Browsing by Author "Tabarestani, Troy Q"

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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
    Beyond Placement of Pedicle Screws - New Applications for Robotics in Spine Surgery: A Multi-Surgeon, Single-Institution Experience.
    (Frontiers in surgery, 2022-01) Tabarestani, Troy Q; Sykes, David; Murphy, Kelly R; Wang, Timothy Y; Shaffrey, Christopher I; Goodwin, C Rory; Horne, Phillip; Than, Khoi D; Abd-El-Barr, Muhammad M
    Interest in robotic-assisted spine surgery has grown as surgeon comfort and technology has evolved to maximize benefits of time saving and precision. However, the Food and Drug Administration (FDA) has currently only approved robotics to assist in determining the ideal trajectory for pedicle screw placement after extensive research supporting its efficacy and efficiency. To be considered a durable and effective option, robotics need to expand beyond the indication of just placing pedicle screws. This article aims to illustrate a multi-surgeon, single-institution experience with unique applications of robotic technologies in spine surgery. We will explore accessing Kambin's Triangle in percutaneous transforaminal interbody fusion (percLIF), iliac fixation in metastatic cancer, and sacroiliac (SI) fusions. Each of these topics will be covered in depth with associated background information and subsequent discussion. We show that with proper understanding of its limitations, robots can help surgeons perform difficult surgeries in a safe manner.
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    ItemOpen Access
    Evaluating the Distribution, Quality, and Educational Value of Videos Related to Shoulder Instability Exercises on the Social Media Platform TikTok.
    (Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews, 2023-06) Bethell, Mikhail A; Anastasio, Albert T; Taylor, Joshua R; Tabarestani, Troy Q; Klifto, Christopher S; Anakwenze, Oke

    Background

    Because of the lack of scientific oversight, the quality, applicability, and consistency of healthcare-related TikTok videos have become a focus of research exploration. The orthopaedic surgery literature lags behind other medical fields in analyzing the widespread utilization of TikTok videos for medical information delivery.

    Methods

    TikTok was queried using the hashtag #shoulderstabilityexercises, and 109 videos were included. The videos were collected by two authors and independently evaluated using DISCERN (a well-validated informational analysis tool) and shoulder stability exercise education score (a self-designed tool for the evaluation of shoulder instability-related exercises).

    Results

    DISCERN scores of videos uploaded by general users had significantly lower scores in all four categories than those uploaded by healthcare professionals (P < 0.001, P = 0.005, P = 0.002, and P < 0.001). For the shoulder stability exercise education score, general users had a significantly lower score than the healthcare professionals at 3.36 and 4.91 on a 25-point scale, respectively (P = 0.034). General users had more videos graded as very poor (84.2%) in comparison to the number of videos uploaded by healthcare professionals deemed very poor (51.5%). However, the remainder of healthcare professionals had their videos graded as poor (48.5%).

