Intraoperative Neuromonitoring During Lateral Lumbar Interbody Fusion

Ram Alluri,Jung Kee Mok,Avani Vaishnav,Tara Shelby,Ahilan Sivaganesan,Raymond Hah,Sheeraz A. Qureshi 대한척추신경외과학회 2021 Neurospine Vol.18 No.3

Objective: To review the evidence for the use of electromyography (EMG), motor-evoked potentials (MEPs), and somatosensory-evoked potentials (SSEPs) intraoperative neuromonitoring (IONM) strategies during lateral lumbar interbody fusion (LLIF), as well as discuss the limitations associated with each technique. Methods: A comprehensive review of the literature and compilation of findings relating to clinical studies investigating the efficacy of EMG, MEP, SSEP, or combined IONM strategies during LLIF. Results: The evidence for the use of EMG is mixed with some studies demonstrating the efficacy of EMG in preventing postoperative neurologic injuries and other studies demonstrating a high rate of postoperative neurologic deficits with EMG monitoring. Multimodal IONM strategies utilizing MEPs or saphenous SSEPs to monitor the lumbar plexus may be promising strategies based on results from a limited number of studies. Conclusion: The use of traditional EMG during LLIF remains without consensus. There is a growing body of evidence utilizing multimodal IONM with MEPs or saphenous SSEPs demonstrating a possible decrease in postoperative neurologic injuries after LLIF. Future prospective studies, with clear definitions of neurologic injury, that evaluate different multimodal IONM strategies are needed to better assess the efficacy of IONM during LLIF.

Strategies for Globalizing Endoscopic Spine Surgery

Ram K. Alluri,Jeffrey C. Wang 대한척추신경외과학회 2023 Neurospine Vol.20 No.1

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Anatomic Evaluation of the Interportal Capsulotomy Made with the Modified Anterior Portal versus Standard Anterior Portal: Comparable Utility with Decreased Capsule Morbidity

Alexander E. Weber,Ram K. Alluri,Eric C Makhni,Ioanna K. Bolia,Eric N. Mayer,Joshua D. Harris,Shane J. Nho 대한고관절학회 2020 Hip and Pelvis Vol.32 No.1

Purpose: To identify potential differences in interportal capsulotomy size and cross-sectional area (CSA) using the anterolateral portal (ALP) and either the: (i) standard anterior portal (SAP) or (ii) modified anterior portal (MAP). Materials and Methods: Ten cadaveric hemi pelvis specimens were included. A standard arthroscopic ALP was created. Hips were randomized to SAP (n=5) or MAP (n=5) groups. The spinal needle was placed at the center of the anterior triangle or directly adjacent to the ALP in the SAP and MAP groups, respectively. A capsulotomy was created by inserting the knife through the SAP or MAP. The length and width of each capsulotomy was measured using digital calipers under direct visualization. The CSA and length of the capsulotomy as a percentage of total iliofemoral ligament (IFL) side-to-side width were calculated. Results: There were no differences in mean cadaveric age, weight or IFL dimensions between the groups. Capsulotomy CSA was significantly larger in the SAP group compared with the MAP group (SAP 2.16±0.64 cm2 vs. MAP 0.65±0.17 cm2, P=0.008). Capsulotomy length as a percentage of total IFL width was significantly longer in the SAP group compared with the MAP group (SAP 74.2±14.1% vs. MAP 32.4±3.7%, P=0.008). Conclusion: The CSA of the capsulotomy and the percentage of the total IFL width disrupted are significantly smaller when the interportal capsulotomy is performed between the ALP and MAP portals, compared to the one created between the ALP and SAP. Surgeons should be aware of this fact when performing hip arthroscopy.

