Feasibility and Patient-Reported Outcomes After Outpatient Single-Level Instrumented Posterior Lumbar Interbody Fusion in a Surgery Center: Preliminary Results in 16 Patients

By Dr. Kingsley Chin

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.Scientific Paper

Chin KR1, Coombs AV, Seale JA.

Interested medical professionals can read through the full paper, as published in Spine, here.

Study Design

Retrospective study.

Objective

To report surgical and patient-reported outcomes after outpatient lumbar fusions in an ambulatory setting.

Summary of Background Data

There is growing interest in the potential benefits of outpatient spine surgery such as reduced costs, consistent operative team, and decreased postoperative complications during in-hospital recovery. However, there are limited studies on outcomes after outpatient lumbar fusions, to guide patient selection, treatment techniques and postoperative expectations.

Methods

Medical records of 16 consecutive patients, who underwent outpatient direct open, single-level, posterior lumbar interbody fusions, were examined by a single surgeon. Outcome measures included visual analogue scale (VAS) scores for lower back and Oswestry Disability Indices (ODIs). Mean body mass indices (BMIs), estimated blood loss, surgical times and complications, and fusion rates were evaluated.

Results

Males represented 56% of patients. Mean age was 42.81 ± 3.05 years (mean ± standard error) and mean body mass index was 28.95 ± 1.04. History of smoking and narcotics use were statistically noncontributory. Mean final follow-up was 15 (range, 5.52-34.2 mo) months. Mean postoperative scores were determined by the final follow-up VAS and ODI. L5-S1 was the most common level of the 16 levels operated on (69%). Preoperative and postoperative VAS and ODI scores for lower back were obtained for 15 patients (93.75%). Mean lower back VAS score of 8.4 ± 0.37 preoperatively reduced to 4.96 ± 0.73 postoperatively, (P = 0.001). Mean ODI improved from 52.71 ± 0.04 preoperatively, to 37.43 ± 0.06 postoperatively, (P = 0.04). One patient experienced postoperative worsened back pain with clinical and radiological signs of possible aseptic discitis. Estimated blood loss was 161 ± 32 mL and average operating time was 124.85 ± 7.10 minutes. The overall fusion rate was 87.5%.

Conclusion

Direct open posterior lumbar interbody fusions were done safely with statistically significant reduction in average pain and ODI scores. Surgical times were approximately 2 hours with minimal blood loss, allowing patients to be comfortably discharged the same day without a drain.

About Author Dr. Kingsley R. Chin

Dr. Kingsley R. Chin, Founder of philosophy and practice of The LES Society and The LESS Institute

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.

Learn more about Dr. Chin here and connect via LinkedIn.

About Less Exposure Surgery

Less Exposure Surgery (LES) is based on a new philosophy of performing surgery, leading the charge to prove through bench and clinical outcomes research that LES treatment options are the best solutions – to lowering the cost of healthcare, improving outcomes and increasing patient satisfaction. Learn more at LESSociety.org.

The LES Society philosophy: “Tailor treatment to the individual aiding in the quickest recovery and return to a pain-free lifestyle, using LES® techniques that lessen exposure, preserve unoffending anatomy and utilize new technologies which are safe, easy to adopt and reproducible. These LES®techniques lessen blood loss, surgical time and exposure to radiation and can be safely performed in an outpatient center. Less is more.” – Kingsley R. Chin, MD

About The LESS Institute

The LESS Institute is the world leader center of excellence in Less Exposure Surgery. Our safe, effective outpatient treatments help patients recover quickly, avoid expensive hospital stays and return home to their family the same day. Watch our patient stories, follow us on Facebook and visit TheLESSInstitute.com to learn more.

About SpineFrontier

The above study utilized LES Technology from SpineFrontier – leading provider of LES Technologies and instruments – offering surgeons and patients superior technology and services.

Scientific Paper Author and Citation Details

Authors

Chin KR1, Coombs AV, Seale JA.

Author information

1. *Department of Clinical Biomedical Sciences, Charles E. Schmidt College of Medicine at Florida Atlantic University, Boca Raton, FL †Less Exposure Surgery Specialists Institute (LESS Institute), Fort Lauderdale, FL; and ‡Less Exposure Surgery Society (LES Society), Beverly, MA.

Molecular Variation in AVP and AVPR1a in New World Monkeys (Primates, Platyrrhini): Evolution and Implications for Social Monogamy

By Dr. Kingsley Chin

Scientific Paper

Ren D1, Chin KR2, French JA2.

Interested medical professionals can read through the full paper, also published in PLOS One, here.

Background

The neurohypophysial hormone arginine vasopressin (AVP) plays important roles in fluid regulation and vascular resistance. Differences in AVP receptor expression, particularly mediated through variation in the noncoding promoter region of the primary receptor for AVP (AVPR1a), may play a role in social phenotypes, particularly social monogamy, in rodents and humans. Among primates, social monogamy is rare, but is common among New World monkeys (NWM). AVP is a nonapeptide and generally conserved among eutherian mammals, although a recent paper demonstrated that some NWM species possess a novel form of the related neuropeptide hormone, oxytocin. We therefore characterized variation in the AVP and AVPR1a genes in 22 species representing every genus in the three major platyrrhine families (Cebidae, Atelidae and Pitheciidae). For AVP, a total of 16 synonymous substitutions were detected in 15 NWM species. No non-synonymous substitutions were noted, hence, AVP is conserved in NWM. By contrast, relative to the human AVPR1a, 66 predicted amino acids (AA) substitutions were identified in NWM. The AVPR1a N-terminus (ligand binding domain), third intracellular (G-protein binding domain), and C-terminus were variable among species. Complex evolution of AVPR1a is also apparent in NWM. A molecular phylogenetic tree inferred from AVPR1a coding sequences revealed some consensus taxonomic separation by families, but also a mixed group composed of genera from all three families. The overall dN/dS ratio of AVPR1a was 0.11, but signals of positive selection in distinct AVPR1a regions were observed, including the N-terminus, in which we identified six potential positive selection sites. AA substitutions at positions 241, 319, 399 and 409 occurred uniquely in marmosets and tamarins. Our results enhance the appreciation of genetic diversity in the mammalian AVP/AVPR1a system, and set the stage for molecular modeling of the neurohypophyseal hormones and social behavior in primates.

Arginine vasopressin (AVP) coding sequences for primates.
New World monkeys (NWM) are indicated by shaded area. ‘.’ represents identity with the human AVPR1a sequence.

Structural model of AVPR1a.
Numbers reflect amino acid substitutions in NWM relative to the human AVPR1a, and radical physicochemical substitutions are indicated by red diamonds and conservative changes by black circles. Potential positively selected sites are highlighted in green.

