Browsing by Author "Salven, David S"

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    ItemOpen Access
    A Novel Approach to Percutaneous Lumbar Surgeries via Kambin's Triangle - A Radiographic and Surgical Planning Analysis with Nerve Segmentation Technology.
    (World neurosurgery, 2023-06) Tabarestani, Troy Q; Sykes, David AW; Kouam, Romaric W; Salven, David S; Wang, Timothy Y; Mehta, Vikram A; Shaffrey, Christopher I; Wiggins, Walter F; Chi, John H; Abd-El-Barr, Muhammad M

    Objective

    While Kambin's triangle has become an ever more important anatomic window given its proximity to the exiting nerve root, there have been limited studies examining the effect of disease on the corridor. Our goal was to better understand how pathology can affect Kambin's triangle thereby altering laterality of approach for percutaneous lumbar interbody fusion (percLIF).

    Methods

    The authors performed a single-center retrospective review of patients evaluated for percLIF. The areas of Kambin's triangle were measured without and with nerve segmentation. For the latter, the lumbosacral nerve roots on 3D T2 MRI were manually segmented. Next, the borders of Kambin's triangle were delineated ensuring no overlap between the area and the nerve above.

    Results

    15 patients (67.5 ± 9.7 years, 46.7% female) were retrospectively reviewed. 150 Kambin's triangles were measured. The mean areas from L1-S1 were 50.0 ± 12.3 mm2, 73.8 ± 12.5 mm2, 83.8 ± 12.2 mm2, 88.5 ± 19.0 mm2, and 116 ± 29.3 mm2, respectively. When pathology was present, the areas significantly decreased at L4-L5 (p = 0.046) and L5-S1 (p = 0.049). Higher spondylolisthesis and smaller posterior disc heights were linked with decreased areas via linear regression analysis (p < 0.05). When nerve segmentation was used, the areas were significantly smaller from L1-L5 (p < 0.05). Among 11 patients who underwent surgery, none suffered from postoperative neuropathies.

    Conclusion

    These results illustrate the feasibility of pre-operatively segmenting lumbosacral nerves and measuring Kambin's triangle to help guide surgical planning and determine the ideal laterality of approach for percLIF.
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    ItemOpen Access
    Awake spinal anesthesia facilitates spine surgery in poor surgical candidates: A case series.
    (Neuro-Chirurgie, 2023-05) Sykes, David AW; Tabarestani, Troy Q; Salven, David S; Chaudhry, Nauman S; Wang, Timothy Y; Gottfried, Oren N; Shaffrey, Christopher I; Guinn, Nicole R; Gadsden, Jeffrey; Ayoub, Chakib M; Bullock, W Michael; Berger, Miles; Abd-El-Barr, Muhammad M

    Background

    Annually, hundreds of thousands of patients undergo surgery for degenerative spine disease (DSD). This represents only a fraction of patients that present for surgical consideration. Procedures are often avoided due to comorbidities that make patients poor candidates for general anesthesia (GA) and its associated risks. With increasing interest in awake surgery under spinal anesthesia (SA), the authors have observed that SA may facilitate spine surgery in patients with relative contraindications to GA. With this in mind, the authors set out to summarize the outcomes of a series of highly comorbid patients who received surgery under SA.

    Methods

    Case logs of a single surgeon were reviewed, and patients undergoing spine surgery under SA were identified. Within this group, patients were identified with relative contraindications to GA, such as advanced age and medical comorbidities. For these patients, for whom surgery was facilitated by SA, the medical records were consulted to report demographic information and patient outcomes.

    Results

    Ten highly comorbid patients were identified who received lumbar spine surgery for DSD under SA. Comorbidities included octogenarian status, obesity, and chronic health conditions such as heart disease. The cohort had a mean age of 75.5 and a mean American Society of Anesthesiologists Physical Status (ASA-PS) score of 3.1. The patients were predicted to have a 2.74-fold increase of serious complications compared to the average patient. There were no adverse events.

