Proceedings of the NASS 17th Annual Meeting / The Spine Journal 2 (2002) 47S–128S tients requiring a second operation after previous laminectomy and posterolateral lumbar fusion. At the time of reoperation, all patients underwent decompressive laminectomy, with or without fusion. Only patients without previous surgery at the adjacent segment and a 12-month symptom-free period after the index operation were included. The clinical features and outcomes were collected by means of thorough chart review. Radiographs underwent independent analysis. Mann-Whitney and two-tailed t tests were used for statistical analysis. Summary of findings: Forty-two patients underwent index decompression and posterolateral fusion for acquired spinal stenosis, degenerative spondylolisthesis and isthmic spondylolisthesis. Low back pain and radicular symptoms developed at an average of 85 months postoperatively. Twelve patients had an uninstrumented fusion. In this group, symptoms developed at an average of 143 months. In contrast, the instrumented fusion patients developed symptoms at an average of 62 months (p.04 with two-tailed test, p.02 with Mann-Whitney test). Of the 24 patients who had a floating lumbar fusion, 20 developed stenosis at the proximal level, 3 developed stenosis at the distal level and 1 developed stenosis at both adjacent levels. The mean time to the second surgical intervention was 95 months. All patients underwent a decompressive lumbar laminectomy at the adjacent level. In 33 patients, the posterolateral fusion was extended to the newly decompressed levels. Patients were followed for an average of 11 months postoperatively. All patients noted significant improvement in their radicular symptoms. Sixty-two percent reported complete resolution. Only nine patients noted resolution of their back pain. No significant complications were encountered. One superficial wound infection was successfully treated with oral antibiotics. Three patients underwent additional spine surgery in the follow-up period. Relationship between findings and existing knowledge: This study describes one of the largest series of surgically treated adjacent-level stenosis patients. Our series documents accelerated symptomatic degeneration in patients undergoing instrumental fusion. Overall significance of findings: Neurogenic symptoms stemming from degeneration adjacent to a previous posterolateral spinal fusion respond to surgical treatment, although outcomes are inferior to primary surgery. Improvement of low back pain was less predictable in this study. Patients fused with instrumentation appeared to degenerate at an accelerated rate when compared with noninstrumented patients (p.04). Although this study is limited by its retrospective nature, it does point out that lumbar fusion is not a benign procedure and may have significant consequences in the long-term outcome of patients. We are currently undertaking a prospective study to address this in a prospective fashion. Disclosures: Device or drug: pedicle screws. Status: investigational. Conflict of interest: No conflicts. PII: S1529-9430(02)00287-5
4:04 Retrograde ejaculation after anterior lumbar interbody fusion: transperitoneal versus retroperitoneal Rick Sasso, MD1, Kenneth Burkus, MD2, Jean Charles Lehuec, MD3; 1 Indiana Spine Group, Indianapolis, IN, USA; 2Hughston Clinic, Columbus, GA, USA; 3Hospital Tripode Pelligrin, Bordeaux, France Purpose of study: One of the most devastating complications of anterior lumbar interbody fusion (ALIF) in the young male patient is retrograde ejaculation. The purpose of this study is to compare the incidence of retrograde ejaculation in a group of patients undergoing ALIF through either a transperitoneal or retroperitoneal approach. Methods used: A total of 279 patients were entered into a randomized, prospective US Food and Drug Administration investigational device exemption (IDE) study evaluating recombinant human bone morphogenic protein (rhBMP)-2 in a tapered titanium cylindrical cage placed through an open anterior approach for treatment of symptomatic degenerative disc dis-
55S
ease. Choice of retroperitoneal or transperitoneal approach was at the surgeon’s discretion. All procedures were at the L4–L5 or L5–S1 level. The investigation group received rhBMP-2 and the control group autograft iliac crest bone in the cage. Of the 143 patients in the rhBMP-2 group, 78 were male. A retroperitoneal approach was performed on 61 and transperitoneal on 17. In the control group, 68 of 136 patients were male. Fifty-five had a retroperitoneal approach, and 13 had a transperitoneal approach. There is no reported influence of type of bone graft on retrograde ejaculation, so the groups were combined for evaluation. A total of 146 male patients were included in this study with 116 undergoing a retroperitoneal approach and 30 a transperitoneal approach. All male patients were advised preoperatively of the risk of retrograde ejaculation. Patients were questioned postoperatively about adverse events. If a patient reported retrograde ejaculation had occurred