Molecular phylogenetic trees in primates.
A. Tree inferred from AVPR1a nucleotide coding sequences in primates. If bootstrap support is <60, no value is shown at nodes. Scale bar indicates the branch length in nucleotide substitutions per site. A red diamond indicates a genus characterized by social monogamy. B. A consensus tree of primates based on 54 nuclear genes (34,927 bp; [30]). Families Cebidae, Atelidae and Pitheciidae are highlighted in green, red and purple lines, respectively. Amino acid substitutions of the AVPR1a gene are plotted on the consensus tree: NWM-specific (green square), Callitrichinae-specific (red square), marmoset-specific (blue square), marmoset and Callicebus-specific (yellow square), and genera-specific (black square).

Sliding window analysis of dN/dS ratios and dN values along the NWM AVPR1a.
The ratio/value are drawn over the midpoint window position (window length 50, step size 10) from whole coding region. A dN/dS ratio above 1 indicates possible positive selection in the region. The elements of AVPR1a are highlighted in red (extracellular), yellow (transmembrane), and green (intracellular) lines.

About Author Dr. Kingsley R. Chin

Dr. Kingsley R. Chin, Founder of philosophy and practice of The LES Society and The LESS Institute

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.

Learn more about Dr. Chin here and connect via LinkedIn.

About Less Exposure Surgery

Less Exposure Surgery (LES) is based on a new philosophy of performing surgery, leading the charge to prove through bench and clinical outcomes research that LES treatment options are the best solutions – to lowering the cost of healthcare, improving outcomes and increasing patient satisfaction. Learn more at LESSociety.org.

The LES Society philosophy: “Tailor treatment to the individual aiding in the quickest recovery and return to a pain-free lifestyle, using LES® techniques that lessen exposure, preserve unoffending anatomy and utilize new technologies which are safe, easy to adopt and reproducible. These LES®techniques lessen blood loss, surgical time and exposure to radiation and can be safely performed in an outpatient center. Less is more.” – Kingsley R. Chin, MD

About The LESS Institute

The LESS Institute is the world leader center of excellence in Less Exposure Surgery. Our safe, effective outpatient treatments help patients recover quickly, avoid expensive hospital stays and return home to their family the same day. Watch our patient stories, follow us on Facebook and visit TheLESSInstitute.com to learn more.

About SpineFrontier

The above study utilized LES Technology from SpineFrontier – leading provider of LES Technologies and instruments – offering surgeons and patients superior technology and services.

Scientific Paper Author and Citation Details

Authors

Ren D1, Chin KR2, French JA2.

Author information

1. Callitrichid Research Center, Department of Psychology, University of Nebraska at Omaha, Omaha, Nebraska, United States of America; Key Laboratory for Animal Biotechnology of Jiangxi Province and the Ministry of Agriculture of China, Jiangxi Agricultural University, Nanchang, China; Department of Biology, University of Nebraska at Omaha, Omaha, Nebraska, United States of America.

2. Callitrichid Research Center, Department of Psychology, University of Nebraska at Omaha, Omaha, Nebraska, United States of America; Department of Biology, University of Nebraska at Omaha, Omaha, Nebraska, United States of America.

Safety and Usefulness of Free Fat Grafts After Microdiscectomy Using an Access Cannula: a Prospective Pilot Study and Literature Review

By Dr. Kingsley Chin

Scientific Paper

Chin KR1, Bassora R, Yu WD.

Interested medical professionals can read the full paper, published also in the American Journal of Orthopedics, here.

Abstract

Placing an interpositional fat graft over the dura has been practiced to prevent sciatica due to nerve tethering from scar. We assessed feasibility, outcomes, and complications of free fat grafts in patients undergoing lumbar microdiscectomy for herniated discs using an access cannula. Retrospective review of prospectively collected data on 69 consecutive patients: those who received autologous fat graft (Group I) and those who did not (Group II). Clinical evaluation of leg pain and nerve tension sign was performed in the immediate postoperative period and at 1 month, 6 months, 12 months, and 24 months. The combined visual analog scale (VAS) scores for leg pain improved from 8.3 preoperatively to 1.3 (P < 0.5). The average VAS score for leg pain was 1.4 (0 to 3) in Group I and 1.3 (0 to 3) in Group II (P > 0.05). Ninety-one percent had resolution of their leg pain immediately postop and 96% at final follow-up. This study found no increased complications with the use of fat graft, but no clinical benefit, therefore the use of fat graft should be discouraged. The potential complication with the use of fat graft is the “mass effect” on the dura, and therefore, the width of the graft should be <1 cm.

About Author & Orthopedic Surgeon Dr. Kingsley R. Chin

Dr. Kingsley R. Chin, Founder of philosophy and practice of The LES Society and The LESS Institute

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.

Learn more about Dr. Chin here and connect via LinkedIn.

About Less Exposure Surgery

Less Exposure Surgery (LES) is based on a new philosophy of performing surgery, leading the charge to prove through bench and clinical outcomes research that LES treatment options are the best solutions – to lowering the cost of healthcare, improving outcomes and increasing patient satisfaction. Learn more at LESSociety.org.

The LES Society philosophy: “Tailor treatment to the individual aiding in the quickest recovery and return to a pain-free lifestyle, using LES® techniques that lessen exposure, preserve unoffending anatomy and utilize new technologies which are safe, easy to adopt and reproducible. These LES®techniques lessen blood loss, surgical time and exposure to radiation and can be safely performed in an outpatient center. Less is more.” – Kingsley R. Chin, MD

About The LESS Institute

The LESS Institute is the world leader center of excellence in Less Exposure Surgery. Our safe, effective outpatient treatments help patients recover quickly, avoid expensive hospital stays and return home to their family the same day. Watch our patient stories, follow us on Facebook and visit TheLESSInstitute.com to learn more.

About SpineFrontier

The above study utilized LES Technology from SpineFrontier – leading provider of LES Technologies and instruments – offering surgeons and patients superior technology and services.

Scientific Paper Author & Citation Details

Authors

Chin KR1, Bassora R, Yu WD.

Author information

Charles E Schmidt College of Medicine at Florida Atlantic University and The Less Exposure Surgeons Surgery Institute (LESS Institute), Fort Lauderdale, FL. kingsleychin@Less-Institute.com.

Ideal Starting Point & Trajectory for C2 Pedicle Screw Placement: a 3D Computed Tomography Analysis Using Perioperative Measurement

By Dr. Kingsley Chin

Scientific Paper

Chin KR1, Mills MV2, Seale J3, Cumming V4.

Interested medical professionals can read through the full paper, as published in The Spine Journal, here.

Background

C2 pedicle screws provide stable fixation for posterior cervical fusion. Placing C2 pedicle screws is fraught with risks, and a misplaced screw can result in cortical breach of the pedicle, resulting in injury to the vertebral artery or spinal cord.

Purpose

We sought to identify a reproducible starting point and trajectory for C2 pedicle screw placement using three-dimensional (3D) computed tomography (CT) imaging. Our aims included identifying correct cephalad and mediolateral angles used for determining the most accurate trajectory through the C2 pedicle.

Study Design

A radiographic analysis of the anatomy of the C2 pedicle using CT.

Patient Sample

A random sample of 34 cervical spine CT scans in patients without medical or surgical pathology of the cervical spine.

Outcome Measures

Normal anatomic measurements made in the axial and sagittal planes of the CT scans. Angles and measures in millimeters were recorded.

