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1.
Background
Anterior cervical discectomy and fusion (ACDF) as well as posterior instrumentation of the cervical spine are frequently performed surgeries for cervical disc prolapse or spinal stenosis. Surgery itself harbors a very low risk of adverse events. Postoperative palsy of the C5 nerve root, however, is a severe complication and its origin is still not fully understood. The risk of such a C5 palsy is reported to be between 0 and 30%; 5% on average according to the literature.Objectives
To describe underlying pathomechanisms and to recommend strategies for risk reduction.Materials and methods
An extensive literature research via Medline was performed.Results
Potential risk factors are male gender, sagittal diameter below 5.6?mm, anterior approach, and higher age.Conclusions
Currently available data only originates from retrospective or anatomical studies. A prospective register study with the goal to put light on the pathogenesis is currently being performed.2.
Chong Leslie Lich Ng Boon Chuan Pang Paul Julius A. Medina Kimberly-Anne Tan Selvaraj Dahshaini Li-Zhen Liu 《European spine journal》2015,24(3):361-368
Purpose
Lateral access lumbar interbody fusion (LLIF) is a minimally invasive technique that has an increasing popularity. It offers unique advantages and circumvents risk of certain serious complications encountered in other conventional spinal approaches. This study provides a statistical analysis defining the lateral access learning curve in the Asian population.Methods
This prospective study included 32 consecutive patients who underwent LLIF from April 2012 to August 2014. The surgeries were performed by two senior spine surgeons and follow-up was conducted at 6 weeks, 3, 6, 9 months and 1 year post-operation.Results
The breakpoint in operating time occurred at the 22nd level operated, from a mean of 71 min in the early phase group to a mean of 42 min in the steady state group. LLIF at L4/5 level is technically more demanding but technically feasible as competency is achieved.Conclusions
During the learning process, there was no compromise of perioperative or clinical outcomes. It should be feasibly incorporated into a spine surgeon’s repertoire of procedures for the lumbar spine.3.
Background
Caring for pediatric spine trauma patients places spine surgeons in situations that require unique solutions for complex problems. Recent case reports have highlighted a specific injury pattern to the lower cervical spine in very young children that is frequently associated with complete spinal cord injury.Methods
This report describes the presentation and treatment of a C6–C7 dislocation in a 3-year-old patient with an incomplete spinal cord injury. The highly unstable cervical injury and the need to prevent neurologic decline added complexity to the case.Results
A multi-surgeon team allowed for ample manpower to position the patient; with individuals with the requisite training and experience to safely move a patient with a highly unstable cervical spine. Initial closed reduction under close neurophysiologic monitoring, posterior fusion and immediate anterior stabilization lead to a successful patient outcome with preserved neurologic function. A traumatic cerebrospinal fluid leak, while a concern early on during the procedure, resolved without direct dural repair and did not complicate the patient’s fusion healing. Additional anterior stabilization and fusion allowed long-term stability with bone healing that may not be achievable with posterior fixation and/or soft tissue healing alone.Conclusions
Familiarity with the challenges and solutions presented in the case may be useful to surgeons who could face a similar challenge in the future.4.
Berjano Pedro Blanco Juan Francisco Rendon Diego Villafa&#;e Jorge Hugo Pescador David Atienza Carlos Manuel 《European spine journal》2015,24(7):918-923
Purpose
To assess, with finite element analysis and an in vitro biomechanical study in cadaver, whether the implementation of an anterior interbody cage made of hedrocel with nitinol shape memory staples in compression increases the stiffness of the stand-alone interbody cage and to compare these constructs’ stiffness to other constructs common in clinical practice.Methods
A biomechanical study with a finite element analysis and cadaveric testing assessed the stiffness of different fixation modes for the L4–L5 functional spinal unit: intact spine, destabilized spine with discectomy, posterior pedicle-screw fixation, anterior stand-alone interbody cage, anterior interbody cage with bilateral pedicle screws and anterior interbody cage with two shape memory staples in compression. These modalities of vertebral fixation were compared in four loading modes (flexion, extension, lateral bending, and axial rotation).Results
The L4–L5 spinal unit with an anterior interbody cage and two staples was stiffer than the stand-alone cage. The construct stiffness was similar to that of a model of posterior pedicular stabilization. The stiffness was lower than that of the anterior cage plus bilateral pedicle-screw fixation.Conclusion
The use of an anterior interbody implant with shape memory staples in compression may be an alternative to isolated posterior fixation and to anterior isolated implants, with increased stiffness.5.