    Conclusion

    Despite slightly improved video quality from healthcare professionals, the overall educational of the videos related to shoulder instability exercises was poor.
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    ItemOpen Access
    Evolution of the Transforaminal Lumbar Interbody Fusion (TLIF): From Open to Percutaneous to Patient-Specific.
    (Journal of clinical medicine, 2024-04) Drossopoulos, Peter N; Ononogbu-Uche, Favour C; Tabarestani, Troy Q; Huang, Chuan-Ching; Paturu, Mounica; Bardeesi, Anas; Ray, Wilson Z; Shaffrey, Christopher I; Goodwin, C Rory; Erickson, Melissa; Chi, John H; Abd-El-Barr, Muhammad M
    The transforaminal lumbar interbody fusion (TLIF) has seen significant evolution since its early inception, reflecting advancements in surgical techniques, patient safety, and outcomes. Originally described as an improvement over the posterior lumbar interbody fusion (PLIF), the TLIF began as an open surgical procedure, that notably reduced the need for the extensive neural retractation that hindered the PLIF. In line with the broader practice of surgery, trending toward minimally invasive access, the TLIF was followed by the development of the minimally invasive TLIF (MIS-TLIF), a technique that further decreased tissue trauma and postoperative complications. Subsequent advancements, including Trans-Kambin's Triangle TLIF (percLIF) and transfacet LIF, have continued to refine surgical access, minimize surgical footprint, and reduce the risk of injury to the patient. The latest evolution, as we will describe it, the patient-specific TLIF, is a culmination of the aforementioned adaptations and incorporates advanced imaging and segmentation technologies into perioperative planning, allowing surgeons to tailor approaches based on individual patient anatomy and pathology. These developments signify a shift towards more precise methods in spine surgery. The ongoing evolution of the TLIF technique illustrates the dynamic nature of surgery and emphasizes the need for continued adaptation and refinement.
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    ItemOpen Access
    Machine learning in the diagnosis, management, and care of patients with low back pain: a scoping review of the literature and future directions.
    (The spine journal : official journal of the North American Spine Society, 2024-09) Seas, Andreas; Zachem, Tanner J; Valan, Bruno; Goertz, Christine; Nischal, Shiva; Chen, Sully F; Sykes, David; Tabarestani, Troy Q; Wissel, Benjamin D; Blackwood, Elizabeth R; Holland, Christopher; Gottfried, Oren; Shaffrey, Christopher I; Abd-El-Barr, Muhammad M

    Background context

    Low back pain (LBP) remains the leading cause of disability globally. In recent years, machine learning (ML) has emerged as a potentially useful tool to aid the diagnosis, management, and prognostication of LBP.

    Purpose

    In this review, we assess the scope of ML applications in the LBP literature and outline gaps and opportunities.

    Study design/setting

    A scoping review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines.

    Methods

    Articles were extracted from the Web of Science, Scopus, PubMed, and IEEE Xplore databases. Title/abstract and full-text screening was performed by two reviewers. Data on model type, model inputs, predicted outcomes, and ML methods were collected.

    Results

    In total, 223 unique studies published between 1988 and 2023 were identified, with just over 50% focused on low-back-pain detection. Neural networks were used in 106 of these articles. Common inputs included patient history, demographics, and lab values (67% total). Articles published after 2010 were also likely to incorporate imaging data into their models (41.7% of articles). Of the 212 supervised learning articles identified, 168 (79.4%) mentioned use of a training or testing dataset, 116 (54.7%) utilized cross-validation, and 46 (21.7%) implemented hyperparameter optimization. Of all articles, only 8 included external validation and 9 had publicly available code.

    Conclusions

    Despite the rapid application of ML in LBP research, a majority of articles do not follow standard ML best practices. Furthermore, over 95% of articles cannot be reproduced or authenticated due to lack of code availability. Increased collaboration and code sharing are needed to support future growth and implementation of ML in the care of patients with LBP.
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    ItemOpen Access
    Novel Merging of CT and MRI to Allow for Safe Navigation into Kambin's Triangle for Percutaneous Lumbar Interbody Fusion-Initial Case Series Investigating Safety and Efficacy.
    (Operative neurosurgery (Hagerstown, Md.), 2023-03) Tabarestani, Troy Q; Sykes, David AW; Sykes, David AW; Maquoit, Gisselle; Wang, Timothy Y; Ayoub, Chakib M; Shaffrey, Christopher I; Wiggins, Walter F; Abd-El-Barr, Muhammad M

    Background

    For percutaneous lumbar fusion (percLIF), magnetic resonance imaging and computed tomography are critical to defining surgical corridors. Currently, these scans are performed separately, and surgeons then use fluoroscopy or neuromonitoring to guide instruments through Kambin's triangle. However, anatomic variations and intraoperative positional changes are possible, meaning that safely accessing Kambin's triangle remains a challenge because nerveroot visualization without endoscopes has not been thoroughly described.