Methods

The C2 pedicles were evaluated using CT scanning with a 3D imaging application. The ideal trajectory through each pedicle was plotted. The mediolateral and cephalad angles were measured using the midline sagittal plane and the inferior vertebral body border as references. Other measurements made were the distances through the pedicle and vertebral bodies, and the surface distances along the laminae between the isthmus and the starting point of the chosen trajectories. Other measurements involving the height of the laminae were also made. The mean values, standard deviations, and intraobserver variations are presented.

Results

CT scans from 34 patients were reviewed. The sex of the patient did not predict angle measurements (p=.2038), so combined male and female patient measures are presented. The mean mediolateral angle measured was 29.2°, and the mean cephalad angle was 23.0°. The mean distance along the lamina surface between the isthmus and the starting point was 8.1 mm. The mean distance from the superior border of the lamina to the starting point was 5.7 mm. There were no statistically significant differences between the dataset collected in duplicate by the same observer (p=.74); as such, we present one data analysis on combined data from the two datasets collected.

Conclusion

It is possible to determine an ideal trajectory through the C2 pedicle. These measurements may facilitate C2 pedicle screw fixation decreasing the risk of injury to the vertebral artery, spinal cord, or nerve roots. Delineating the individual anatomy in each case with imaging before surgery is recommended.

Copyright © 2014 Elsevier Inc. All rights reserved.

About Author Dr. Kingsley R. Chin

Dr. Kingsley R. Chin, Founder of philosophy and practice of The LES Society and The LESS Institute

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.

Learn more about Dr. Chin here and connect via LinkedIn.

About Less Exposure Surgery

Less Exposure Surgery (LES) is based on a new philosophy of performing surgery, leading the charge to prove through bench and clinical outcomes research that LES treatment options are the best solutions – to lowering the cost of healthcare, improving outcomes and increasing patient satisfaction. Learn more at LESSociety.org.

The LES Society philosophy: “Tailor treatment to the individual aiding in the quickest recovery and return to a pain-free lifestyle, using LES® techniques that lessen exposure, preserve unoffending anatomy and utilize new technologies which are safe, easy to adopt and reproducible. These LES®techniques lessen blood loss, surgical time and exposure to radiation and can be safely performed in an outpatient center. Less is more.” – Kingsley R. Chin, MD

About The LESS Institute

The LESS Institute is the world leader center of excellence in Less Exposure Surgery. Our safe, effective outpatient treatments help patients recover quickly, avoid expensive hospital stays and return home to their family the same day. Watch our patient stories, follow us on Facebook and visit TheLESSInstitute.com to learn more.

About SpineFrontier

The above study utilized LES Technology from SpineFrontier – leading provider of LES Technologies and instruments – offering surgeons and patients superior technology and services.

Scientific Paper Author & Citation Details

Authors

Chin KR1, Mills MV2, Seale J3, Cumming V4.

Author information

1. Charles E. Schmidt College of Medicine at Florida Atlantic University and LESS (LESSurgeons) Institute, Division LESSpine Institute, 1100 W. Oakland Park Blvd., Suite #3, Fort Lauderdale, FL 33311, USA. Electronic address: kingsleychin@gmail.com.

2. Department of Orthopedic Surgery, Howard University Hospital, Washington, DC, USA.

3. LESS (LESSurgeons) Institute, Division, LESSpine Institute, 1100 W. Oakland Park Blvd., Suite #3, Fort Lauderdale, FL 33311, USA.

4. Less Exposure Surgery (LES) Society, 300 E. Oakland Park Blvd., Suite 502, Fort Lauderdale, FL 33334, USA.

Stability of Transforaminal Lumbar Interbody Fusion in the Setting of Retained Facets and Posterior Fixation Using Transfacet or Standard Pedicle Screws

Scientific Paper

Chin KR1, Reis MT2, Reyes PM2, Newcomb AG2, Neagoe A2, Gabriel JP3, Sung RD4, Crawford NR2.

Interested medical professionals can read through the full paper, as published in the Spine Journal, here.

Background Concept

The transforaminal lumbar interbody fusion (TLIF) technique supplements posterior instrumented lumbar spine fusion and has been tested with different types of screw fixation for stabilization. Transforaminal lumbar interbody fusion is usually placed through a unilateral foraminal approach after unilateral facetectomy, although extraforaminal entry allows the facet to be spared.

Purpose

To characterize the biomechanics of L4-L5 lumbar motion segments instrumented with bilateral transfacet pedicle screw (TFPS) fixation versus bilateral pedicle screw-rod (PSR) fixation in the setting of intact facets and native disc or after discectomy and extraforaminal placement of a TLIF technology graft.

Study Design

Human cadaveric lumbar spine segments were biomechanically tested in vitro to provide a nonpaired comparison of four configurations of posterior and interbody instrumentation.

Methods

Fourteen human cadaveric spine specimens (T12-S1) underwent standard pure moment flexibility tests with intact L4-L5 disc and facets. Seven were studied with intact discs, after TFPS fixation, and then with TLIF and TFPS fixation. The others were studied with intact discs, after PSR fixation, and then combined with extraforaminally placed TLIF. Loads were applied about anatomic axes to induce flexion-extension, lateral bending, and axial rotation. Three-dimensional specimen motion in response to applied loads during flexibility tests was determined. A nonpaired comparison of the four configurations of posterior and interbody instrumentation was made.

Results

Transfacet pedicle screw and PSR, with or without TLIF, significantly reduced range of motion during all directions of loading. Transfacet pedicle screw provided greater stability than PSR in all directions of motion except lateral bending. In flexion, TFPS was more stable than PSR (p=.042). A TLIF device provided less stability than the intact disc in constructs with TFPS and PSR.

Conclusions

These results suggest that fixation at L4-L5 with TFPS is a promising alternative to PSR, with or without TLIF. A TLIF device was less stable than the native disc with both methods of instrumentation presumably because of a fulcrum effect from a relatively small footplate. Additional interbody support may be considered for improved biomechanics with TLIF.

Copyright © 2015 Elsevier Inc. All rights reserved.

About Author Dr. Kingsley R. Chin

Dr. Kingsley R. Chin, Founder of philosophy and practice of The LES Society and The LESS Institute

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.

Learn more about Dr. Chin here and connect via LinkedIn.

About Less Exposure Surgery

Less Exposure Surgery (LES) is based on a new philosophy of performing surgery, leading the charge to prove through bench and clinical outcomes research that LES treatment options are the best solutions – to lowering the cost of healthcare, improving outcomes and increasing patient satisfaction. Learn more at LESSociety.org.

The LES Society philosophy: “Tailor treatment to the individual aiding in the quickest recovery and return to a pain-free lifestyle, using LES® techniques that lessen exposure, preserve unoffending anatomy and utilize new technologies which are safe, easy to adopt and reproducible. These LES®techniques lessen blood loss, surgical time and exposure to radiation and can be safely performed in an outpatient center. Less is more.” – Kingsley R. Chin, MD

About The LESS Institute

The LESS Institute is the world leader center of excellence in Less Exposure Surgery. Our safe, effective outpatient treatments help patients recover quickly, avoid expensive hospital stays and return home to their family the same day. Watch our patient stories, follow us on Facebook and visit TheLESSInstitute.com to learn more.

