Adrian M Nowitzke

Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom

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Publications (15)44.18 Total impact

  • Richard J Mannion, Adrian M Nowitzke, Martin J Wood
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    ABSTRACT: Using bone morphogenic protein (BMP) to augment fusion in spine surgery is widespread and lends itself in particular to minimally invasive lumbar fusion, where the surface area for fusion is significantly less than the equivalent open procedure. Here we described the use of very low-dose BMP in promoting fusion in minimally invasive lumbar interbody fixation but also highlight some of the potential complications of BMP-2 use and techniques available to reduce or avoid them. Prospective observational study of consecutive patients undergoing minimally invasive lumbar interbody fusion with percutaneous pedicle screws. Thirty patients aged between 22 and 78 years (mean 53 years). Thin-slice lumbar computed tomography scanning with multiplanar reconstruction at 6 and 12 months postoperative. Thirty-six spinal levels were instrumented in total, of which four underwent posterior lumbar interbody fusion and 32 underwent transforaminal lumbar interbody fusion. Bone graft harvested locally was placed in the disc space with low-dose BMP-2 (1.4 mg per level). Thirty-three of 36 spinal levels showed complete fusion at a mean postoperative scan time of 7.1 months. Two levels demonstrated partial fusion at 6 months, which was complete at 12 months. There was one case of nonunion at 12 months, which also demonstrated vertebral body osteolysis. Despite very low-dose BMP-2, two cases of asymptomatic heterotopic ossification were observed, and there were two cases of perineural cyst formation, one of whom required revision of the interbody cage. The use of BMP with autograft in the disc space during minimally invasive lumbar interbody fusion is associated with a high rate of early fusion. Even with very low-dose BMP used in this study, complications related to BMP usage were not avoided completely.
    The spine journal: official journal of the North American Spine Society 06/2011; 11(6):527-33. · 2.90 Impact Factor
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    ABSTRACT: Prospective observational study. To describe our experience with the first 50 cases of minimally invasive lumbar canal decompression in terms of patient outcome up to 2 years, the learning curve incurred, and complications when compared with our most recent 50 cases. Lumbar canal stenosis is a common condition in the elderly population, the symptoms of which respond well to surgical decompression. A minimally invasive approach offers potential short and long-term benefits to patients but the technique is associated with a learning curve and equivalence to open surgery regarding efficacy and complications needs to be demonstrated. Fifty patients (mean age 70 y) who presented with clinical and radiological features of lumbar canal stenosis and who had failed a period of conservative management underwent lumbar canal decompression through a paramedian oblique, muscle splitting approach using a 16 to 18 mm operating tube and microscope. Outcome was assessed using the Oswestry Disability Index and Short Form-36 at 3 months, 1 year, and 2 years. Significant clinical improvements were seen at 3 months that were sustained at 1 and 2 years. Clinical outcome improved whereas operative time and complications fell as experience increased, helping to define the learning curve with this technique. Minimally invasive lumbar decompression seems to offer patients a clinical benefit comparable to that observed in published open series, with potential advantages in terms of postoperative pain and recovery. However, there is a learning curve and whether this technique offers long-term benefits with regard to a reduction in back pain or postoperative spondylolisthesis is not yet known.
    Journal of spinal disorders & techniques 05/2011; 25(1):47-51. · 1.21 Impact Factor
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    ABSTRACT: Although minimally invasive surgery for intradural tumors offers the potential benefits of less postoperative pain, a quicker recovery, and the avoidance of long-term instability from multilevel laminectomy, there are concerns over whether one can safely and effectively remove intradural extramedullary tumors in a fashion comparable to open techniques and whether the advantages of minimally invasive surgery are clinically significant. To review our early experience with minimally invasive techniques for intradural extramedullary tumors of the spine. Thirteen intradural tumors (1 cervical, 6 thoracic, 6 lumbar) in 11 patients were operated on using a muscle-splitting, tube-assisted paramedian oblique approach with hemilaminectomy to access the spinal canal while preserving the spinous process and ligaments. Fluoroscopy and navigation were used to determine the surgical level in all thoracic and lumbar cases. Satisfactory tumor resection using standard microsurgical techniques was achieved in all but 1 case using a minimally invasive approach. Surgical time and intraoperative blood loss were favorable compared with our open technique cases. There was no postoperative morbidity with the minimally invasive approach, although in 2 patients with tumors in the mid- and upper thoracic spine, the surgical incision was inaccurately placed by 1 level. In 1 case, the approach was converted to open when the tumor could not be found, and postoperatively there was a cerebrospinal fluid leak with infection that required readmission. Intradural extramedullary tumors can be safely and effectively removed using minimally invasive techniques. The pros and cons of minimally invasive vs open surgery are discussed.
