Ultrasound-Guided Posterolateral Approach for Midline Calcified Thoracic Disc Herniation

Objective

Symptomatic thoracic disc herniation often requires prompt surgical treatment to prevent neurological deterioration and permanent deficits. Anterior approaches offer direct visualization and access to the herniated disc and anterior dura but require access surgeons and are often associated with considerable postoperative pain and pulmonary complications. A disadvantage with using posterior approaches in the setting of central calcified thoracic disc herniation however, has been the limited visualization of anterior dura and difficulty to accurately assess the extent of decompression.

Methods

We report our experience with intraoperative ultrasound (US) guidance during a modified posterior transpedicular approach for removal of a central calcified thoracic disc herniation with a review of pertinent literature.

Results

The herniated thoracic disc was successfully removed with posterior approach with the aid of intraoperative US. The patient had significant neurological improvement at three months follow-up.

Conclusion

Intraoperative ultrasound is a simple yet valuable tool for real-time imaging during transpedicular thoracic discectomy. Visualization provided by intraoperative US increases the safety profile of posterior approaches and may make thoracotomy unnecessary in a selected group of patients, especially when a patient has existing pulmonary disease or is otherwise not medically fit for the transthoracic approach.     

Magnetic resonance image findings and surgical considerations in T1-2 disc herniation

OBJECTIVE: To report a case of disc herniation at T1-2. CLINICAL PRESENTATION: A 57-year-old man presented with hand weakness, Horner's syndrome, and pain radiating along the medial aspect of one upper extremity. Magnetic resonance imaging demonstrated extruded T1-2 disc herniation with upward herniation of a sequestrated fragment. INTERVENTION: An anterior approach was used to excise the disc, that was compressing the spinal cord and the T1 nerve root. All the patient's symptoms resolved completely, including Horner's syndrome. CONCLUSION: Anterior discectomy may be the simplest and most effective method for disc excision and relief of spinal cord and T1 nerve root compression.     

Aneurysmal cyst of the cervico-thoracic junction of the spine

The authors report an extensive aneurysmal cyst of the spine at the cervicothoracic junction. During the disease in the patient (a girl aged 9 years) high-grade tetraparesis developed (with complete paralysis of lower extremities but with spared deep sensation and retained sphincter control). In the treatment a two-stage operation with radical removal of the cyst from anterior and posterior approach, spondylodesis and radiotherapy gave very good results as compared with the very poor condition before the operation. Nearly complete movements of all extremities returned, superficial sensation loss regressed. The usefulness of surgical treatment even in such advanced cases is stressed. CT was very helpful in the assessment of the extent of the tumour and its growth rate.     

The Ligamentotactic Effect on a Herniated Disc at the Level Adjacent to the Anterior Lumbar Interbody Fusion : Report of Two Cases

The authors report two cases of spontaneous regression of disc herniation at the level adjacent to the anterior lumbar interbody fusion (ALIF) level. This phenomenon may be due to the increased tension on the posterior longitudinal ligament (PLL) by appropriate restoration of the disc height and lumbar lordosis, which is a mechanism similar to ligamentotaxis applied to the thoracolumbar burst fracture.     

Direct lateral interbody fusion (DLIF) at the lumbosacral junction L5-S1

The direct lateral interbody fusion (DLIF), a minimally invasive lateral approach for placement of an interbody fusion device, does not require nerve root retraction or any contact with the great vessels and can lead to short operative times with little blood loss. Due to anatomical restrictions, this procedure has not been used at the lumbosacral (L5-S1) junction. Lumbosacral transitional vertebrae (LSTV), a structural anomaly of the lumbosacral spine associated with low back pain, can result in a level being wrongly identified pre-operatively due to misnumbering of the vertebral levels. To our knowledge, use of the DLIF graft in this patient is the first report of an interbody fusion graft being placed at the disc space between the LSTV and S1 via the transpsoas route. We present a review of the literature regarding the LSTV variation as well as the lateral placement of interbody fusion grafts at the lumbosacral junction.     