    Objective

    To overcome the known challenges of percLIF and reduce the likelihood of iatrogenic injuries by showing real-time locations of neural and bony anatomy.

    Methods

    The authors demonstrate an intraoperative navigational platform that applies nerve root segmentation and image fusion to assist with percLIF. Five patients from a single institution were included.

    Results

    Of the 5 patients, the mean age was 71 ± 8 years and 3 patients (60%) were female. One patient had general anesthesia while the remaining 4 patients underwent awake surgery with spinal anesthesia. The mean area for the L4-L5 Kambin's triangle was 76.1 ± 14.5 mm 2 . A case example is shown where the side of approach was based on the fact that Kambin's triangle was larger on one side compared with the other. The mean operative time was 170 ± 17 minutes, the mean blood loss was 32 ± 16 mL, and the mean hospital length of stay was 19.6 ± 8.3 hours. No patients developed postoperative complications.

    Conclusion

    This case series demonstrates the successful and safe application of nerve segmentation using magnetic resonance imaging/computed tomography fusion to perform percLIF and provide positive patient outcomes.
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    ItemOpen Access
    Pushing the Limits of Minimally Invasive Spine Surgery-From Preoperative to Intraoperative to Postoperative Management.
    (Journal of clinical medicine, 2024-04) Drossopoulos, Peter N; Sharma, Arnav; Ononogbu-Uche, Favour C; Tabarestani, Troy Q; Bartlett, Alyssa M; Wang, Timothy Y; Huie, David; Gottfried, Oren; Blitz, Jeanna; Erickson, Melissa; Lad, Shivanand P; Bullock, W Michael; Shaffrey, Christopher I; Abd-El-Barr, Muhammad M
    The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery.
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    ItemOpen Access
    The Importance of Planning Ahead: A Three-Dimensional Analysis of the Novel Trans-Facet Corridor for Posterior Lumbar Interbody Fusion Using Segmentation Technology.
    (World neurosurgery, 2024-05) Tabarestani, Troy Q; Drossopoulos, Peter N; Huang, Chuan-Ching; Bartlett, Alyssa M; Paturu, Mounica R; Shaffrey, Christopher I; Chi, John H; Ray, Wilson Z; Goodwin, C Rory; Amrhein, Timothy J; Abd-El-Barr, Muhammad M

    Background

    The rise of minimally invasive lumbar fusions and advanced imaging technologies has facilitated the introduction of novel surgical techniques with the trans-facet approach being one of the newest additions. We aimed to quantify any pathology-driven anatomic changes to the trans-facet corridor, which could thereby alter the ideal laterality of approach to the disc space.

    Methods

    In this retrospective cohort study, we measured the areas and maximum permissible cannula diameters of the trans-facet corridor using commercially available software (BrainLab, Munich, Germany). Exiting and traversing nerve roots, thecal sacs, and lumbar vertebrae were manually segmented on T2-SPACE magnetic resonance imaging. Spondylolisthesis, disc protrusions, and disc space heights were recorded.

    Results

    A total of 118 trans-facet corridors were segmented bilaterally in 16 patients (65.6 ± 12.1 years, 43.8% female, body mass index 29.2 ± 5.1 kg/m2). The mean areas at L1-L2, L2-L3, L3-L4, and L4-L5 were 89.4 ± 24.9 mm2, 124 ± 39.4 mm2, 123 ± 26.6 mm2, and 159 ± 42.7 mm2, respectively. The mean permissible cannula diameter at the same levels were 7.85 ± 1.43 mm, 8.98 ± 1.72 mm, 8.93 ± 1.26 mm, and 10.2 ± 1.94 mm, respectively. Both parameters increased caudally. Higher degrees for spondylolisthesis were associated with larger areas and maximum cannula diameters on regression analysis (P < 0.001).