    Conclusion

    For patients with symptomatic, refractory DSD and relative contraindications to GA, SA may facilitate safe surgical intervention with excellent outcomes.
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    ItemOpen Access
    Awake Spinal Fusion Is Associated with Reduced Length of Stay, Opioid Use, and Time to Ambulation Compared to General Anesthesia: A Matched Cohort Study.
    (World neurosurgery, 2023-05) Sykes, David AW; Tabarestani, Troy Q; Chaudhry, Nauman S; Salven, David S; Shaffrey, Christopher I; Bullock, W Michael; Guinn, Nicole R; Gadsden, Jeffrey; Berger, Miles; Abd-El-Barr, Muhammad M

    Objective

    There is increasing interest in awake spinal fusion under spinal anesthesia (SA). Evidence supporting SA has been positive, albeit limited. The authors set out to investigate the effects of SA vs general anesthesia (GA) for spinal fusion procedures on length of stay (LOS), opioid use, time to ambulation (TTA), and procedure duration.

    Methods

    The authors performed a retrospective review of a single surgeon's patients who underwent lumbar fusions under SA vs GA from June of 2020 to June of 2022. SA patients were compared to demographically matched GA counterparts undergoing comparable procedures. Analyzed outcomes include operative time, opioid usage in morphine milligram equivalents (MME), TTA, and LOS.

    Results

    10 SA patients were matched to 10 GA counterparts. The cohort had a mean age of 66.77, a mean body mass index of 27.73 kg/m2, and a median American Society of Anesthesiologists Physical Status Score of 3.00. LOS was lower in SA vs GA patients (12.87 vs 50.79 hours, p=0.001). Opioid utilization was reduced in SA vs GA patients (10.76 vs 31.43 MME, p=0.006). TTA was reduced in SA vs GA patients (7.22 vs 29.87 hours, p=0.022). Procedure duration was not significantly reduced in SA patients compared to GA patients (139.3 vs 188.2 minutes, p=0.089).

    Conclusion

    These preliminary retrospective results suggest the use of SA rather than GA for lumbar fusions is associated with reduced hospital LOS, reduced opioid utilization, and reduced TTA. Future randomized prospective studies are warranted to determine if SA usage truly leads to these beneficial outcomes.
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    ItemOpen Access
    Using Novel Segmentation Technology to Define Safe Corridors for Minimally Invasive Posterior Lumbar Interbody Fusion.
    (Operative neurosurgery (Hagerstown, Md.), 2023-12) Tabarestani, Troy Q; Salven, David S; Sykes, David AW; Bardeesi, Anas M; Bartlett, Alyssa M; Wang, Timothy Y; Paturu, Mounica R; Dibble, Christopher F; Shaffrey, Christopher I; Ray, Wilson Z; Chi, John H; Wiggins, Walter F; Abd-El-Barr, Muhammad M

    Background and objectives

    There has been a rise in minimally invasive methods to access the intervertebral disk space posteriorly given their decreased tissue destruction, lower blood loss, and earlier return to work. Two such options include the percutaneous lumbar interbody fusion through the Kambin triangle and the endoscopic transfacet approach. However, without accurate preoperative visualization, these approaches carry risks of damaging surrounding structures, especially the nerve roots. Using novel segmentation technology, our goal was to analyze the anatomic borders and relative sizes of the safe triangle, trans-Kambin, and the transfacet corridors to assist surgeons in planning a safe approach and determining cannula diameters.

    Methods

    The areas of the safe triangle, Kambin, and transfacet corridors were measured using commercially available software (BrainLab, Munich, Germany). For each approach, the exiting nerve root, traversing nerve roots, theca, disk, and vertebrae were manually segmented on 3-dimensional T2-SPACE magnetic resonance imaging using a region-growing algorithm. The triangles' borders were delineated ensuring no overlap between the area and the nerves.

    Results

    A total of 11 patients (65.4 ± 12.5 years, 33.3% female) were retrospectively reviewed. The Kambin, safe, and transfacet corridors were measured bilaterally at the operative level. The mean area (124.1 ± 19.7 mm2 vs 83.0 ± 11.7 mm2 vs 49.5 ± 11.4 mm2) and maximum permissible cannula diameter (9.9 ± 0.7 mm vs 6.8 ± 0.5 mm vs 6.05 ± 0.7 mm) for the transfacet triangles were significantly larger than Kambin and the traditional safe triangles, respectively (P < .001).

    Conclusion

    We identified, in 3-dimensional, the borders for the transfacet corridor: the traversing nerve root extending inferiorly until the caudal pedicle, the theca medially, and the exiting nerve root superiorly. These results illustrate the utility of preoperatively segmenting anatomic landmarks, specifically the nerve roots, to help guide decision-making when selecting the optimal operative approach.