颈胸交界区前入路手术的解剖学研究及临床意义

目的观察颈胸交界区前入路手术的显露范围并测量相关解剖学参数,以为临床应用提供解剖学依据。方法10具成年国人尸体标本,模拟颈胸交界区前入路手术,劈开部分胸骨,观察显露范围及解剖结构,并测量相关解剖学参数。结果10具标本右侧喉返神经均于C7椎体下缘平面以上进入气管食管沟,位置较高,走行变异较大;左侧喉返神经于T3椎体下缘平面以下进入气管食管沟,位置较低,且全程走行于气管食管沟内,位置恒定。双侧头臂静脉汇合点解剖位置不尽一致,其中4具位于右侧第1胸肋关节后方,4具位于第1肋间隙胸骨柄右缘,2具位于第2胸肋关节后方。7具胸导管于C7-T1椎间盘平面至T2椎体上缘平面之间汇入左侧静脉角。结论颈胸交界区前入路手术可充分显露C3～T3椎体,双侧头臂静脉汇合点位置是决定手术显露范围的关键。采用左侧切口,对喉返神经损伤小,但须注意保护胸导管。     

Trans-sternal approach to the cervicothoracic junction

Cervicothoracic junction and upper thoracic spine down to T4 can be reached through anterior approach via sternotomy. Transsternal approach is the best route to gain access to lesions localized within vertebral bodies of the upper thoracic spine allowing for their resection, interbody fusion and replacement with bone cement. Consecutive modifications of transsternal approach evolved toward less extensive osteotomy from full median sternotomy, through manubriotomy with clavicle resection and partial lateral manubriotomy. Less extensive modifications provide limited lateral exposure of the spine and are more demanding technically. We present two cases of upper thoracic spine tumours operated on through full medial sternotomy. We believe that median sternotomy has several advantages over less extensive modifications: it is technically simple to perform for trained thoracic surgeon, safer as it provides better exposure of the mediastinum and thus sufficient control of great vessels including subclavian ones, gives better exposure of T3, T4 and even T5 vertebral bodies, allows perpendicular sight and attack to anterior surface of the upper thoracic spine and therefore good visualizing of the posterior longitudinal ligament and dura, do not destabilize shoulder girdle nor affect function of the upper limb. Additional caudal exposure of the thoracic spine as down as T5 can be obtained by dissecting a plane between the brachiocephalic vein, vena cava superior and ascending aorta.     

颈椎人工髓核柔性稳定一体化系统的设计和制备

背景：对于年轻的颈椎间盘突出患者,人工髓核和人工椎间盘置换是目前研究的热点,但单纯人工髓核置入可能导致髓核向前或向后突出,在颈椎可能引起脊髓压迫或吞咽困难等并发症。课题结合柔性稳定概念,提出并设计出了颈椎人工髓核-柔性稳定一体化系统,目的是利用柔性稳定系统限制人工髓核的前后移位。目前这方面的研究国内外未见报道。 目的：结合柔性稳定概念,设计并制备人工髓核柔性稳定一体化系统。 设计、时间及地点：方法学实验,于2003-06/2007-07完成,髓核的包被外形以及编织由天津工业大学纺织学院设计和制备,人工髓核及系统合成在北京科技大学进行。 材料：PVA原料,1795型,聚合度1 750±50,醇解度99.9%,超高分子量聚乙烯。 方法：以聚乙烯醇水凝胶为材料,根据颈椎椎间盘的解剖参数,设计制备人工髓核内核,以超高分子量聚乙烯纤维为材料,编织制备人工髓核外套、翼状韧带和连接系带,制备人工髓核柔性稳定一体化系统。 主要观察指标：实物形式。 结果：设计并制备出符合颈椎解剖的一体化人工髓核-柔性稳定系统。 结论：人工髓核-柔性稳定一体化系统是一种新型的优异的国产化人工髓核柔性固定系统,是一种新的颈椎人工髓核设计理念。     

