGY2, Department of Orthopaedics, Wayne State University, Detroit, Michigan, Kumar Sinha, MD, Associate Professor, Seton Hall University, St Joseph's Regional Medical Center, Paterson, NJ, Ki Hwang, MD, Associate Professor, Seton Hall University, St Joseph's Regional Medical Center, Paterson, NJ, Arash Emami, MD, Chairman, Department of Orthopaedic Surgery, Seton Hall University, St Joseph's Regional Medical Center, Paterson, NJ

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