About SpineFrontier

The above study utilized LES Technology from SpineFrontier – leading provider of LES Technologies and instruments – offering surgeons and patients superior technology and services.

Scientific Paper Author and Citation Details

Authors

Chin KR1, Reis MT2, Reyes PM2, Newcomb AG2, Neagoe A2, Gabriel JP3, Sung RD4, Crawford NR2.

Author information

1. Charles E. Schmidt College of Medicine at Florida Atlantic University, 777 Glades Rd, Building 71, Boca Raton, FL 33431, USA; Department of Orthopaedic Surgery, The LES Spine Institute, 1100 W. Oakland Park Blvd., Suite #3, Fort Lauderdale, FL 33311, USA. Electronic address: kingsleychin@imissurgery.com.

2. Department of Neurosurgery, Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ 85013, USA.

3. Department of Orthopedics, Grant Medical Center, 111 South Grant Ave, Columbus, OH 43215, USA.

4. The Spine Center at The Colorado Springs Orthopaedic Group, 3010 North Circle Dr, Suite 200, Colorado Springs, CO 80909, USA.

Stabilizing Effects of a Particulate Demineralized Bone Matrix in the L4 Interbody Space with and Without PEEK Cage – A Literature Review and Preliminary Results of a Cadaveric Biomechanical Study

By Dr. Kingsley Chin

Scientific Paper

Bruce C1, Chin KR2, Cumming V3, Crawford NR4.

Interested medical professionals can read through the full paper, also published the West Indian Medical Journal, here.

Abstract

We reviewed the biological elements supporting the usefulness of a specifically designed particulate form of demineralized bone matrix (DBM) with spinal fusion, and report some limitations of its use described in the medical literature and in the interbody space using a cadaveric biomechanical model. A literature review and description of the techniques used to augment spinal fusion are presented, including a more thorough review of recent findings of cadaveric biomechanical flexibility studies using DBM alone at different percentage fills of the existing disc space and DBM with a polyetheretherketone (PEEK) interbody cage. The need for DBM was established by reviewing limitations of autografts and allografts in spinal fusion. Demineralized bone matrix used alone did not increase stability post discectomy at L4-L5, but was demonstrated to exhibit satisfactory stability when used with a PEEK interbody cage. There may be a future role for DBM that hardens and fills disc space more rigidly, overcoming this limitation to its use.

About Author Dr. Kingsley R. Chin

Dr. Kingsley R. Chin, Founder of philosophy and practice of The LES Society and The LESS Institute

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.

Learn more about Dr. Chin here and connect via LinkedIn.

About Less Exposure Surgery

Less Exposure Surgery (LES) is based on a new philosophy of performing surgery, leading the charge to prove through bench and clinical outcomes research that LES treatment options are the best solutions – to lowering the cost of healthcare, improving outcomes and increasing patient satisfaction. Learn more at LESSociety.org.

The LES Society philosophy: “Tailor treatment to the individual aiding in the quickest recovery and return to a pain-free lifestyle, using LES® techniques that lessen exposure, preserve unoffending anatomy and utilize new technologies which are safe, easy to adopt and reproducible. These LES®techniques lessen blood loss, surgical time and exposure to radiation and can be safely performed in an outpatient center. Less is more.” – Kingsley R. Chin, MD

About The LESS Institute

The LESS Institute is the world leader center of excellence in Less Exposure Surgery. Our safe, effective outpatient treatments help patients recover quickly, avoid expensive hospital stays and return home to their family the same day. Watch our patient stories, follow us on Facebook and visit TheLESSInstitute.com to learn more.

About SpineFrontier

The above study utilized LES Technology from SpineFrontier – leading provider of LES Technologies and instruments – offering surgeons and patients superior technology and services.

Scientific Paper Author & Citation Details

Authors

Bruce C1, Chin KR2, Cumming V3, Crawford NR4.

Author information

1. Department of Surgery, Radiology, Anaesthesia and Intensive Care, The University of the West Indies, Kingston 7, Jamaica.

2. Charles E Schmidt College of Medicine at Florida Atlantic University and the Less Exposure Surgeons Surgery Institute (LESS Institute), Fort Lauderdale, FL, USA. kingsleychin@gmail.com.

3. Less Exposure Surgery Society, Fort Lauderdale, FL, USA.4Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA.

Effects of Misalignment on Static Torsional Strength of Anterior Cervical Plate Systems

By Dr. Kingsley Chin

Scientific Paper

Chin KR1, Cumming VB, Henson M, Murrell B, Chan FW.

Interested medical professionals can read through the full paper, as published in the Spine Journal, here.

Background

There is little understanding of cervical plate misalignment as a risk factor for plate failure at the plate-screw-bone interface.

Purpose

To assess the torsional strength and mode of failure of cervical plates misaligned relative to the midsagittal vertical axis.

Study Design

Plastic and foam model spine segments were tested using static compression and torsion to assess effects of misaligned and various lengths anterior cervical plate (ACPs).

Methods

Different length ACPs and cancellous fixed angle screws underwent axial torsional testing on a servo-hydraulic test frame at a rate of 0.5°/s. A construct consisted of one ACP, four screws, one ultrahigh-molecular weight polyethylene inferior block, and one polyurethane foam superior block. Group 1 had ACPs aligned in the midsagittal vertical axis, group 2 plates were positioned 20° offset from the midline, and group 3 had the ACP shifted 5 mm away and 20° offset from midline. Torques versus angle data were recorded. The failure criterion was the first sign of pullout determined visually and graphically.

Results

Group 1 had a more direct screw pullout during failure. For the misaligned plates, failure was a combination of the screws elongating the holes and shear forces acting between the plate and block. The misaligned plates needed more torque to failure. The failure torque was 50% reduced for the longer versus the shorter plates in the neutral position. Graphically shown initial screw slippage inside the block preceded visual identification of slippage in some cases.

Conclusions

We observed different failure mechanisms for neutral versus misaligned plates. Clinically, misalignment may have the benefit of needing more torque to fail. Misalignment was a risk factor for failure of the screw-bone interface, especially in longer plate constructs. These comparisons of angulations may be a solid platform for expansion toward a more applicable in vivo model.

Copyright © 2013 Elsevier Inc. All rights reserved.

About Author Dr. Kingsley R. Chin

Dr. Kingsley R. Chin, Founder of philosophy and practice of The LES Society and The LESS Institute

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.

Learn more about Dr. Chin here and connect via LinkedIn.

About Less Exposure Surgery

Less Exposure Surgery (LES) is based on a new philosophy of performing surgery, leading the charge to prove through bench and clinical outcomes research that LES treatment options are the best solutions – to lowering the cost of healthcare, improving outcomes and increasing patient satisfaction. Learn more at LESSociety.org.