Cervical intervertebral disc calcification in children

Intervertebral disc calcification in children is a rare occurrence. The clinical symptoms and signs are distinctively confined to the cervical area with pain, limitation of motion, and torticollis. Long tract signs or radicular involvement are extremely unusual. CT scan and cervical spinal X-ray films shown the calcification to be in the nucleus pulposus with anterior or posterior mild protrusion into the spinal canal. Recovery without neurological sequelae is the rule in most of the pediatric cases with conservative treatment. Intervertebral disc calcification does not necessarily disappear with the onset of clinical symptoms. A case with persistent and even denser calcification at the same level of intervertebral disc space at the second episode of recurrence is illustrated.     

Brown-Séquard Syndrome Caused by a Cervical Synovial Cyst

Synovial cysts are recognized as an uncommon cause of radicular and myelopathic symptoms. They are most frequently found in the lumbar region. The cervical spine or cervicothoracic junction is a rare location for a degenerative intraspinal synovial cyst as compared with the lumbar spine. At given cervical spinal levels, synovial cysts probably share clinical features with disc herniation and stenosis. However, the pathogenesis of synovial cysts remains still controversial. Here, we report a rare case of a synovial cyst in the lower cervical spine presented as Brown-Séquard syndrome and include a brief review of the literature. To the best of our knowledge, no previous report has been issued in the English literature on a synovial cyst presenting with Brown-Séquard syndrome. Neurologic function recovered completely after complete removal of the cyst and expansive laminoplasty.     

Anterior spinal artery syndrome caused by thoracic disc herniation

We present a case of a midline thoracic disc herniation causing acute anterior spinal artery (ASA) syndrome successfully managed surgically. A 54-year-old female with no significant past medical history presented with sudden onset severe back pain followed by rapidly evolving paraparesis with urinary and bowel incontinence. Her neurological exam was consistent with ASA syndrome. An MRI revealed T2 signal change in the thoracic spinal cord and midline disc herniation at the level of T8/T9. Spinal angiography revealed an ASA arising the right T11 segmental artery with no flow towards the T8/T9 region. The patient underwent a T8/T9 discectomy with a lateral interbody fusion that resulted in dramatic clinical improvement. A postoperative angiogram confirmed improvement of flow in the ASA. This is the first report of an angiographically confirmed symptomatic ASA syndrome caused by a thoracic disc herniation successfully managed with up-front surgery.     

Anterior lumbar interbody surgery for spondylosis results from a classically-trained neurosurgeon

Anterior lumbar surgery for degenerative disc disease (DDD) is a relatively novel technique that can prevent damage to posterior osseous, muscular and ligamentous spinal elements. This study reports the outcomes and complications in 286 patients who underwent fusion – with artificial disc implants or combined fusion and artificial disc implants – by a single-operator neurosurgeon, with up to 24 months of follow-up. The visual analogue scale (VAS), Oswestry Disability Index (ODI), Short Form 36 (SF36) and prospective log of adverse events were used to assess the clinical outcome. Radiographic assessments of implant position and bony fusion were analysed. Intraoperative and postoperative complications were also recorded. Irrespective of pre-surgical symptoms (back pain alone or back and leg pain combined), workers’ compensation status and type of surgical implant, clinically significant improvements in VAS, ODI and SF36 were primarily observed at 3 and/or 6 month follow-up, and improvements were maintained at 24 months after surgery. A 94% fusion rate was obtained; the overall complication was 9.8% which included 3.5% with vascular complications. The anterior lumbar approach can be used for treating DDD for both back pain and back and leg pain with low complication rates. With appropriate training, single-operator neurosurgeons can safely perform these surgeries.     