Caroline Scemama Vincent Lestrat Benoit Combourieu Thierry Judet 《International orthopaedics》2016,40(9):1821-1825
Purpose
Hip fusion conversion has shown mixed results, in particular a higher rate of failure than primary total hip replacement. Conversion is usually carried out by a lateral approach.Methods
We reported a series of 37 hip fusion conversions performed by an anterior approach. Clinical and radiographic outcomes of this unusual approach were reported at eight years of follow up.Results
At eight years of follow up, survivorship was 86. 6 % (IC 95 %: 62.4–95.7 %). Sixteen patients reported good relief of the pre-operative back spine or knee pain. PMA score was significantly improved. Two implant aseptic loosenings needing revision surgery were reported.Conclusion
The anterior approach seemed to be as good as the other hip approaches for hip fusion conversion to total hip replacement.6.
Introduction
Flat-back syndrome is one of the main causes of surgical failure after lumbar fusion and can lead to a revision surgery to correct it. Three-column pedicle subtraction osteotomy is an efficient technique to restore lumbar lordosis (LL) for fixed sagittal malalignment. The fusion mass stemming from the past surgeries makes the procedure demanding as most anatomical landmarks are missing.Material and methods
This review article will focus on the correction of this lack of LL through the fusion mass. We will successively review the preoperative management, the surgical specificities, and various types of clinical cases that can be encountered in flat-back syndromes.Conclusion
PSO in the fixed fusion mass is technically demanding. Preoperative CT-scan and preoperative navigation allow us to push the limits when anatomical landmarks disappear. Bleeding and neurologic are the two major complications feared by the surgeon. The best way to avoid these revision surgeries is to restore a proper lumbar lordosis at the time of initial surgery by considering lumbo-pelvic indexes.8.
Background
Continued innovation in surgery requires a knowledge and understanding of historical advances with a recognition of successes and failures.Questions/purposes
To identify these successes and failures, we selectively reviewed historical literature on cervical spine surgery with respect to the development of (1) surgical approaches, (2) management of degenerative disc disease, and (3) methods to treat segmental instability.Methods
We performed a nonsystematic review using the keywords “cervical spine surgery” and “history” and “instrumentation” and “fusion” in combination with “anterior approach” and “posterior approach,” with no limit regarding the year of publication. Used databases were PubMed and Google Scholar. In addition, the search was extended by screening the reference list of all articles.Results
Innovative surgical approaches allowed direct access to symptomatic areas of the cervical spine. Over the years, we observed a trend from posterior to anterior surgical techniques. Management of the degenerative spine has evolved from decompressive surgery alone to the direct removal of the cause of neural impingement. Internal fixation of actual or potential spinal instability and the associated instrumentation have continuously evolved to allow more reliable fusion. More recently, surgeons have developed the basis for nonfusion surgical techniques and implants.Conclusions
The most important advances appear to be (1) recognition of the need to directly address the causes of symptoms, (2) proper decompression of neural structures, and (3) more reliable fusion of unstable symptomatic segments.9.
Objective
The goal of this paper was to describe how endoscope-assisted oblique lumbar interbody fusion (OLIF) could remove huge lumbar disc herniation (HLDH) manifested with cauda equina syndrome (CES).Methods
In this study, the authors made an attempt to treat CES with a direct endoscopic decompression through the OLIF corridor and performed OLIF in two patients with HLDH.Results
Two patients with HLDH were successfully treated using OLIF with spinal endoscopic discectomy. We achieved direct ventral decompression by removal of herniated disc fragments located beyond the posterior longitudinal ligament (PLL). All preoperative symptoms in two patients improved postoperatively.Conclusions
Endoscope-assisted oblique lumbar interbody fusion (OLIF) could successfully achieve neural decompression without additional posterior decompression in CES and could be used as an alternative treatment in well selected cases.10.
Luca Denaro Umile Giuseppe Longo Alberto Corrado Di Martino Nicola Maffulli Vincenzo Denaro 《BMC musculoskeletal disorders》2017,18(1):552
Background
Even though internal fixation has expanded the indications for cervical spine surgery, it carries the risks of fracture or migration, with associated potential life threatening complications. Removal of metal work from the cervical spine is required in case of failure of internal fixation, but it can become challenging, especially when a great amount of scar tissue is present because of previous surgery and radiotherapy.Case presentation
We report a 16 year old competitive basketball athlete who underwent a combined anterior and posterior approach for resection of an osteosarcoma of the sixth cervical vertebra. Fourteen years after the index procedure, the patient eliminated spontaneously one screw through the intestinal tract via an oesophageal perforation and developed a severe dysphagia. Three revision surgeries were performed to remove the anterior plate because of the great amount of post-surgery and post-irradiation fibrosis.Conclusions
Screw migration and oesophageal perforation after cervical spine surgery are uncommon potentially life-threatening occurrences. Revision surgery may be challenging and it requires special skills.11.