The LES Society philosophy: “Tailor treatment to the individual aiding in the quickest recovery and return to a pain-free lifestyle, using LES® techniques that lessen exposure, preserve unoffending anatomy and utilize new technologies which are safe, easy to adopt and reproducible. These LES®techniques lessen blood loss, surgical time and exposure to radiation and can be safely performed in an outpatient center. Less is more.” – Kingsley R. Chin, MD

About The LESS Institute

The LESS Institute is the world leader center of excellence in Less Exposure Surgery. Our safe, effective outpatient treatments help patients recover quickly, avoid expensive hospital stays and return home to their family the same day. Watch our patient stories, follow us on Facebook and visit TheLESSInstitute.com to learn more.

About SpineFrontier

The above study utilized LES Technology from SpineFrontier – leading provider of LES Technologies and instruments – offering surgeons and patients superior technology and services.

Scientific Paper Author & Citation Details

Authors

Chin KR1, Cumming VB, Henson M, Murrell B, Chan FW.

Author information

1. Institute for Modern and Innovative Surgery, 1100 W. Oakland Park Blvd, Suite #3, Fort Lauderdale, FL 33311, USA. Electronic address: kingsleychin@imissurgery.com.

Postoperative Cervical Haematoma Complicated by Ipsilateral Carotid Thrombosis and Aphasia After Anterior Cervical Fusion: a Case Report

By Dr. Kingsley Chin

Scientific Paper

Chin KR1, Seale J, Butron V, Cumming V.

Interested medical professionals can read the full paper, as published in Case Reports in Medicine, here.

Abstract

Hematoma alone is the most common vascular complication reported after anterior cervical decompression and fusion (ACDF). We present this case to report the occurrence of postoperative cervical hematoma complicated by ipsilateral carotid thrombosis and aphasia after an uncomplicated C4-6 ACDF. This is a case of a 65-year-old woman who underwent revision fusions of the C4-5 and C6-7 levels complicated by postoperative cervical hematoma and carotid thrombosis. The patient’s history, clinical examination, imaging findings, and treatment are reported. The revision fusions were performed and deemed routine. Approximately eight hours later 200 mL of blood was evacuated from a postoperative cervical hematoma. The patient became unresponsive and disoriented a few hours after evacuating the hematoma. Computed tomography and magnetic resonance imaging of the brain were normal, but magnetic resonance angiography demonstrated total occlusion of the left carotid artery. Thrombectomy was performed and the patient was discharged without residual deficits. At the latest followup she is fully functional and asymptomatic in her neck. We suggest, after evacuating a cervical hematoma, an evaluation of the carotids be made with MRA or cerebral angiography, as this may demonstrate a clot before the patient develops symptoms.

Introduction

Anterior cervical decompression and fusion (ACDF), a common treatment for cervical disc disease, is associated with good outcomes and low complication rates [1–5]. Complications can be devastating, especially hematoma, vascular injury, esophageal injury, neurological deficits, or graft dislodgement [4, 6–9]. Complications related to the carotid artery during ACDF are rare [10], and thrombosis has never been reported in association with a postoperative cervical hematoma, although interruption of laminar blood flow during retraction is documented [11].

We report a case of postoperative cervical hematoma complicated by ipsilateral carotid thrombosis and aphasia after a revision ACDF at C4-5 and C6-7 for adjacent segment disease. This case is presented to share the first documented case including this series of complications and to be instructive in sharing our management experience.

Case Presentation

A 65-year-old female patient with a body mass index of 19.2 kg/m2 and past medical history including hepatitis C treated with interferon, Lyme disease, hypertension, osteoarthritis, lumbar laminectomy and fusion, C5-6 fusion, hysterectomy, and breast biopsy presented with multilevel spondylosis and adjacent level breakdown at C4-5 and C6-7.

She underwent revision fusions of C4-5 and C6-7 levels with interbody PEEK cage (Invibio PEEK Optima), demineralized bone matrix, and cervical plates (SpineFrontier Indus InVue cervical plate, Beverly, MA, USA). These procedures were completed via a left-sided approach. Hemostasis was achieved before closing the wound. This procedure was completed and was deemed routine without surgical, anesthetic, or cord monitoring complications.

Approximately 8 hours later swelling of the anterior neck was noted. This was assessed as a hematoma of the cervical spine causing airway compromise. Immediately the patient was returned to the operating suite for an urgent evacuation of the hematoma. Approximately 200 mL clotted blood was drained. Active oozing was noted from the muscles and cauterized. The wound was irrigated without force, then collagen sponge and gelatin matrix hemostatic sealant around the muscle areas were placed. After Penrose drain replacement and wound closure, excessive bleeding was noted, so the wound was reopened and more collagen sponge and thrombin were used along with cauterization. A bulb drain was placed with a 1/4 inch Penrose and the wound was closed.

Later that evening, the patient became increasingly disoriented and eventually unresponsive to commands. Clinically posterior fossa dysfunction was assessed with the patient obtunded and eyes gazing downward. The possibility of a cerebrovascular accident (CVA) in the posterior fossa was considered and computed tomography (CT) brain ordered. CT brain was normal and MRI demonstrated no acute infarct; however magnetic resonance angiography (MRA) revealed total occlusion of the left common carotid artery, including the bifurcation and external carotid artery with some reconstitution of the internal carotid at the level of the siphon from collateral blood flow (Figure 1). Therefore, without delay, vascular surgeons performed exploration and thrombectomy of the left carotid artery. The vascular surgeon commented only on the large size of the thrombus. There was no obvious intimal damage or arteriosclerosis as reported postoperatively. After all vascular clamps were released and good pulsations obtained in the entire common, external, and internal carotid arteries, the heparin injected prior to clamping was reversed with protamine sulfate and hemostasis was considered satisfactory. Another Penrose drain was left in the surgical bed.

MRA postoperative day 2 demonstrates total occlusion of the left common carotid artery, including bifurcation and external carotid artery.

Our patient’s hospital stay was further complicated by an acute right brachial deep vein thrombosis secondary to a line in situ, and a heparin-induced thrombocytopenia. She also suffered a reactive leucocytosis immediately postoperatively and a nosocomial (MSSE) pneumonia. However, the patient was discharged from hospital on postoperative day 20 without any residual deficits, and at her latest followup at nine months she is fully functional and asymptomatic in her neck. Of note: our patient, since these reported procedures, had occipital and external carotid artery embolization performed, the coils and clips are obvious on X-ray (Figure 2). These procedures were completed by a separate team of vascular surgeons for discrete indications and are not directly related to the reported events herewith.

Postoperative lateral radiograph showing fixation at 9 months. (Please note: clips and coils postembolization of the occipital and external carotid arteries apparent in the anterolateral left neck.)

