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OBJECTIVEThe objective of this study was to describe the use of a minimally invasive surgical treatment of lumbar spondylolysis in athletes by a fluoroscopically guided direct pars screw placement with recombinant human bone morphogenetic protein–2 (rhBMP-2) and to report on clinical and radiographic outcomes.METHODSA retrospective review was conducted of all patients treated surgically for lumbar spondylolysis via a minimally invasive direct pars repair with cannulated screws. Demographic information, clinical features of presentation, perioperative and intraoperative radiographic imaging, and postoperative data were collected. A 1-cm midline incision was performed for the placement of bilateral pars screws utilizing biplanar fluoroscopy, followed by placement of a fully threaded 4.0-mm-diameter titanium cannulated screw. A tubular table-mounted retractor was utilized for direct pars fracture visualization and debridement through a separate incision. The now-visualized pars fracture could then be decorticated, with care taken not to damage the titanium screw when using a high-speed drill. Local bone obtained from the curettage was then placed in the defect with 1.05 mg rhBMP-2 divided equally between the bilateral pars defects.RESULTSNine patients were identified (mean age 17.7 ± 3.42 years, range 14–25 years; 6 male and 3 female). All patients had bilateral pars fractures of L-4 (n = 4) or L-5 (n = 5). The mean duration of preoperative symptoms was 17.22 ± 13.2 months (range 9–48 months). The mean operative duration was 189 ± 29 minutes (range 151–228 minutes). The mean intraoperative blood loss was 17.5 ± 10 ml (range 10–30 ml). Radiographic follow-up was available in all cases; the mean length of time from surgery to the most recent imaging study was 30.8 ± 23.3 months (range 3–59 months). The mean hospital length of stay was 1.13 ± 0.35 days (range 1–2 days). There were no intraoperative complications.CONCLUSIONSLumbar spondylolysis treatment with a minimally invasive direct pars repair is a safe and technically feasible option that minimizes muscle and soft-tissue dissection, which may particularly benefit adolescent patients with a desire to return to a high level of physical activity.

OBJECT The use of intrawound vancomycin is rapidly being adopted for the prevention of surgical site infection (SSI) in spinal surgery. At operative closure, the placement of vancomycin powder in the wound bed—in addition to standard infection prophylaxis—can provide high concentrations of antibiotics with minimal systemic absorption. However, despite its popularity, to date the majority of studies on intrawound vancomycin are retrospective, and there are no prior reports highlighting the risks of routine treatment. METHODS A MEDLINE search for pertinent literature was conducted for studies published between 1966 and May 2015 using the following MeSH search terms: “intrawound vancomycin,” “operative lumbar spine complications,” and “nonoperative lumbar spine complications.” This was supplemented with references and known literature on the topic. RESULTS An advanced MEDLINE search conducted on May 6, 2015, using the search string “intrawound vancomycin” found 22 results. After a review of all abstracts for relevance to intrawound vancomycin use in spinal surgery, 10 studies were reviewed in detail. Three meta-analyses were evaluated from the initial search, and 2 clinical studies were identified. After an analysis of all of the identified manuscripts, 3 additional studies were included for a total of 16 studies. Fourteen retrospective studies and 2 prospective studies were identified, resulting in a total of 9721 patients. A total of 6701 (68.9%) patients underwent treatment with intrawound vancomycin. The mean SSI rate among the control and vancomycin-treated patients was 7.47% and 1.36%, respectively. There were a total of 23 adverse events: nephropathy (1 patient), ototoxicity resulting in transient hearing loss (2 patients), systemic absorption resulting in supratherapeutic vancomycin exposure (1 patient), and culture-negative seroma formation (19 patients). The overall adverse event rate for the total number of treated patients was 0.3%. CONCLUSIONS Intrawound vancomycin use appears to be safe and effective for reducing postoperative SSIs with a low rate of morbidity. Study disparities and limitations in size, patient populations, designs, and outcomes measures contribute significant bias that could not be fully rectified by this systematic review. Moreover, care should be exercised in the use of intrawound vancomycin due to the lack of well-designed, prospective studies that evaluate the efficacy of vancomycin and include the appropriate systems to capture drug-related complications.