Two-level en bloc spondylectomy for osteosarcoma at the cervicothoracic junction

En bloc resection of osteosarcoma is critical for a chance at curing the disease. In the spine, a spondylectomy should be performed to optimize the chances of survival. Involvement of two contiguous segments in the spinal column poses technical challenges, and performing a spondylectomy at the cervicothoracic junction adds another set of clinical concerns. We present a 22-year-old female with a two-level vertebral involvement at the cervicothoracic junction who underwent a two-level en bloc spondylectomy for osteosarcoma, and we describe our technique.     

Pneumorrhachis and Paraspinal Air with Vacuum Disc : Case Report and Literature Review

Air within the spinal canal called pneumorrhachis has been seen rarely. We report a case showing multiple air pockets in the paraspinal and epidural space with vacuum disc and review pathogenesis and treatment of pneumorrhachis.     

Posterior Epidural Migration of Thoracic Disc Fragment

Migration of a disc fragment to the posterior epidural space is rare, especially in the thoracic spine. Only four such cases of posterior epidural migration of thoracic disc fragments have been reported. The authors report a case of 66-year-old man who presented with back pain and right leg weakness due to posterior epidural migration of thoracic disc fragment. The patient was successfully treated by laminectomy and partial facetectomy with disc removal.     

Acute paraplegia revealing an intraspinal neurenteric cyst in a child

The authors report a case of intraspinal neurenteric cyst in a 22-month-old child, who presented with acute paraplegia following a vesicourethrogram. Despite 8 days' delay in surgical decompression, he made a complete neurological recovery. Neurenteric cysts are rare congenital lesions of the spinal canal lined with an epithelium of endodermal origin. They are usually located at the cervicothoracic junction and present with progressive mild to moderate signs of myelopathy. This is a unique case in regard both to its clinical presentation and to the excellent outcome after 8 days of complete paraplegia.     

Clinical and Radiological Findings of Nerve Root Herniation after Discectomy of Lumbar Disc Herniation

The authors report 2 cases of nerve root herniation after discectomy of a large lumbar disc herniation caused by an unrecognized dural tear. Patients complained of the abrupt onset of radiating pain after lumbar discectomy. Magnetic resonance imaging showed cerebrospinal fluid signal in the disc space and nerve root displacement into the disc space. Symptoms improved after the herniated nerve root was repositioned. Clinical symptoms and suggestive radiologic image findings are important for early diagnosis and treatment.     

Avulsed lumbar vertebral rim plate in an adolescent: trauma or malformation?

Avulsion of lumbar vertebral rim plate is an uncommon lesion, seen specially in young adults. Its occurrence in pediatric age is very infrequent. As with intervertebral disc herniation in children, an accurate diagnosis may be often delayed due to concerns for neoplasm, infection, and spondylolisthesis. We report a 15-year-old boy with symptoms and myelographic details of disc protrusion. Plain radiographs, computerized tomography of the lumbar spine, and operative findings showed that the cause of root compression was a slipping of the entire disc together with the posterior rim plate at the L4–5 space. Pertinent literature on the subject is briefly reviewed. The proposed mechanism for apophyseal ring fracture is a combination of two factors: congenital insufficiency of the rim plate and injury to the lumbar spine. Received: 29 August 1996     

Bilateral Optic Disc Drusen Mimicking Papilledema

Background

Optic disc drusen, which are calcified deposits that form anterior to the lamina cribrosa in the optic nerve, may mimic papilledema.

Case Report

We report herein three cases referred to us with suspicion of disc swelling and papilledema. Following ophthalmologic evaluation with B-scan ultrasound, red-free fundus photography, and computed tomography, the diagnosis of papilledema was excluded in all cases and optic disc drusen was diagnosed.

Conclusions

Clinical suspicion of optic disc drusen in cases presenting with swelling of the optic nerve head is important in order to avoid unnecessary interventions and anxiety. The reported cases highlight the commonly encountered clinical presentations and the practical aspects of diagnosis and management of optic disc drusen.