Discussion

Virchow’s triad describes three broad categories which contribute to the development of thrombosis: stasis, endothelial damage, and/or hypercoagulability. In this case our patient was not in a hypercoagulable state as evidenced by the hematoma and her normal liver function and bleeding indices, despite a history of hepatitis C [12]. No endothelial damage was identified at thrombectomy in this case, and considering that her aphasia developed after removal of the hematoma, it is our suspicion that the hematoma compressed the carotid artery enough to decrease laminar blood flow inducing stasis and providing a nidus for the development of a thrombus. Chronic long-term occlusion of the carotid may be another explanation of this patient’s second event postoperatively certainly, but her medical history yielded no prior report of CVA-type events. This may have been masked, however, by compensatory mechanisms such as elevated oxygen extraction fraction improvement and/or improvements in blood flow with chronic occlusion [13].

It is unknown whether she would have developed aphasia from compression within the same time frame had we not removed the hematoma; nonetheless, our experience should raise awareness and prompt prophylactic action before evacuating a hematoma.

Conclusion

Our literature review yielded no prior cases detailing similar complications. This case documents perhaps the first report of this occurrence, is instructive, and raises awareness. We suggest after evacuating a cervical hematoma, especially in patients with risk factors, an evaluation of the carotids be made with MRA, Doppler ultrasonography, intraoperative pulse examination, or cerebral angiography as this may demonstrate a clot before the patient develops symptoms.

About Author Dr. Kingsley R. Chin

Dr. Kingsley R. Chin, Founder of philosophy and practice of The LES Society and The LESS Institute

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.

Learn more about Dr. Chin here and connect via LinkedIn.

About Less Exposure Surgery

Less Exposure Surgery (LES) is based on a new philosophy of performing surgery, leading the charge to prove through bench and clinical outcomes research that LES treatment options are the best solutions – to lowering the cost of healthcare, improving outcomes and increasing patient satisfaction. Learn more at LESSociety.org.

The LES Society philosophy: “Tailor treatment to the individual aiding in the quickest recovery and return to a pain-free lifestyle, using LES® techniques that lessen exposure, preserve unoffending anatomy and utilize new technologies which are safe, easy to adopt and reproducible. These LES®techniques lessen blood loss, surgical time and exposure to radiation and can be safely performed in an outpatient center. Less is more.” – Kingsley R. Chin, MD

About The LESS Institute

The LESS Institute is the world leader center of excellence in Less Exposure Surgery. Our safe, effective outpatient treatments help patients recover quickly, avoid expensive hospital stays and return home to their family the same day. Watch our patient stories, follow us on Facebook and visit TheLESSInstitute.com to learn more.

About SpineFrontier

The above study utilized LES Technology from SpineFrontier – leading provider of LES Technologies and instruments – offering surgeons and patients superior technology and services.

Scientific Paper Author & Citation Details

Authors

Chin KR1, Seale J, Butron V, Cumming V.

Author information

1. Charles E. Schmidt College of Medicine, Florida Atlantic University and Institute for Modern and Innovative Surgery (iMIS), 1100 W. Oakland Park Boulevard, Suite No. 3, Fort Lauderdale, FL 33311, USA.

“White Cord Syndrome” of Acute Tetraplegia After Anterior Cervical Decompression and Fusion for Chronic Spinal Cord Compression: a Case Report

By Dr. Kingsley Chin

Scientific Paper

Chin KR1, Seale J, Cumming V.

Interested medical professionals can read the full paper, as published in Case Reports in Orthopedics, here.

Abstract

Paralysis is the most feared postoperative complication of ACDF and occurs most often due to an epidural hematoma. In the absence of a clear etiology, inadequate decompression or vascular insult such as ischemia/reperfusion injury are the usual suspects. Herewith we report a case of complete loss of somatosensory evoked potentials (SSEPs) during elective ACDF at C4-5 and C5-6 followed by postoperative C6 incomplete tetraplegia without any discernible technical cause. A postoperative MRI demonstrated a large area of high signal changes on T2-weighted MRI intrinsic to the cord “white cord syndrome” but no residual compression. This was considered consistent with spinal cord gliosis with possible acute edema. The acute decompression of the herniated disc resulted in cord expansion and rush-in reperfusion. We postulate that this may have led to disruption in the blood brain barrier (BBB) and triggered a cascade of reperfusion injuries resulting in acute neurologic dysfunction. At 16 months postoperatively our patient is recovering slowly and is now a Nurick Grade 4.

Introduction

Anterior cervical decompression and fusion (ACDF) are commonly performed procedures for conditions resulting in symptomatic nerve root and/or spinal compression anteriorly. ACDF is associated with favorable fusion rates and good outcomes [1–4]. Paralysis is extremely rare but the most feared among postoperative complications [5]. Paralysis is most often due to an epidural hematoma, but in the absence of clear etiology, inadequate decompression or vascular insult such as ischemia/reperfusion injury possibly due to oxygen-derived free radical damage [6–8] are the usual suspects. Oxygen-derived free radicals seem implicated in neuronal injury as are mitochondria-dependent apoptosis, TNF-α production, and specific phospholipid signaling cascades [9–11].

We report a case of complete loss of somatosensory evoked potentials (SSEPs) during elective ACDF at C4-5 and C5-6 followed by postoperative C6 incomplete tetraplegia without any discernable technical cause. We describe this occurrence as a “white cord syndrome” because of the postoperative appearance of a large area of cord edema behind the massive herniated disc seen on sagittal T2-weighted magnetic resonance imaging (MRI). The MRI appearance of the preoperative and postoperative management, outcome, and proposed pathophysiology of this syndrome are discussed.

Case Presentation

A 59-year-old male patient was referred to us with a MRI diagnosis of a large C5-6 herniated disc causing severe cord compression, neck pain, radiculomyelopathy, and ataxia. The patient gave a seven-month history of neck pain with shoulder radiation, pain in the lower back radiating to both legs, and balance difficulties. At initial examination cervical range of motion was limited (flexion, extension, left and right rotation), and he reported pain specifically at the end of extension. A markedly positive Hoffman’s sign (right > left) was elicited. He was assessed as Nurick Grade 3 at this initial visit and diagnosed with cervical radiculomyelopathy. MRI demonstrated a massive herniated nucleus pulposus at C5-6 with severe cord compression and myelomalacia at the level of the herniated disc (Figures 1 and 2).

Figure 1: Preoperative axial T2-weighted MRI showing severe C5-6 cord compression by a massive disc herniation.

Figure 2: Preoperative MRI sagittal showing large area of high signal intensity centered behind the massive C5-6 herniated disc.

The patient underwent C4-5 and C5-6 ACDF. Intraoperative electroneurophysiological monitoring was performed continuously throughout the surgical procedure. This involved spinal cord monitoring with somatosensory recordings (somatosensory evoked potentials (SSEPs)), nerve activity monitoring, cortical recordings, and motor evoked potentials (MEPs) are performed.