    Neurosurgery 12/2010; 68(1 Suppl Operative):208-16; discussion 216. · 2.53 Impact Factor
  • R. J. Mannion, A. M. Nowitzke, M. J. Wood
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    ABSTRACT: Purpose: While minimally invasive surgery offers the potential benefit of less post-operative pain, a quicker recovery and the avoidance of long-term instability from multilevel laminectomy, there are concerns over whether one can safely and effectively remove intradural extramedullary tumours in a fashion comparable to open techniques, and whether the theoretical advantages of minimally invasive surgery are clinically significant. Here we review our early experience with minimally invasive techniques for intradural tumours in the thoracolumbar spine.Methodology: Eleven intradural thoracic or lumbar tumours in 9 patients were operated upon using a muscle splitting, tube-assisted para-median approach with hemilaminectomy to access the spinal canal. Fluoroscopy and navigation were used to determine the surgical level in all cases.Results: Satisfactory tumour resection using standard microsurgical techniques was achieved in all but one case through a minimally invasive approach. Surgical time and intra-operative blood loss were favourable compared to open techniques. There was no post-operative morbidity in any of these cases although there were 2 cases in the high thoracic spine in which the surgical site was inaccurately placed by 1 level. In one case, the approach was converted to open when the tumour could not be found. In this case there was a post-operative CSF leak which required re-admission.Conclusions: Intradural tumours can be safely and effectively removed using minimally invasive techniques. The pros and cons of minimally invasive versus open surgery are discussed.
    ANZ Journal of Surgery 01/2009; 79. · 1.50 Impact Factor
  • R. J. Mannion, A. M. Nowitzke, M. J. Wood
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    ABSTRACT: Introduction: Posterolateral pedicle screw fixation with interbody fusion is a popular technique to treat degenerative lumbar spine disease with radiculopathy, particularly in the presence of foramenal stenosis and/or lumbar spondylolisthesis. Recently, minimally invasive techniques have been developed with which to achieve the same surgical goals as open surgery, offering the patient the potential for less post-operative pain and a quicker recovery.Methodology: 64 consecutive patients between 2005 & 2008 were treated with minimally invasive interbody fusion and percutaneous pedicle screw fixation with navigation (Stealth, Medtronic). Following removal of the disc contents, the interbody cage(s) were inserted with iliac crest bone graft +/− BCP in the first half of the series, and local bone graft and BMP in the latter half.Results: Our current technique includes a number of key changes which have evolved to overcome specific difficulties and as technology has advanced. We now perform the procedure using CT-guided navigation for pedicle screw insertion and muscle splitting minimally invasive tube surgery for decompression and interbody fusion for all but a small number of cases at L5/S1 where the lumbosacral angle precludes access through a tube. A number of improvements have been introduced with regard to – radiation exposure; interbody fusion technique; navigation with fluoroscopy versus CT, and methods to encourage fusion including the use of BMP.Conclusions: Minimally invasive interbody fusion is an attractive alternative to open techniques, with less post-operative pain and quicker recovery for the patient. The pros and cons of minimally invasive versus open techniques will be discussed.
    ANZ Journal of Surgery 01/2009; 79. · 1.50 Impact Factor
  • Adrian Nowitzke
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    ABSTRACT: A fundamental dilemma that faces both neurosurgery in general and the subspecialty field of spine surgery is the question of whether those who trained in the former and now work in the latter should maintain their links with their origins and remain under the broader umbrella of neurosurgery, or whether they should develop their own organizational structure and identity separate from organized neurosurgery. This challenge raises many questions with respect to future potential for growth and development, professional identity, and collegiality. This paper is an edited version of an invited speech to the 2007 Annual Meeting of the Joint Section on Disorders of the Spine and Peripheral Nerves. It uses the concept of synergy to review relevant history and explore possible future options for neurosurgery, neurospine, and neuroscience. An example from medical politics is used to illustrate the importance of perspective in approaching these questions, and examples of current therapeutic cutting-edge endeavors highlight the need for team-based behavior that takes a broad view. The premise of the paper is that while individual and specialty aspirations need to be acknowledged, considered, and managed, the results from truly working together will be greater than the sum of the individual efforts-synergy.