Cervical Disc Replacement: Trends, Costs, and Complications

Jain Nickul Saral,Nguyen Ailene,Formanek Blake,Alluri Ram,Buser Zorica,Hah Ray,Wang Jeffrey Chun 대한척추외과학회 2020 Asian Spine Journal Vol.14 No.5

Study Design: Retrospective review of insurance database.Purpose: To investigate national trends, complications, and costs after cervical disc replacement (CDR) using an administrative insurance database representative of the United States population.Overview of Literature: As CDR continues to be used to treat patients with cervical stenosis, it is important to gain a better understanding of its use on a national level, potential complications, and cost. This information will allow for optimal patient counseling, risk stratification, and healthcare cost assessments. Several prior studies have investigated complications associated with CDR, but they have been limited by small sample size, single institution experiences, limited follow-up, and potential conflicts of interest.Methods: Patients who underwent single or multilevel CDR between 2007 and 2015 were identified using an insurance database. We collected data on annual trends, reimbursement costs, patient demographic information, hospital information, and information on complications from the time of operation to 1 year postoperative.Results: Total of 293 patients underwent either single or multilevel CDR. The number of procedures increased nonlinearly over time at an average of 17% per year, with a greater increase seen in the outpatient setting. Less than 3.7% of patients had new onset pain within 1 year after CDR. Within 1 year, 12.3% of patients reported a mechanical and/or bone-related complication. There were no patients who indicated a new nerve injury within 6 months of follow-up. Less than 3.7% of patients presented with dysphagia or dysphonia within 6 months, infection within 3 months, or a revision or reoperation within 1 year. Average reimbursement for single-level inpatient versus outpatient CDR was $33,696.28 and $34,675.12, respectively (p =0.29).Conclusions: This study demonstrated that the use of CDR continued to increase. The most common complication was mechanical and/or bone-related, and cost analysis demonstrated no significant difference between inpatient and outpatient CDR.

Acute Operative Management of Osteoporotic Vertebral Compression Fractures Is Associated with Decreased Morbidity

Mills Emily S.,Ton Andy T.,Bouz Gabriel,Alluri Ram K.,Hah Raymond J. 대한척추외과학회 2022 Asian Spine Journal Vol.16 No.5

Study Design: Retrospective national database study design.Purpose: This study was designed to determine whether acute percutaneous vertebral augmentation (PVA) alters morbidity compared with nonoperative management.Overview of Literature: Osteoporotic vertebral compression fractures (OCFs) are common and represent a large economic and patient burden. Several recent studies have focused on whether PVA offers benefits compared with nonoperative treatment.Methods: A retrospective cohort analysis was conducted using the Nationwide Inpatient Sample from 2015 to 2018. Patients with nonelective admissions for OCFs were identified using International Classification of Diseases (10th edition) codes. The exclusion criteria included age of less than 50 years, fusion and decompression procedures, and the presence of neoplasms and infections. Propensity score matching was implemented to construct 2:1 matched cohorts with similar comorbidities at admission. The patients were divided into the operative and nonoperative treatment groups. Univariate and multivariate regression analyses were performed to compare differences in in-hospital complication rates between the groups. All <i>p</i>-values of less than 0.05 were considered significant.Results: We identified 14,850 patients in the operative group and 29,700 patients in the nonoperative group. In the multivariate analysis, operative treatment was associated with significantly lower rates of pneumonia (odds ratio [OR], 0.75; <i>p</i><0.001), acute respiratory failure (OR, 0.84; <i>p</i>=0.009), myocardial infarction (OR, 0.20; <i>p</i><0.001), acute heart failure (OR, 0.80; <i>p</i>=0.001), cardiogenic shock (OR, 0.23; <i>p</i>=0.001), sepsis (OR, 0.39; <i>p</i><0.001), septic shock (OR 0.50; <i>p</i><0.001), and pressure ulcerations (OR, 0.71; <i>p</i><0.001). However, operative treatment was associated with a significantly greater risk of acute renal failure (OR, 1.19; <i>p</i><0.001) than nonoperative treatment.Conclusions: Patients who undergo acute PVA for OCFs have lower rates of respiratory complications, cardiac complications, sepsis, and pressure ulcerations while having a higher risk of acute renal failure.