postoperatively, they were questioned at each subsequent visit to determine if it was a transient or permanent condition. Summary of findings: Six of 146 male patients reported retrograde ejaculation. Two occurred in the retroperitoneal group (2 of 116) for a 1.7% rate. Four occurred in the transperitoneal group (4 of 30) for a 13.3% rate. This was statistically significant using the Fisher’s exact test (p.017). One patient who developed retrograde ejaculation had an L4–L5 fusion using a retroperitoneal approach and five had an L5–S1 fusion, four with a transperitoneal approach and one with a retroperitoneal approach. Two patients had resolution of their condition at the 1-year postoperative interval, one from the retroperitoneal group and one from the transperitoneal approach. One patient with transient symptoms had an L4–L5 fusion through the retroperitoneal approach, and one patient had an L5–S1 fusion through a transperitoneal approach. At the 2-year postoperative evaluation, four patients had persistent retrograde ejaculation. One was in the retroperitoneal group (1 of 116) for a rate of 0.86% and three in the transperitoneal group (3 of 30) for a rate of 10%. The difference in the rate of permanent retrograde ejaculation is statistically significant between the retroperitoneal and transperitoneal groups using the Fisher’s exact test (p.027) Relationship between findings and existing knowledge: The first reports of retrograde ejaculation after ALIF were made in the 1960s. Although a rare complication, concern arose in the 1990s when a higher rate was noted with laparoscopic procedures. The results of this study show a statistically significant higher rate of permanent retrograde ejaculation in men undergoing a transperitoneal compared with a retroperitoneal approach (10% vs. 0.86%). Overall significance of findings: Transperitoneal approaches to the lumbar spine at L4–L5 and L5–S1 have a 10 times higher chance of retrograde ejaculation compared with retroperitoneal approaches in male patients. Disclosures: No disclosures. Conflict of interest: Rick Sasso, MD, grant research support; Rick Sasso, MD, consultant; Kenneth Burkus, MD, grant research support; Kenneth Burkus, MD, consultant; Jean Charles LeHuec, MD, grant research support; Jean Charles LeHuec, MD, consultant. PII: S1529-9430(02)00288-7
4:10 Complications of spinal fusion in treatment of adult spinal deformity Jen-Yi Chang, MD1, John Kostuik, MD1, Ann Sieber, RN, MSN1; 1Johns Hopkins University, Baltimore, MD, USA Purpose of study: Surgical treatment for adult spinal deformity from 1992 to 2000 with a minimum of 1-year follow-up. To describe the overall complications in 363 adult spinal deformity patients who underwent 410 spinal fusion operations. Methods used: Included were 62 men and 301 women, average age 48 years (range, 20 to 86). There were 101 patients aged 20 to 40 years, 161 patients aged 41 to 60 years and 101 patients older than 60 years. Procedures included 278 deformities and 132 deformities with pseudarthrosis.
Proceedings of the NASS 17th Annual Meeting / The Spine Journal 2 (2002) 47S–128S
56S
There were 24 anterior, 156 posterior, 161 same-day anterior/posterior and 69 staged anterior/posterior approaches. Summary of findings: The major complications rate was 29%. The overall major/minor complications rate was 58%. The major complications included 11 pulmonary emboli, 6 lower limbs paraparesis, 5 leg weakness with muscle strength 1 to 3/5, 2 cauda equina syndromes, 2 epidural hematoma requiring emergency decompression, 5 major vessel injury, 3 bowel necrosis, 1 bowel perforation, 2 SIADH, 2 ARDS, 24 respiratory compromise, 6 sepsis, 12 deep wound infection, 5 deep vein thrombosis and 2 ureteral injuries. Minor complications included 4 hook pull-outs, 3 pedicle screw pull-outs, 11 dural tears, 6 spinal headache, 1 acute hearing loss, 7 nerve root entrapment, 8 lower limb weakness with muscle strength 4/5, 14 pleural effusions, 25 postoperative ileus, 4 Clostridium difficile– positive diarrhea, 18 urinary tract infections, 17 urinary retention, 6 superficial wound infections, 3 transfusion reactions and 27 altered mental status. There were 9 deaths, 3 from pulmonary embolism, 1 intra-abdominal bleeding, 1 sepsis, 1 coagulopathy, 1 brain herniation, 1 bowel necrosis and multiple organ failure and 1 intraoperative death resulting from cardiac ischemia. Tracheostomy was performed for 8 patients. Instrumentation removal in 26 patients. The pseudarthrosis rate was 6%. In the 132 patients for pseudarthrosis repair, 10 continued to have pseudarthrosis. The fusion rate for pseudarthrosis repair was 92%. Relationship between findings and existing knowledge: The study contributes to the literature by reporting on the largest series of patients with adult reconstructive deformity surgery complications. Overall significance of findings: Major complications in adult reconstructive deformity surgery are significant and age related but with knowledge can be decreased. Disclosures: No disclosures. Conflict of interest: No conflicts. Table 1 Fusion rate for pseudarthrosis repair