    Journal of Neurosurgery Spine 11/2008; 9(4):319-25. · 1.98 Impact Factor
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    ABSTRACT: Olfactory ensheathing cells show promise in preclinical animal models as a cell transplantation therapy for repair of the injured spinal cord. This is a report of a clinical trial of autologous transplantation of olfactory ensheathing cells into the spinal cord in six patients with complete, thoracic paraplegia. We previously reported on the methods of surgery and transplantation and the safety aspects of the trial 1 year after transplantation. Here we address the overall design of the trial and the safety of the procedure, assessed during a period of 3 years following the transplantation surgery. All patients were assessed at entry into the trial and regularly during the period of the trial. Clinical assessments included medical, psychosocial, radiological and neurological, as well as specialized tests of neurological and functional deficits (standard American Spinal Injury Association and Functional Independence Measure assessments). Quantitative test included neurophysiological tests of sensory and motor function below the level of injury. The trial was a Phase I/IIa design whose main aim was to test the feasibility and safety of transplantation of autologous olfactory ensheathing cells into the injured spinal cord in human paraplegia. The design included a control group who did not receive surgery, otherwise closely matched to the transplant recipient group. This group acted as a control for the assessors, who were blind to the treatment status of the patients. The control group also provided the opportunity for preliminary assessment of the efficacy of the transplantation. There were no adverse findings 3 years after autologous transplantation of olfactory ensheathing cells into spinal cords injured at least 2 years prior to transplantation. The magnetic resonance images (MRIs) at 3 years showed no change from preoperative MRIs or intervening MRIs at 1 and 2 years, with no evidence of any tumour of introduced cells and no development of post-traumatic syringomyelia or other adverse radiological findings. There were no significant functional changes in any patients and no neuropathic pain. In one transplant recipient, there was an improvement over 3 segments in light touch and pin prick sensitivity bilaterally, anteriorly and posteriorly. We conclude that transplantation of autologous olfactory ensheathing cells into the injured spinal cord is feasible and is safe up to 3 years of post-implantation, however, this conclusion should be considered preliminary because of the small number of trial patients.
    Brain 10/2008; 131(Pt 9):2376-86. · 10.23 Impact Factor
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    ABSTRACT: Olfactory ensheathing cells show promise in preclinical animal models as a cell transplantation therapy for repair of the injured spinal cord. This is a report of a clinical trial of autologous transplantation of olfactory ensheathing cells into the spinal cord in six patients with complete, thoracic paraplegia. We previously reported on the methods of surgery and transplantation and the safety aspects of the trial 1 year after transplantation. Here we address the overall design of the trial and the safety of the procedure, assessed during a period of 3 years following the transplantation surgery. All patients were assessed at entry into the trial and regularly during the period of the trial. Clinical assessments included medical, psychosocial, radiological and neurological, as well as specialized tests of neurological and functional deficits (standard American Spinal Injury Association and Functional Independence Measure assessments). Quantitative test included neurophysiological tests of sensory and motor function below the level of injury. The trial was a Phase I/IIa design whose main aim was to test the feasibility and safety of transplantation of autologous olfactory ensheathing cells into the injured spinal cord in human paraplegia. The design included a control group who did not receive surgery, otherwise closely matched to the transplant recipient group. This group acted as a control for the assessors, who were blind to the treatment status of the patients. The control group also provided the opportunity for preliminary assessment of the efficacy of the transplantation. There were no adverse findings 3 years after autologous transplantation of olfactory ensheathing cells into spinal cords injured at least 2 years prior to transplantation. The magnetic resonance images (MRIs) at 3 years showed no change from preoperative MRIs or intervening MRIs at 1 and 2 years, with no evidence of any tumour of introduced cells and no development of post-traumatic syringomyelia or other adverse radiological findings. There were no significant functional changes in any patients and no neuropathic pain. In one transplant recipient, there was an improvement over 3 segments in light touch and pin prick sensitivity bilaterally, anteriorly and posteriorly. We conclude that transplantation of autologous olfactory ensheathing cells into the injured spinal cord is feasible and is safe up to 3 years of post-implantation, however, this conclusion should be considered preliminary because of the small number of trial patients.
    Brain. 01/2008; 131:2376-86.