Object Thoracolumbar spine injuries are commonly encountered in patients with trauma, accounting for almost 90% of all spinal fractures. Thoracolumbar burst fractures comprise a high percentage of these traumatic fractures (45%), and approximately half of the patients with this injury pattern are neurologically intact. However, a debate over complication rates associated with operative versus nonoperative management of various thoracolumbar fracture morphologies is ongoing, particularly concerning those patients presenting without a neurological deficit. Methods A MEDLINE search for pertinent literature published between 1966 and December 2013 was conducted by 2 authors (G.G. and R.D.), who used 2 broad search terms to maximize the initial pool of manuscripts for screening. These terms were “operative lumbar spine adverse events” and “nonoperative lumbar spine adverse events.” Results In an advanced MEDLINE search of the term “operative lumbar spine adverse events” on January 8, 2014, 1459 results were obtained. In a search of “nonoperative lumbar spine adverse events,” 150 results were obtained. After a review of all abstracts for relevance to traumatic thoracolumbar spinal injuries, 62 abstracts were reviewed for the “operative” group and 21 abstracts were reviewed for the “nonoperative” group. A total of 14 manuscripts that met inclusion criteria for the operative group and 5 manuscripts that met criteria for the nonoperative group were included. There were a total of 919 and 436 patients in the operative and nonoperative treatment groups, respectively. There were no statistically significant differences between the groups with respect to age, sex, and length of stay. The mean ages were 43.17 years in the operative and 34.68 years in the nonoperative groups. The majority of patients in both groups were Frankel Grade E (342 and 319 in operative and nonoperative groups, respectively). Among the studies that reported the data, the mean length of stay was 14 days in the operative group and 20.75 in the nonoperative group. The incidence of all complications in the operative and nonoperative groups was 300 (32.6%) and 21 (4.8%), respectively (p = 0.1065). There was no significant difference between the 2 groups with respect to the incidence of pulmonary, thromboembolic, cardiac, and gastrointestinal complications. However, the incidence of infections (pneumonia, urinary tract infection, wound infection, and sepsis) was significantly higher in the operative group (p = 0.000875). The incidence of instrumentation failure and need for revision surgery was 4.35% (40 of 919), a significant morbidity, and an event unique to the operative category (p = 0.00396). Conclusions Due to the limited number of high-quality studies, conclusions related to complication rates of operative and nonoperative management of thoracolumbar traumatic injuries cannot be definitively made. Further prospective, randomized studies of operative versus nonoperative management of thoracolumbar and lumbar spine trauma, with standardized definitions of complications and matched patient cohorts, will aid in properly defining the risk-benefit ratio of surgery for thoracolumbar spine fractures.

Cavernous malformations (CMs) are angiographically occult vascular malformations that are frequently found incidentally on MR imaging. Despite this benign presentation, these lesions could cause symptomatic intracranial hemorrhage, seizures, and focal neurological deficits. Cavernomas can be managed conservatively with neuroimaging studies, surgically with lesion removal, or with radiosurgery. Considering recent studies examining the CM's natural history, imaging techniques, and possible therapeutic interventions, the authors provide a concise review of the literature and discuss the optimal management of incidental CMs.

OBJECT Unintended durotomy is a common occurrence during lumbar spinal surgery, particularly in surgery for degenerative spinal conditions, with the reported incidence rate ranging from 0.3% to 35%. The authors performed a systematic literature review on unintended lumbar spine durotomy, specifically aiming to identify the incidence of durotomy during spinal surgery for lumbar degenerative conditions. In addition, the authors analyzed the incidence of durotomy when minimally invasive surgical approaches were used as compared with that following a traditional midline open approach. METHODS A MEDLINE search using the term “lumbar durotomy” (under the 2015 medical subject heading [MeSH] “cerebrospinal fluid leak”) was conducted on May 13, 2015, for English-language medical literature published in the period from January 1, 2005, to May 13, 2015. The resulting papers were categorized into 3 groups: 1) those that evaluated unintended durotomy rates during open-approach lumbar spinal surgery, 2) those that evaluated unintended durotomy rates during minimally invasive spine surgery (MISS), and 3) those that evaluated durotomy rates in comparable cohorts undergoing MISS versus open-approach lumbar procedures for similar lumbar pathology. RESULTS The MEDLINE search yielded 116 results. A review of titles produced 22 potentially relevant studies that described open surgical procedures. After a thorough review of individual papers, 19 studies (comprising 15,965 patients) pertaining to durotomy rates during open-approach lumbar surgery were included for analysis. Using the Oxford Centre for Evidence-Based Medicine (CEBM) ranking criteria, there were 7 Level 3 prospective studies and 12 Level 4 retrospective studies. In addition, the authors also included 6 studies (with a total of 1334 patients) that detailed rates of durotomy during minimally invasive surgery for lumbar degenerative disease. In the MISS analysis, there were 2 prospective and 4 retrospective studies. Finally, the authors included 5 studies (with a total of 1364 patients) that directly compared durotomy rates during open-approach versus minimally invasive procedures. Studies of open-approach surgery for lumbar degenerative disease reported a total of 1031 durotomies across all procedures, for an overall durotomy rate of 8.11% (range 2%–20%). Prospectively designed studies reported a higher rate of durotomy than retrospective studies (9.57% vs 4.32%, p = 0.05). Selected MISS studies reported a total of 93 durotomies for a combined durotomy rate of 6.78%. In studies of matched cohorts comparing open-approach surgery with MISS, the durotomy rates were 7.20% (34 durotomies) and 7.02% (68), respectively, which were not significantly different. CONCLUSIONS Spinal surgery for lumbar degenerative disease carries a significant rate of unintended durotomy, regardless of the surgical approach selected by the surgeon. Interpretation of unintended durotomy rates for lumbar surgery is limited by a lack of prospective and cohort-matched controlled studies.