Brian E. Louie 《Journal of gastrointestinal surgery》2010,14(1):115-120
Introduction
Esophagectomy is considered one of the most complicated, difficult to perform, and physiologically altering operations performed by surgeons.Discussion
Outcome, not only depends upon surgeon and hospital volume but also involves a “supporting cast” of health professionals, such as physical therapy and ICU. The complementary skill set of the surgeon may also influence esophagectomy outcomes.Conclusions
Young surgeons can perform esophagectomy with low mortality while their volume increases if they engage and involve all of the components in this paradigm.12.
Background
When discussing potential treatment with patients choosing to undergo surgery for disruption of the anterior cruciate ligament (ACL) and their families, surgeons spend considerable time discussing expectations of the short- and long-term health of the knee. Most of the research examining patient expectations in orthopedic surgery has focused largely on arthroplasty.Questions/Purposes
The purpose of this study was to quantitatively assess the differences between the patient’s and the surgeon’s expectations before primary anterior cruciate ligament reconstruction (ACLR).Methods
In this case series, we prospectively enrolled 93 patients scheduled for primary ACLR between 2011 and 2014. Expectations were measured using the Hospital for Special Surgery 23-item Knee Expectations Survey; scores were calculated for each subject.Results
In all but six categories, patients had expectations that either aligned with their surgeons’ or were lower. The largest discordance between surgeon and patient expectations in which the patient had lower expectations was employment; 75% of patients had similar expectations to the surgeon when asked if the knee would be “back to the way it was before the problem started,” less than 1% had higher expectations, and 17% had lower expectations.Conclusion
In general, patient expectations align well with surgeon expectations. Patients who are older, have a lower activity level, and who have selected allograft over autograft for ACLR could also be at risk for greater discordance. Understanding these differences, and their predictors, will help guide physicians when they are counseling patients about ACLR and also help them interact with patients after surgery as they assess outcomes.13.
Purpose
Primary spinal osteosarcoma is quite rare, and the 5-year survival rate is very low. Because of its rarity, successful treatment experience with spinal osteosarcoma is limited. The purpose of this study is to report the effect of therapy of primary osteosarcoma of spine by carbon-ion radiotherapy (CIRT) and long-term follow.Methods
A 70-year-old with primary spinal osteosarcoma who received CIRT underwent combined anterior artificial vertebral body replacement and posterior lumbar fusion (L1–L5) 3 years later.Results
According to the surgical resection of tumoral lesion, pathological results showed that the intertrabecular space previously filled with tumor cells on the initial biopsy sample now contained necrotic tissue without tumor cells. This means that primary osteosarcoma of the spine was completely eliminated and achieved local control with CIRT, with a 7-year follow-up after the initial treatment.Conclusions
Carbon ion beam treatment is an effective local treatment for patients with spinal osteosarcoma for whom surgical resection is not a feasible option, especially for elderly patients. However, more patients need to be evaluated over a longer term to assess the curative effect of CIRT.14.
Introduction
With a survey among Dutch orthopedic surgeons, we try to assess whether eponymous terms are still in use in daily practice. We also tried to find out whether younger generations tend to use them less than our older colleagues.Materials and methods
In a survey consisting of 57 eponymous terms, 67 participants were asked to mark the eponyms they knew and whether they used them in daily practice.Results
No correlation was observed in known/used eponyms or years of experience in 58 completed surveys. Respondents who classified themselves as trauma or general orthopedic surgeons knew or used a significantly higher number of eponyms in daily practice than orthopedic surgeons who classified themselves as spine, upper limb, lower limb, sports or pediatric surgeons.Discussion
Eponymous terms are used frequently in daily practice. Super-specialization might eradicate the general orthopedic surgeon, and the number of eponyms known and used might become smaller and more focused on the super-specialty.Conclusion
Our survey showed that eponymous terms are still used frequently in daily practice among both young and more senior orthopedic surgeons in The Netherlands.15.
