Jean-Marc Voyadzis’s research while affiliated with University of Washington and other places

Surgical drains are utilized in spinal surgery to reduce the incidence of epidural hematomas (EDHs) and to facilitate optimal wound healing. Despite their widespread use, there is a paucity of data to support their utility. The goal of this systematic review and meta-analysis is to compare the effect of using drains versus no drains on postoperative outcomes in adult and pediatric patients undergoing posterior spinal fusions for deformity or degenerative conditions. The following outcomes were assessed: SSIs, EDHs, reoperations, transfusions, and length of stay (LOS). A systematic review of the literature in databases was conducted for all relevant literature. Exclusion criteria included single level decompressions, minimally invasive fusions, anterior-only approaches, and any surgical procedures performed for tumor, trauma, and osteomyelitis. Forest plots for Odds Ratios (ORs) and Mean Differences (MDs) were generated using random effects model. The search identified 2,210 titles, of which 11 studies were chosen for final analysis. 5 studies involved pediatric patients, while 6 included adult patients. A total of 3293 patients were analyzed—2,060 had a drain, and 1,233 had no drain. There were no statistically significant differences in the ORs of SSIs, EDHs, reoperations, and transfusions. LOS in adults was higher in the Drain group (MD 1.36 days 95% CI 0.25 – 2.47). This meta-analysis found no benefit in surgical drains in posterior spinal fusion in reducing the incidence of SSI, EDH, and reoperation. Drains may be associated with longer LOS in the adult population. PROSPERO registration number: CRD42023417315.

BACKGROUND Robot-assisted techniques are increasingly integrated into the field of spine surgery, with the potential benefits of increased accuracy and reduced radiation exposure. The objective of this study was to describe the technique of minimally invasive robot-assisted direct pars repair with 2 case illustrations. OBSERVATIONS An 18-year-old male and a 42-year-old male, both with bilateral L5 spondylolysis, underwent successful minimally invasive L5 direct pars repairs with robotic assistance after conservative measures failed, and their cases are presented herein. LESSONS A robot-assisted direct pars repair is a safe and effective technique for treating bilateral lumbar spondylolysis. The integration of robot-assisted techniques in spine surgery has the potential to improve outcomes, decrease surgical time, and reduce the amount of radiation exposure to operating room staff. https://thejns.org/doi/10.3171/CASE2415

BACKGROUND Here the authors present the case of a 43-year-old male with a history of T-cell lymphoma, which was treated with azacitidine plus cyclophosphamide, doxorubicin, vincristine, and prednisone and autologous hematopoietic cell transplant, and high-risk polycythemia vera (PCV) presenting with severe lower-back pain radiating to the bilateral legs with associated lower-extremity weakness and splenomegaly. OBSERVATIONS T2-weighted magnetic resonance imaging revealed multilevel epidural lesions involving T1–10 and S1–2. Because of severe spinal canal stenosis, the patient underwent surgical decompression of T5–7, with immediate postoperative alleviation of the lower-extremity pain and complete resolution of the lower-leg weakness. Biopsy results revealed extramedullary hematopoiesis (EMH) mimicking a spinal epidural tumor. EMH is radiosensitive and displays a rapid response to low dosages, so the patient was further treated with palliative radiation therapy for residual tumors and symptom alleviation, as well as hydroxyurea and corticosteroids as indicated for cytoreduction. LESSONS EMH associated with PCV or myeloproliferative conditions occurring within the spine is a rare phenomenon without a standard treatment approach. https://thejns.org/doi/10.3171/CASE23659

Recent years have seen significant advancements in the implementation of computer-assisted surgery in spine. Enabling technologies like robots and navigation have been refined to compliment the field's shift towards minimally invasive techniques and to fit more seamlessly into the existing workflow. Robotic-surgery and navigation in deformity can be particularly helpful in cases where the severe curves of the spinal column or the abnormal pedicle anatomy make pedicle screw placement challenging with the use of traditional anatomic landmarks. Furthermore, the ability to pre-plan patient specific rods has opened the door for greater precision in rod contouring. Drawbacks of robotic-assisted surgery include the steep upfront cost, the need for additional staff and training and the lack of tactile feedback. This review will discuss the current state of navigation and robotics, with a specific focus on their applications to deformity surgery.