Object One often overlooked aspect of spinal epidural abscesses (SEAs) is the timing of surgical management. Limited evidence is available correlating earlier intervention with outcomes. Spinal epidural abscesses, once a rare diagnosis carrying a poor prognosis, are steadily becoming more common, with one recent inpatient meta-analysis citing an approximate incidence of 1 in 10,000 admissions with a mortality approaching 16%. One key issue of contention is the benefit of rapid surgical management of SEA to maximize outcomes. Timing of surgical management is definitely one overlooked aspect of care in spinal infections. Therefore, the authors performed a retrospective analysis in which they evaluated patients who underwent early (evacuation within 24 hours) versus delayed surgical intervention (> 24 hours) from the point of diagnosis, in an attempt to test the hypothesis that earlier surgery results in improved outcomes. Methods A retrospective review of a prospectively maintained adult neurosurgical database from 2009 to 2011 was conducted for patients with the diagnostic heading: epidural abscess, infection, osteomyelitis, osteodiscitis, spondylodiscitis, and abscess. The primary end point for each patient was neurological grade, measured as an American Spinal Injury Association Impairment Scale grade using hospital inpatient records on admission and discharge. Patients were divided into early surgical (< 24 hours) and delayed surgical cohorts. Results Eighty-seven consecutive patients were identified (25 females; mean age 55.5 years, age range 18–87 years). Fifty-four patients received surgery within 24 hours of admission (mean time from admission to incision, 11.2 hours), and 33 underwent surgery longer than 24 hours (mean 59 hours) after admission. Of the 54 patients undergoing early surgery 45 (85%) had a neurological deficit, whereas in the delayed surgical group 21 (64%) of 33 patients presented with a neurological deficit (p = 0.09). Patients in the delayed surgery cohort were significantly older by 10 years (59.6 vs 51.8 years, p = 0.01). With regard to history of prior revision, body mass index, intravenous drug abuse, tobacco use, prior radiation therapy, diabetes, chronic systemic infection, and prior osteomyelitis, there were no significant differences. There was no significant difference between early and delayed surgery groups in neurological grade on presentation, discharge, or location of epidural abscess. The most common organism isolated was Staphylococcus aureus (n = 51, 59.3%). The incidence of methicillin-resistant S. aureus was 21% (18 of 87). Conclusions Evacuation within 24 hours appeared to have a relative advantage over delayed surgery with regard to discharge neurological grade. However, due to a limited, variable sample size, a significant benefit could not be shown. Further subgroup analyses with larger populations are required.

Multimodal endovascular intervention is becoming more commonplace for the acute intervention of ischemic stroke. Hyperdensity in a portion of the treated territory is a common finding on postthrombolytic noncontrast CT (NCCT), but its significance is poorly understood. The authors conducted a single-institution, retrospective chart review of patients who had intraarterial thrombolysis of the anterior circulation between 2010 and 2011 with evidence of hyperdensity on NCCT following recanalization. Eighteen patients had evidence of postoperative contrast stasis causing hyperdensity on NCCT. One hundred percent of the patients had MR imaging evidence of completed strokes postoperatively in the same distribution as the stasis. Stasis on NCCT after intervention had a sensitivity and specificity of 82% and 0% for predicting stroke, respectively. Furthermore, the positive predictive value was 100%. The presence of contrast stasis on postthrombolytic NCCT correlates well with stroke seen on subsequent MR imaging.