  • Adrian Nowitzke, Martin Wood, Ken Cooney
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    ABSTRACT: The accurate identification of the correct vertebral level during surgery remains problematic and still accounts for a significant percentage of litigation. The ideal technique for spinal-level localization would have the following characteristics: easy availability in the operating theater, lowest-possible radiation exposure for the professional team and the patient, simple technique which is easily reproducible at any time during surgery, usable with all forms of spine surgery, permanently recordable, able to be used throughout the spine, able to be easily checked by nonspecialist members of the team, and accurate. We describe a new technique for thoracolumbar-level localization, based on these principles, which uses computer-assisted image guidance. Surgery technique development in clinical practice. The technique uses standard image intensifier radiology with FluoroNav Spine or FluoroNav MAST software on the StealthStation computer-assisted surgery system. (Medtronic Navigation, Louisville, ed) Adjacent, contiguous, images are taken in the desired plane from the reference area of the lumbosacral junction to the general area of operative interest. These images can then be displayed simultaneously on the computer screen. Use of the probe extension feature allows counting, external to the skin and drapes, from the reference level to the level of interest at any time without additional radiation exposure. Standard navigation can then be undertaken at the operative level. This technique has been used in 17 cases, all of which have been undertaken in the mid- or low-thoracic and lumbar regions where the operative level is not visible on the same image intensifier image as the lumbosacral junction. All cases have undergone postoperative radiology to check the surgery level and no cases of incorrect level of surgery have occurred. No accuracy errors have developed during surgery and no complications from the reference arc have occurred. This technique is indicated for level localization in the spine where the operative level cannot be visualized on the same fluoroscopy field of view as the reference level. It has a relative contraindication in the upper thoracic spine, in the very obese, and in the presence of osteoporosis where fluoroscopic imaging is difficult, although we postulate a technique using preoperative computed tomography (CT) to overcome these difficulties. This technique satisfies a number of criteria for the "ideal technique" and has advantages over current methods. A number of caveats are level localization and the use of this technique are presented.
    The Spine Journal 01/2008; 8(4):597-604. · 3.36 Impact Factor
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    ABSTRACT: Olfactory ensheathing cells transplanted into the injured spinal cord in animals promote regeneration and remyelination of descending motor pathways through the site of injury and the return of motor functions. In a single-blind, Phase I clinical trial, we aimed to test the feasibility and safety of transplantation of autologous olfactory ensheathing cells into the injured spinal cord in human paraplegia. Participants were three male paraplegics, 18-55 years of age, with stable, complete thoracic injuries 6-32 months previously, with stable spinal column, no implanted prostheses, and no syrinx. Olfactory ensheathing cells were grown and purified in vitro from nasal biopsies and injected into the region of damaged spinal cord. The trial design includes a matched injury group as a control for the assessors, who are blind to treatment status. Assessments, made before transplantation and at regular intervals subsequently, include MRI, medical, neurological and psychosocial assessments, and standard American Spinal Injury Association and Functional Independence Measure assessments. One year after cell implantation, there were no medical, surgical or other complications to indicate that the procedure is unsafe. There is no evidence of spinal cord damage nor of cyst, syrinx or tumour formation. There was no neuropathic pain reported by the participants, no change in psychosocial status and no evidence of deterioration in neurological status. Participants will be followed for 3 years to confirm long-term safety and to compare neurological, functional and psychosocial outcomes with the control group. We conclude transplantation of autologous olfactory ensheathing cells into the injured spinal cord is feasible and is safe up to one year post-implantation.
    Brain 01/2006; 128(Pt 12):2951-60. · 10.23 Impact Factor
  • Martin J Wood, Adrian M Nowitzke
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    ABSTRACT: To examine the epidemiology of spontaneous subarachnoid haemorrhage (SAH) within the population of Queensland, Australia in 2002. A retrospective population and hospital-based survey of all cases of spontaneous SAH occurring within the population of Queensland (3.7 million) during the calendar year 2002 was performed. Cases were identified from hospital separation coding data and the register of births, deaths and marriages. Standard demographic data was recorded for each case identified. The annual incidence of SAH in our population was 9.4 cases per 100,000. There was a steady increase in the incidence of SAH with increasing age, with the incidence rising to 38.8 per 100,000 in those aged greater than 80. The overall mortality rate was 33.1%, with 6% of all cases dying before reaching hospital care. The annual incidence in the indigenous population of Queensland was 8.9 /100,000.
    Journal of Clinical Neuroscience 10/2005; 12(7):770-4. · 1.25 Impact Factor
  • P Hlincik, A Nowitzke
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    ABSTRACT: A man with a spontaneous spinal dural fistula and significant fluctuations in level of consciousness is discussed. The presentation was that of headache and vomiting followed by an initially enigmatic acute reduction in the level of consciousness. This required urgent evacuation of bilateral chronic subdural haematomas, believed to be causative. Following mobilisation, several episodes of presumed orthostatic intracranial hypotension occurred rendering the patient rapidly unconscious. A large spinal extradural CSF collection extending through the full length of the vertebral canal was later diagnosed however, the precise location of the fistulous leak could not be found radiologically. Non-operative management was successful. To the best of our knowledge, this is the first description of a spontaneous spinal cerebrospinal fluid leak of this magnitude. The case, pathogenesis, investigations and management of this rare entity are considered and the literature reviewed.