up telephone interview by 134 patients (71.6%). Average follow-up was 48 months (range, 24 to 72 months). Acute symptoms were reported at the following rates: ambulation difficulty, 50.7%; extended antibiotic usage, 7.5%; persistent drainage, 3.7%; wound dehiscence, 2.2% and incision and drainage, 1.5%. The chronic symptom questionnaire demonstrated a high degree of satisfaction with the cosmetic result (92.5%). Pain at the donor site was reported by 26.1% of patients with a mean VAS score of 3.8 of 10, and 11.2% chronically used pain medication. Twenty-one patients (15.7%) reported dysthesias at the donor site, but only 5.2% reported discomfort with clothing. Functional assessment revealed current impairments at the following rates: ambulation, 12.7%; recreational activities, 11.9%; work activities, 9.7%; activities of daily living, 8.2%; sexual activity, 7.5% and household chores, 6.7%. Relationship between findings and existing knowledge: The basic principles of an ACDF procedure include adequate decompression and a biologically compatible bone graft providing restoration of structural integrity and allowing a solid bony union. When autologous iliac crest bone graft is used, however, possible donor site morbidity must be taken into account. Similar to previous studies, the present study demonstrated substantial donor site morbidity, even at long-term follow-up. This study is unique, however, in that it also explores long-term functional outcome, and the results demonstrate significant impairment in day-to-day activities relating to anterior iliac crest bone graft donation site. Overall significance of findings: A large percentage of patients report chronic donor site pain after anterior ICBG donation, even when only a single-level ACDF procedure is performed. Moreover, long-term functional impairment can also be significant. Patients should be counseled regarding these potential problems, and alternative sources of graft material should be considered. Disclosures: No disclosures. Conflict of interest: No conflicts. PII: S1529-9430(02)00290-5
Age (years)
Total complication
Major complication
Minor complication
20–40 40–60 60 All procedures
47% 58% 67% 58%
20% 31% 32% 29%
34% 44% 55% 45%
Wednesday, October 30, 2001 4:42–5:25 PM Concurrent Session 2A: Cervical Spine Surgery Complications
PII: S1529-9430(02)00289-9
4:16 Functional assessment of donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion by a single surgeon Jeff Silber, MD1, D. Greg Anderson, MD2, Scott Daffner, MD3, Brian Brislin, MD3, J. Martin Leland, BA3, Alan Hilibrand, MD3, Alexander Vaccaro, MD3, Todd Albert, MD3; 1Long Island Jewish Medical Center, Great Neck, NY, USA; 2University of Virginial Medical Center, Charlottesville, VA, USA; 3Thomas Jefferson University, Philadelphia, PA, USA Purpose of study: The purpose of the study was to evaluate acute and chronic problems associated with anterior iliac crest bone graft donation for single-level anterior cervical discectomy and fusion (ACDF), particularly long-term functional outcomes and impairments resulting from graft donation. Methods used: A questionnaire was mailed to 187 consecutive patients who were retrospectively identified to have undergone autologous anterior iliac crest bone harvest (ICBG) harvest for single-level ACDF between 1994 and 1998. The questionnaire divided items into symptomatic (acute and chronic) and functional assessments. Patients answered either yes, no or not applicable; pain was assessed with a visual analog scale (VAS). Summary of findings: Surveys were completed either by mail or follow-
4:42 Anterior discectomy and plating for traumatic unilateral cervical jumped facet: an analysis of failures in a single-institution series of 56 cases Larry T. Khoo, MD1, K. Anthony Kim, MD2, Srinath Samudrala, MD2; 1 University of Southern California, Pasadena, CA, USA; 2University of Southern California, Los Angeles, CA, USA Purpose of study: Significant controversy persists regarding the ideal treatment of an isolated unilateral jumped or locked facet after cervical spine trauma. The purpose of this study was to examine the efficacy and outcomes of such a purely anterior technique for the treatment of a unilateral jumped facet. Methods used: Between 1994 and 2002, a retrospective review was conducted at the Los Angeles County General Hospital to identify a total of 56 patients with cervical spine trauma and unilateral jumped facet syndrome who were subsequently treated by anterior cervical discectomy and fusion. Demographic data, initial neurological examinations, surgical data, radiographic findings and follow-up records were reviewed. The mean followup was 14.5 months with greater than 6-month follow-up available in 95% of patients. Treatment failure was identified as progression of cervical deformity, graft or hardware migration, or new neurological deficit. Time to failure was divided arbitrarily into immediate (0 to 4 weeks), early (4 weeks to 3 months), middle (3 to 6 months) and late (longer than 6 months).