An interbody PEEK cage (8 mm) (Eminent Spine, Texas) was placed at the C5-6 level. After cage placement at C5-6 the surgical team was informed about diminished MEP signals. The cage was removed without any changes and so replacing and monitoring continued. The surgical procedure was repeated at the C4-5 level with partial corpectomies, discectomy, and placement of an 8 mm interbody PEEK cage. It was then reported that the diminished signal recordings were attributed to marked dysfunction of spinal cord conduction pathways. At this time there were no measureable MEPs, and so the PEEK cages were removed. The signal did not return with removal of the cages, so the patient was awoken and asked to move his limbs; he was able to move his arms only at the time. The procedure was urgently completed by replacing the interbodies and placing an anterior plate (SpineFrontier Inc., InVue plate, Beverly, MA, USA) between C4, C5, and C6. Postoperatively the patient demonstrated a C6 incomplete tetraplegia. MRI raised concerns about residual bony compression at C5 (Figure 3). MRI and CT were done emergently postoperatively which raised concern for residual bony compression mostly behind the C5 body and the edges of C4 and C6. The surgeon was concerned about a vascular/reperfusion phenomenon given the acute decompression of a severely and chronically compressed spinal cord. The patient was urgently returned to the operating room for more extensive decompression, and corpectomy at C5, to provide the cord with as much room possible for recovery. During the revised procedure SSEP responses from the left lower limb were noted to be poorly reproduced and to have very low amplitude but were noted to be present in the right lower limb. Transcranial MEPs were present and reproducible from upper limb but not lower limb muscle groups. This was deemed encouraging.

Figure 3: Immediate postoperative MRI after primary C4-5, C5-6 ACDF demonstrates residual C5 compression.

There were no cerebrospinal fluid (CSF) leaks or increased blood loss reported intraoperatively during this patient’s surgical procedures. In fact, from a surgical perspective the procedures were quite uneventful and uncomplicated apart from the complete loss of SSEPs.

Hydrocortisone 100 mg was given intravenously intraoperatively during the revised procedure. Subsequently, the patient was placed on acute inpatient rehabilitation in the intensive care unit for his C6 incomplete tetraplegia and an acute spinal cord injury steroid protocol [12] was begun and tapering intravenous dexamethasone was added.

At day 3 a postoperative MRI demonstrated a large area of high signal changes on T2-weighted MRI intrinsic to the cord (“white cord syndrome”) but no residual compression (Figure 4). Following intravenous administration of gadopentetate dimeglumine contrast at MRI postoperatively there was no pathologic enhancement of the spinal cord lesion, and therefore the hyperintense changes involving the cervical spine at the C5 level were considered consistent with spinal cord edema (Figure 3). When compared to the preoperative MRI, it was clearly present but partially masked by the large herniated disc. Day 2 postoperatively the patient was returned to the operating room to investigate any SSEP changes to and to see if there was continued recovery. There were no changes to SSEP compared with intraoperatively. The decision was then made to continue steroids and follow the patient clinically with serial MRIs. Within two days the patient moved both upper limbs and had 3/5 power in the toes.

Figure 4: Day 3 postoperative MRI demonstrates more clearly the spinal cord edema intrinsic to the cord—a “white cord syndrome.”

The patient was discharged to an inpatient rehabilitation facility at day four postoperatively without any signs of recovery. His bulbocavernosus reflex was equivocal. Gradually over the next two months, his bilateral upper limb strength improved to full strength except for 3+/5 left finger flexion, extension, and interossei. His right lower extremity also improved to full strength. His left lower extremity strength lagged substantially behind with grade 3/5 hip flexor, adductor, and abductor strength. At the latest 16-month followup he was still weak in his left finger flexion (3/5), finger extension and interossei (4/5), and his left lower limb with 5−/5 hip abduction power, 4/5 quadriceps and hamstrings, and 2/5 in all other muscle groups. Reflexes were 2+ except 1+ right triceps and 3+ at the left knee with sustained left ankle clonus. Sensation was decreased on the left hand, leg, and thigh. At this visit a Nurick Grade 4 and ASIA score D were assessed. A slight improvement in standing and walking was noted, but he still required an assistive frame to get around the house and a wheelchair outside (Table 1). Radiography and MRI reviewed at this visit confirmed fusion but demonstrated persistent gliosis (Figures 5 and 6).

Table 1: Rehabilitation assessment: American Spinal Injury Association (ASIA) scores.

Figure 5: Sagittal CT reconstruction at the latest followup shows graft consolidation confirming fusion.

Figure 6: Sagittal T2-weighted MRI at the latest 16-month followup showing a persistent “white cord syndrome.”

Discussion

In this patient, a massive herniated disc seemed to have compressed the cord chronically and produced a large area of cord edema, but the patient had compensated. Over time his radiculomyelopathic symptoms progressed and he sought surgical treatment. The acute decompression of the herniated disc resulted in immediate cord expansion within the open canal space, and the compressed segment of the cord exposed to a rush in blood supply. We postulate that this sudden cord expansion and reperfusion may have lead to disruption in the blood brain barrier (BBB), or in the blood spinal cord barrier, and triggered a cascade of reperfusion injury resulting in acute neurologic dysfunction at and below the C6 level. The MRI appearance on sagittal T2-weighted MRI and the clinical results of incomplete paralysis without a clear understanding of the pathophysiology of this condition led us to use the term “white cord syndrome.”

A cohort study reported by Seichi et al. in 2004 followed more than one hundred patients with MRI three weeks postlaminoplasty to determine the frequency of swelling of the spinal cord with an intramedullary lesion and the possible mechanism of postoperative motor paresis of the upper extremity [13]. They reported a 6.1% incidence of postoperative abnormal expansion of the T2 high signal intensity area; of which 43% were asymptomatic. The upper motor paresis described in their cohort was strongly related to distal and diffuse type of postoperative paresis of the upper extremity without deterioration of lower motor function. This report was the only other description of similar MRI findings as what we experienced with our patient. That being said, our patient’s presentation was more dramatic after ACDF and followed a different pattern of motor paresis from that described in the previously mentioned postlaminoplasty cohort.

Spinal cord ischemia/reperfusion injury appears contingent on oxygen-derived free radical damage [6–8], mitochondria-dependant apoptosis, TNF-α production, and specific phospholipid signaling cascades resulting in neuronal injury in human and animal models [9–11, 14–16]. It has been suggested that acute and chronic spinal cord ischemic injury may in fact induce the passage of blood borne or neurotrophic substances (specifically TNF- α) through the BBB past its saturation point [14, 16–18]. It appears that decoupling of astrocyte foot processes from endothelial cell surfaces inhibits tight junction function in the BBB [15, 19, 20]. Transport systems and ionic buffering would then be disrupted allowing worsened reperfusion injury upon decompression of a previously ischemic spinal cord.

To date substantial efforts have focused on the mitigation of spinal cord ischemic injury. These efforts have included surgical techniques (such as timing of surgical decompression, temporary shunts, or partial bypass), pharmacological interventions (such as methylprednisolone), and mechanical methods (e.g., hypothermia or drainage of cerebrospinal fluid) [18, 21–26]. More recently it has been suggested that potent antioxidants may also play a role in the management of spinal cord ischemic/reperfusion injury [7].