Background Lumbar synovial cysts (LSCs) can cause painful radiculopathy, sensory and/or motor deficits. Historically, first-line surgical treatment has been decompression with fusion. Recently, minimally invasive laminectomy without fusion has shown equal or superior results to traditional decompression and fusion methods. Objective This study investigates the long-term efficacy of minimally invasive laminectomy without fusion in the treatment of LSC as it relates to the rate of subsequent fusion surgery. Methods A retrospective review was performed over a 10-year period of patients undergoing minimally invasive laminectomy for symptomatic LSCs. The primary endpoint was the rate of revision surgery requiring fusion. Results Eighty-five patients with symptomatic LSCs underwent minimally invasive laminectomy alone January 2010-August 2020 at our institution. The most common location was L4-5 (72%). Pre-operative imaging identified spondylolisthesis (grade 1) in 43 (57%) patients, none of which were unstable on available dynamic radiographs. Average procedure duration was 93 minutes, with 78% of patients discharged home on the same day of surgery. Over 46 months of mean follow-up, seventeen patients (20%) required nineteen revision operations. Of those, 16 were spinal fusions (17.6%). Median time to fusion surgery was 36 months. There were no identifiable risk factors on multivariate regression analysis that predicted the need for fusion. Conclusion Minimally invasive laminectomy is an effective first-line treatment for symptomatic lumbar synovial cysts and avoids the need for fusion in the majority of treated patients. 18% of our patients required a fusion over 46 months, suggesting that further studies are required to guide patient selection.

INTRODUCTION The concept of accelerated degeneration at the level adjacent to a fused spinal segment is a well-known and studied phenomenon. Most current surgical paradigms address this with extension of fusion. However, decompression with laminectomy and/or discectomy, particularly with MIS approaches, are viable options. METHODS A single-center retrospective review of consecutive cases from 2013-2020 was performed. All patients who underwent lumbar surgery for ASD were included. The primary outcome was need for revision surgery following either a decompression, microdiscectomy, or instrumented fusion for lumbar ASD. Multivariable regression analysis (chi-square and ANOVA) was performed on demographic, operative, and follow-up data. RESULTS We identified 176 patients who underwent surgery for lumbar ASD with mean follow-up of 9.3 years. 129 patients were treated with fusion, 37 with laminectomy, and 10 with microdiscectomy. In total, 41 patients required revision surgery following their ASD operation: 28 (21.7%) after fusion, 10 (27%) after laminectomy, and 3 (30%) after microdiscectomy (p = 0.697). Symptomatic disc herniation manifested sooner requiring reoperation -- on average 43.8 months (p = 0.006) after index procedure. CONCLUSION There was no significant difference in revision rate among patients undergoing extension of fusion, laminectomy, or discectomy in the treatment of lumbar ASD. Focal adjacent stenosis or disc herniation can be durably treated with MIS laminectomy or discectomy, respectively. Accelerated disc degeneration after discectomy for lumbar ASD may require a subsequent fusion. Lumbar ASD associated with mobile spondylolisthesis should be treated by extension of fusion.

INTRODUCTION Lumbar synovial cysts (LSC), most often occurring at L4-5, can cause painful radiculopathy and/or sensory or motor deficits when symptomatic. The etiology of these lesions is thought to be related to degeneration of the facet joints. Historically, the first-line surgical treatment has been decompression with fusion. More recently, minimally invasive laminectomy without fusion has been shown to achieve equal or superior results to traditional decompression and fusion methods. METHODS A retrospective review was performed at a single institution, over a 10-year period, of patients undergoing minimally invasive laminectomy for symptomatic LSCs. The primary outcome in this study was the rate of revision surgery requiring fusion. Secondary outcomes were based on analysis of baseline patient characteristics, operative details, and postoperative outcomes. RESULTS Eighty-five patients with symptomatic LSC underwent minimally invasive laminectomy alone from January 2010 to August 2020 at our institution. The most common location was L4-5 (71%), followed by L5-S1 (17%), and then L3-4 (11%). The average patient was 65 years old with a BMI of 28.6. All patients (100%) presented with symptoms of painful radiculopathy. Pre-operative imaging identified spondylolisthesis in 44 (57%) patients, none of which were considered unstable on dynamic X-rays. Average length of the procedure was 93 minutes, with 78% of patients discharged home on the same day of their procedure. There was only one reported intraoperative durotomy. Over 45 months of mean follow-up, seventeen patients (20%) required eighteen revision operations. Of those, 15 were primary spinal fusions (17.6%), 2 were washouts for epidural hematoma (2.4%), and 1 was a revision decompression for recurrent cyst (1.2%). Mean time to fusion surgery was 31 months. There were no identifiable risk factors on multivariate regression analysis that predicted the need for fusion. CONCLUSION After minimally invasive laminectomy for lumbar synoval cyst, only 18% of the 85 patients in our cohort went on to require a fusion over a ten-year period.