    Journal of Clinical Neuroscience 09/2005; 12(6):717-20. · 1.25 Impact Factor
  • Paul Licina, Adrian M Nowitzke
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    ABSTRACT: Spinal trauma often results in a complex interaction of injuries to the musculoskeletal and nervous systems. This combination of biomechanical and neurological considerations provides a unique challenge to those dealing with the spinally injured patient. Proper assessment of the injuries sustained by the patient remains the initial, yet key, step in determining appropriate management. The aim of the physical examination is not only to characterize the nature of the injury to the vertebral column, but also to determine the extent of actual and potential damage to the neural elements. It is also concerned with detecting associated injuries of the brain, viscera, and limbs that can impact on management and outcome, particularly of any neurological deficit. Further information about the spinal column and spinal cord is derived from appropriate radiological assessment, which is evolving with the increasing sophistication of imaging modalities. In spinal injury, classification systems are particularly important as they simplify a diverse range of injury patterns into a useable and reproducible form that may be used to aid communication among clinicians, guide management for individual patients, and provide the basis for research consistency. The medical management involves consideration of the impact of spinal injury, in particular cord injury, on aspects including resuscitation and anticoagulation, as well as the role of steroids. The definitive management of the spinal column injury may be operative or nonoperative. Factors influencing this decision are biomechanical (stabilization of the unstable spine and reduction of deformity) and neurological (improvement in deficit and decompression of neural elements). This article considers these issues and aims to present a balanced and useful algorithm for clinicians to use when faced with spinal injury.
    Injury 08/2005; 36 Suppl 2:B2-12. · 2.46 Impact Factor
  • Adrian M Nowitzke
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    ABSTRACT: An understanding of the learning curve of a new surgical procedure is essential for its safe clinical integration, teaching, and assessment. This knowledge is currently deficient for lumbar microendoscopic discectomy (MED). The present article aims to profile the learning curve for MED of an individual surgeon in a hospital not previously exposed to this procedure. The first 35 cases of MED for posterolateral lumbar disc prolapse causing radiculopathy performed at the Princess Alexandra Hospital, Brisbane, Australia, were studied prospectively. The learning curve was assessed using surgery time, conversion rate, complication rate, surgeon "comfort," and key learning steps. The duration of surgical operating time decreased over the course of the study, initially rapidly and then more gradually. There were three conversions to open discectomy in the first 7 cases and none in the next 28 cases. The complexity of cases increased over the series, and the complication rate decreased. The asymptote of the learning curve seems to be approximately 30 cases. The specific learning tasks of MED include lateral lamina radiology, scope vision, visuospatial orientation, smaller field of view, angle of approach and tube position, and care and handling of endoscope equipment. A learning curve for MED has been demonstrated. Further assessment of this curve for a population of surgeons is necessary before a clinical assessment of open discectomy versus MED can be embarked upon.
    Neurosurgery 05/2005; 56(4):755-62; discussion 755-62. · 2.53 Impact Factor
  • M J Wood, G Dimeski, A M Nowitzke
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    ABSTRACT: To assess the sensitivity and specificity of CSF spectrophotometry for the detection of xanthochromia in patients with clinical symptoms suggestive of subarachnoid haemorrhage (SAH) but normal cranial computed tomography (CT). All consecutive patients undergoing both cranial CT and lumbar puncture for investigation of possible SAH at the Princess Alexandra Hospital, Brisbane, between January 2000 and April 2003 were included in the study. All case histories, radiology and laboratory results were retrospectively assessed. The sensitivity, specificity and positive predictive value of the spectrophotometry test were calculated. 253 patients were included in the study. Spectrophotometry was shown to have a sensitivity of 100% but a specificity of only 75.2%. The positive predictive value of spectrophotometry as an indicator of SAH was 3.3%. CSF spectrophotometry has an unacceptably low specificity and positive predictive value, which greatly limit its use as a clinical tool.
    Journal of Clinical Neuroscience 03/2005; 12(2):142-6. · 1.25 Impact Factor

Publication Stats

487 Citations
44.18 Total Impact Points

Institutions

  • 2011
    • Cambridge University Hospitals NHS Foundation Trust
      Cambridge, England, United Kingdom
  • 2005–2011
    • Princess Alexandra Hospital (Queensland Health)
      • Department of Neurosurgery
      Brisbane, Queensland, Australia