Books and Book Chapters

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  Special Patient Populations

  Michael D. Staudt, Eric Z. Herring, Berje H. Shammassian, Sonia A. Havele, Jerry Lipinski, and Jennifer A. Sweet

  Publication Date: 1-2024

  As the use of intrathecal therapy has become more common in our armamentarium for the treatment of chronic pain, the indications for implantation have expanded to include new conditions and patient populations; however, the literature regarding these developing indications is sparse, consisting primarily of case reports and case series. As such, robust, long-term data are lacking. In this chapter, we review the management of intrathecal drug therapy in specific patient populations that require further attention. This includes patients with atypical pain syndromes, children, immunocompromised patients, and patients on blood thinning agents. In addition, we discuss treatment options for individuals with other implantable devices. Finally, we examine the treatment algorithm in the setting of cerebrospinal fluid leaks. Of note, while there are currently only three intrathecal agents approved for use by the Food and Drug Administration, morphine (an opioid), ziconotide (a non-opioid calcium channel antagonist), and baclofen (a GABAB receptor agonist), this chapter also reports on the use of investigational intrathecal therapies that are considered off-label.

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  ERAS and Spine Surgery

  Michael D. Staudt, Xiaofei Zhou, Olindi Wijesekera, Jonathan Miller, and Jennifer Sweet

  Publication Date: 1-1-2023

  Enhanced Recovery After Surgery (ERAS) protocols are multidisciplinary approaches to perioperative care, which aim to optimize surgical recovery by incorporating evidence-based approaches in the preoperative, intraoperative, and postoperative periods. As such, the goal of these strategies is to minimize stressors from various physiological and psychological sources. There is a compelling case for the implementation of ERAS into the routine management of spinal surgery, as many of these procedures are associated with long operative durations, considerable homeostatic stress, and significant postoperative pain which can lead to prolonged recovery, delayed mobilization, and increased opioid use. Elderly patients are a particularly vulnerable patient population in elective spinal surgery, as they tend to have more medical comorbidities and are also more sensitive to opioids. The purpose of this chapter is to summarize the components of ERAS protocols as they relate to spine surgery, and highlight advances in perioperative management such as the role of multimodal analgesia and minimally invasive techniques. A comprehensive literature review of published ERAS protocols and outcomes is provided.

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  Intrathecal Drug Delivery for Pain

  Tessa A. Harland, Michael D. Staudt, and Vishad V. Sukul

  Publication Date: 10-14-2022

  This chapter discusses the important role of intrathecal drug delivery for the treatment of chronic cancer and non-cancer pain. Specific diagnostic considerations and the role of an intrathecal trial for appropriate patient selection are discussed in depth. There are presently only two intrathecal agents approved for use by the FDA in chronic pain therapy, including morphine (an opioid), and ziconitide (a non-opioid calcium channel antagonist). Current recommendations, supporting evidence, and safety profiles of both FDA approved and off-label intrathecal medications for pain control are reviewed. The roles of combination intrathecal therapy and dual modality therapy in conjunction with spinal cord stimulation are also briefly discussed. Finally, the process of surgical implantation, commonly used drug delivery systems, and associated post-implant and pharmacologic complications are described in detail.

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  Minimally Invasive Treatment of Spinal Metastasis

  Eric R. Mong and Daniel K. Fahim

  Publication Date: 2-25-2022

  Advancements in the treatment of systemic cancer have improved life expectancy in cancer patients and consequently the incidence of spinal metastasis. Traditionally, open spinal approaches combined with cEBRT (conventional external beam radiation therapy) allowed for local tumor control as well as stabilization and decompression of the spine and neural elements, but these larger operations can be fraught with one complications and delayed healing as well as additional morbidity. Recently, minimally invasive spine techniques are becoming increasingly popular in the treatment of spinal metastasis for many reasons, including smaller incisions with less perioperative complications and potential for expedited time to radiation therapy. These techniques include kyphoplasty with radiofrequency ablation, percutaneous stabilization, laminectomy, and epidural tumor resection through tubular retractors, as well as minimally invasive corpectomy. These techniques combined with highly conformal stereotactic radiosurgery have led to the advent of separation surgery, which allows for decompression of neural elements while creating space between neural elements and the tumor so adequate radiation may be delivered, improving local tumor control. The versatility of these minimally invasive techniques has significantly improved the modern management of metastatic disease of the spine by protecting and restoring the patient’s quality of life while allowing them to quickly resume radiation and systemic treatment.

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  Limiting morbidity in neuromodulation

  Michael D. Staudt, Olga Khazen, Shrey Patel, Konstantin V. Slavin, and Julie G. Pilitsis

  Publication Date: 7-15-2022

  Complications resulting from surgery are not uncommon; however, many measures can be taken to reduce the severity and rate of them. It is the responsibility of the surgeon to mitigate such risks. The field of neuromodulation poses additional risks due to the implantation of hardware, opening the door for infection, migration, erosion, and more. Thoroughly understanding the risks involved with the procedure, educating patients and caretakers, and carefully selecting patients is essential for minimizing and avoiding complications.

  In this chapter, we will present pre-, intra-, and postoperative considerations and strategies to minimize complications and morbidity. Specifically, we will offer methods to prevent infection preoperatively by considering modifiable lifestyle factors and comorbidities that have been correlated with higher morbidity. Next, we will consider surgical techniques to mitigate the various intraoperative complications that may arise. Finally, we will discuss what to do when complications and/or suboptimal outcomes occur postoperatively.