Objective: The use of technology-enhanced methods in spine surgery has increased immensely over the past decade. Here, the authors present the largest systematic review and meta-analysis to date that specifically addresses patient-centered outcomes, including the risk of inaccurate screw placement and perioperative outcomes in spinal surgeries using robotic instrumentation and/or augmented reality surgical navigation (ARSN). Methods: A systematic review of the literature in the PubMed, EMBASE, Web of Science, and Cochrane Library databases spanning the last decade (January 2011-November 2021) was performed to present all clinical studies comparing robot-assisted instrumentation and ARSN with conventional instrumentation techniques in lumbar spine surgery. The authors compared these two technologies as they relate to screw accuracy, estimated blood loss (EBL), intraoperative time, length of stay (LOS), perioperative complications, radiation dose and time, and the rate of reoperation. Results: A total of 64 studies were analyzed that included 11,113 patients receiving 20,547 screws. Robot-assisted instrumentation was associated with less risk of inaccurate screw placement (p < 0.0001) regardless of control arm approach (freehand, fluoroscopy guided, or navigation guided), fewer reoperations (p < 0.0001), fewer perioperative complications (p < 0.0001), lower EBL (p = 0.0005), decreased LOS (p < 0.0001), and increased intraoperative time (p = 0.0003). ARSN was associated with decreased radiation exposure compared with robotic instrumentation (p = 0.0091) and fluoroscopy-guided (p < 0.0001) techniques. Conclusions: Altogether, the pooled data suggest that technology-enhanced thoracolumbar instrumentation is advantageous for both patients and surgeons. As the technology progresses and indications expand, it remains essential to continue investigations of both robotic instrumentation and ARSN to validate meaningful benefit over conventional instrumentation techniques in spine surgery.

Objective: Single-position lateral lumbar interbody fusion (SP-LLIF) has recently gained significant popularity due to increased operative efficiency, but it remains technically challenging. Robot-assisted percutaneous pedicle screw (RA-PPS) placement can facilitate screw placement in the lateral position. The authors have reported their initial experience with SP-LLIF with RA-PPS placement in the lateral position, and they have compared this accuracy with that of RA-PPS placement in the prone position. Methods: The authors reviewed prospectively collected data from their first 100 lateral-position RA-PPSs. The authors graded screw accuracy on CT and compared it to the accuracy of all prone-position RA-PPS procedures during the same time period. The authors analyzed the effect of several demographic and perioperative metrics, as a whole and specifically for lateral-position RA-PPS placement. Results: The authors placed 99 lateral-position RA-PPSs by using the ExcelsiusGPS robotic platform in the first 18 consecutive patients who underwent SP-LLIF with postoperative CT imaging; these patients were compared with 346 prone-position RA-PPSs that were placed in the first consecutive 64 patients during the same time period. All screws were placed at L1 to S1. Overall, the lateral group had 14 breaches (14.1%) and the prone group had 25 breaches (7.2%) (p = 0.032). The lateral group had 5 breaches (5.1%) greater than 2 mm (grade C or worse), and the prone group had 4 (1.2%) (p = 0.015). The operative level had an effect on the breach rate, with breach rates (grade C or worse) of 7.1% at L3 and 2.8% at L4. Most breaches were grade B (< 2 mm) and lateral, and no breach had clinical sequelae or required revision. Within the lateral group, multivariate regression analysis demonstrated that BMI and number of levels affected accuracy, but the side that was positioned up or down did not. Conclusions: RA-PPSs can improve the feasibility of SP-LLIF. Spine surgeons should be cautious and selective with this technique owing to decreased accuracy in the lateral position, particularly in obese patients. Further studies should compare SP-LLIF techniques performed while the patient is in the prone and lateral positions.