    Conclusions

    Our results illustrate that pathology, like spondylolisthesis, can increase the area of the trans-facet corridor. By understanding this effect, surgeons can better decide on the optimal approach to the disc while taking into consideration a patient's unique anatomy.
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    ItemOpen Access
    Two-Year Clinical and Radiographic Outcomes for Percutaneous Lumbar Interbody Fusion With an Expandable Titanium Cage Through Kambin's Triangle Without Facetectomy.
    (International journal of spine surgery, 2023-12) Tabarestani, Troy Q; Wang, Timothy Y; Sykes, David AW; Mehta, Vikram A; Yang, Lexie Z; Chow, Shein-Chung; Shaffrey, Christopher I; Wiggins, Walter F; Chi, John H; Abd-El-Barr, Muhammad M

    Background

    There has been heightened interest in performing percutaneous lumbar interbody fusions (percLIFs) through Kambin's triangle, an anatomic corridor allowing entrance into the disc space. However, due to its novelty, there are limited data regarding the long-term benefits of this procedure. Our objective was to determine the long-term efficacy and durability of the percutaneous insertion of an expandable titanium cage through Kambin's triangle without facetectomy.

    Methods

    A retrospective review of patients undergoing percLIF via Kambin's triangle using an expandable titanium cage was performed. Demographics, visual analog scale (VAS) scores, Oswestry Disability Index (ODI), radiographic measurements, perioperative variables, and complications were recorded. VAS, ODI, and radiographic measurements were compared with baseline using the generalized estimating equations assuming normally distributed data. Fusion was assessed with computed tomography (CT) at 1 and 2 years after the procedure.

    Results

    A total of 49 patients were included. Spondylolisthesis, lumbar lordosis (LL), sacral slope, pelvic tilt, and anterior/posterior disc space height were all significantly improved postoperatively at each time point of 3, 6, 12, and 24 months (P < 0.001). Pelvic incidence-LL mismatch decreased significantly at each follow-up (P < 0.001) with a mean reduction of 4° by 24 months. VAS back scores reduced by >2 points at the 6, 12, and 24 month follow-ups. ODI scores reduced by >15 points at the 12- and 24-month follow-ups. Of the patients who had 1- and 2-year CT images, fusion rates at those time points were 94.4% (17/18) and 87.5% (7/8), respectively. The mean annual rate of surgically significant adjacent segment disease was 2.74% through an average follow-up of 2.74 years.

    Conclusion

    These results highlight that percLIF, a procedure done without an endoscope or facetectomy, can be performed using an expandable titanium cage through Kambin's triangle with excellent radiographic and clinical results.

    Clinical relevance

    percLIF via Kambin's triangle is a safe and succesful procedure with long-term improvements in both clinical and radiographic outcomes.

    Level of evidence: 3

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    ItemOpen Access
    Using Augmented Reality Technology to Optimize Transfacet Lumbar Interbody Fusion: A Case Report
    (Journal of Clinical Medicine, 2024-03-01) Bardeesi, Anas; Tabarestani, Troy Q; Bergin, Stephen M; Huang, Chuan-Ching; Shaffrey, Christopher I; Wiggins, Walter F; Abd-El-Barr, Muhammad M
    The transfacet minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a novel approach available for the management of lumbar spondylolisthesis. It avoids the need to manipulate either of the exiting or traversing nerve roots, both protected by the bony boundaries of the approach. With the advancement in operative technologies such as navigation, mapping, segmentation, and augmented reality (AR), surgeons are prompted to utilize these technologies to enhance their surgical outcomes. A 36-year-old male patient was complaining of chronic progressive lower back pain. He was found to have grade 2 L4/5 spondylolisthesis. We studied the feasibility of a trans-Kambin or a transfacet MIS-TLIF, and decided to proceed with the latter given the wider corridor it provides. Preoperative trajectory planning and level segmentation in addition to intraoperative navigation and image merging were all utilized to provide an AR model to guide us through the surgery. The use of AR can build on the safety and learning of novel surgical approaches to spine pathologies. However, larger high-quality studies are needed to further objectively analyze its impact on surgical outcomes and to expand on its application.
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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.