In our case described herewith, MRI performed at day 1 postoperatively demonstrated gliosis. However, there remains much debate about the clinical relevance of high signal intensity on the T2-weighted MR images. The debate extends to the reversibility of the spinal cord edema also [27]. It should be noted that the increased T2-weighted signal intensity was present even before the decompression, so demyelination may also be a possibility in this patient. We highlight these factors simply to reflect on the different possible reasons for the edema and the increased signal intensity.

We have presented this theory as to the pathophysiology behind this patient’s intra- and postoperative complications as there was no clinically significant hematoma or CSF leakage reported that could have led to a pseudomeningocele and made a more plausible explanation of our findings.

In light of the proposed etiologies implicated in triggering this syndrome [6, 7, 9–11] the clinical presentation of this patient is instructive in raising awareness. The management of this “white cord syndrome” will conceivably include adequate surgical decompression and pharmacological treatment options [7, 18, 21–26]. However, patients and surgeons should be aware of the potential catastrophic results after a seemingly routine ACDF to treat a large herniated disc with severe and chronic cord compression. This patient had motor function return fairly rapidly within two months but slowed down substantially in the ensuing months. This may help the surgeon to advise patients. A full corpectomy is a good option in this scenario to ensure adequate decompression. Postoperative SSEP monitoring is an option to monitor recovery during the immediate postoperative period. The use of steroids should be individually weighed against the risks.

About Author Dr. Kingsley R. Chin

Dr. Kingsley R. Chin, Founder of philosophy and practice of The LES Society and The LESS Institute

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.

Learn more about Dr. Chin here and connect via LinkedIn.

About Less Exposure Surgery

Less Exposure Surgery (LES) is based on a new philosophy of performing surgery, leading the charge to prove through bench and clinical outcomes research that LES treatment options are the best solutions – to lowering the cost of healthcare, improving outcomes and increasing patient satisfaction. Learn more at LESSociety.org.

The LES Society philosophy: “Tailor treatment to the individual aiding in the quickest recovery and return to a pain-free lifestyle, using LES® techniques that lessen exposure, preserve unoffending anatomy and utilize new technologies which are safe, easy to adopt and reproducible. These LES®techniques lessen blood loss, surgical time and exposure to radiation and can be safely performed in an outpatient center. Less is more.” – Kingsley R. Chin, MD

About The LESS Institute

The LESS Institute is the world leader center of excellence in Less Exposure Surgery. Our safe, effective outpatient treatments help patients recover quickly, avoid expensive hospital stays and return home to their family the same day. Watch our patient stories, follow us on Facebook and visit TheLESSInstitute.com to learn more.

About SpineFrontier

The above study utilized LES Technology from SpineFrontier – leading provider of LES Technologies and instruments – offering surgeons and patients superior technology and services.

Scientific Paper Author & Citation Details

Authors

Chin KR1, Seale J, Cumming V.

Author information

1. Charles E. Schmidt College of Medicine, Florida Atlantic University and Institute for Modern & Innovative Surgery (iMIS), 1100 W. Oakland Park Boulevard, Suite No. 3, Fort Lauderdale, FL 33311, USA ; iMIS Surgery, 1100 W. Oakland Park Boulevard, Suite No. 3, Fort Lauderdale, FL 33311, USA.

Postoperative Magnetic Resonance Imaging Assessment for Potential Compressive Effects of Retained Posterior Longitudinal Ligament After Anterior Cervical Fusions: a Cross-Sectional Study

By Dr. Kingsley Chin

Scientific Paper

Chin KR1, Ghiselli G, Cumming V, Furey CG, Yoo JU, Emery SE.

Interested medical professionals can read the full paper, as published in Spine, here.

Study Design

A cross-sectional study.

Objective

To assess using postoperative magnetic resonance imaging whether the posterior longitudinal ligament (PLL) caused residual cord compression after anterior cervical decompression and fusion (ACDF) in a series of patients in whom the PLL was retained.

Summary of Background Data

There is a lack of data evaluating the postoperative compressive effects of the PLL in patients undergoing ACDF providing guidance as to whether to remove or retain the PLL during discectomy to facilitate adequate decompression.

Methods

Postoperative gadolinium enhanced magnetic resonance images were reviewed in a series of 33 patients who underwent ACDF for cervical radiculomyelopathy and who had persistent or recurrent postoperative symptoms. Patients with ossification of the posterior longitudinal ligament or with a herniated disc behind the PLL were excluded from this study.

Results

There were no cases of discernible compression by the retained PLL identified on the magnetic resonance image (P < 0.001) as assessed by 2 independent reviewers. Four patients underwent subsequent revision surgery unrelated to the PLL.

Conclusion

We were unable to demonstrate magnetic resonance imaging evidence to suggest that the retained PLL caused compression after ACDF in this patient cohort. Therefore we suggest that removing the PLL should be considered for reasons other than concern about residual compression.

About Author Dr. Kingsley R. Chin

Dr. Kingsley R. Chin, Founder of philosophy and practice of The LES Society and The LESS Institute

Dr. Kingsley R. Chin is a board-certified Harvard-trained Orthopedic Spine Surgeon and Professor with copious business and information technology exposure. He sees a niche opportunity where medicine, business and info. tech meet – and is uniquely educated at the intersection of these three professions. He has experience as Professor of Clinical Biomedical Sciences & Admissions Committee Member at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Professor of Clinical Orthopedic Surgery at the Herbert Wertheim College of Medicine at Florida International University, Assistant Professor of Orthopaedics at the University of Pennsylvania Medical School, Visiting Spine Surgeon & Professor at the University of the West Indies, Mona, and Adjunct Professor of Clinical Biomedical Sciences at the University of Technology, Jamaica.

Learn more about Dr. Chin here and connect via LinkedIn.

About Less Exposure Surgery

Less Exposure Surgery (LES) is based on a new philosophy of performing surgery, leading the charge to prove through bench and clinical outcomes research that LES treatment options are the best solutions – to lowering the cost of healthcare, improving outcomes and increasing patient satisfaction. Learn more at LESSociety.org.

The LES Society philosophy: “Tailor treatment to the individual aiding in the quickest recovery and return to a pain-free lifestyle, using LES® techniques that lessen exposure, preserve unoffending anatomy and utilize new technologies which are safe, easy to adopt and reproducible. These LES®techniques lessen blood loss, surgical time and exposure to radiation and can be safely performed in an outpatient center. Less is more.” – Kingsley R. Chin, MD

About The LESS Institute

The LESS Institute is the world leader center of excellence in Less Exposure Surgery. Our safe, effective outpatient treatments help patients recover quickly, avoid expensive hospital stays and return home to their family the same day. Watch our patient stories, follow us on Facebook and visit TheLESSInstitute.com to learn more.

About SpineFrontier

The above study utilized LES Technology from SpineFrontier – leading provider of LES Technologies and instruments – offering surgeons and patients superior technology and services.

Scientific Paper Author & Citation Details

Authors

Chin KR1, Ghiselli G, Cumming V, Furey CG, Yoo JU, Emery SE.

Author information

1. Institute for Modern & Innovative Surgery (iMIS), Fort Lauderdale, FL 33311, USA. Kingsleychin@gmail.com