Rachelle N. Damle Julie M. Flahive Jennifer S. Davids W. Brian Sweeney Paul R. Sturrock Justin A. Maykel Karim Alavi 《Journal of gastrointestinal surgery》2016,20(2):335-342
Background
Volume has been shown to be an important determinant of quality and cost outcomes.Methods
We performed a retrospective study of patients who underwent surgery for diverticulitis using the University HealthSystem Consortium database from 2008–2012. Outcomes evaluated included minimally invasive approach, stoma creation, intensive-care admission, post-operative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized into four categories by mean annual volumes: very-high (VHVS) (>31), high (HVS) (13–31), medium (MVS) (6–12), and low (LVS) (≤5).Results
A total of 19,212 patients with a mean age of 59 years, 54 % female makeup, and 55 % rate of private insurance were included. Similar to the unadjusted analysis, multivariable analysis revealed decreasing odds of stoma creation, complications, ICU admission, reoperation, readmission, and inpatient mortality with increasing surgeon volume. Additionally, compared with LVS, a higher surgeon volume was associated with higher rates of the minimally invasive approach. Median length of stay and costs were also notably lower with increasing surgeon volume.Conclusion
Quality and the use of minimally invasive technique are tightly associated with surgeon volume. Further studies are necessary to validate the direct association of volume with outcomes in surgery for diverticulitis.16.
F. Dellabiancia I. Parel M. V. Filippi G. Porcellini G. Merolla 《Musculoskeletal surgery》2017,101(2):159-166
Study design
A retrospective case review of patients who underwent 18F sodium fluoride PET/CT imaging of the spine with postoperative pain following vertebral fusion.Objective
To determine the benefit of 18F sodium fluoride PET/CT imaging in the diagnosis of persistent pain in the postoperative spine.Summary of background data
The diagnosis of pain generators in the postoperative spine has proven to be a diagnostic challenge. The conventional radiologic evaluation of persistent pain after spine surgery with the use of plain radiographs, MRI, and CT can often fall short of diagnosis in the complex patient. 18F sodium fluoride PET/CT imaging is an alternative tool to accurately identify a patient’s source of pain in the difficult patient.Methods
This retrospective study looked at 25 adult patients who had undergone 18F sodium fluoride PET/CT imaging. All patients had persistent or recurrent back pain over the course of a 15-month period after having undergone spinal fusion surgery. All patients had inconclusive dedicated MRI. The clinical accuracy of PET/CT in identifying the pain generator and contribution to altering the decision making process was compared to the use of CT scan alone.Results
Of the 25 patients studied, 17 patients had increased uptake on the 18F sodium fluoride PET/CT fusion images. There was a high-level correlation of radiotracer uptake to the patients’ pain generator. Overall 88% of the studies were considered beneficial with either PET/CT altering the clinical diagnosis and treatment plan of the patient or confirming unnecessary surgery.Conclusion
18F sodium fluoride PET/CT proves to be a useful tool in the diagnosis of complex spine pathology of the postoperative patients. In varied cases, a high correlation of metabolic activity to the source of the patient’s pain was observed.17.
Purpose
Correction of rigid cervical deformities often requires osteotomies to realign the spine. Cervical pedicle subtraction osteotomy can be technically challenging due to the presence of cervical nerve roots and usually can only be performed at C7 or T1 due to the presence of vertebral arteries. In contrast, anterior cervical osteotomy can be performed throughout the cervical spine and is a safe and effective method for correction of both sagittal and coronal cervical deformities. We describe the anterior cervical osteotomy technique with a review of the pertinent literature.Methods
A step-by-step technical guide for anterior cervical osteotomy is provided with a focus on surgical nuances and complication avoidance. Two illustrative cases of fixed sagittal and coronal deformities are included to demonstrate the substantial amount of deformity correction achievable using the anterior cervical osteotomy technique.Results
Both patients in the illustrative cases had successful clinical and radiographic outcome following deformity correction utilizing the anterior cervical osteotomy technique.Conclusion
Anterior cervical osteotomy is a safe and effective technique for correction of rigid cervical deformities. Spine surgeons should be familiar with this technique to optimize clinical outcome in patients undergoing cervical deformity correction.18.
Study Design
A report of two cases with complex cervical spondylotic myelopathy (CSM) and review of the literature.Objective
To describe two unique patients with complex CSM due to simultaneous anomalies as anteroposterior compressions of the spinal cord in both upper and lower cervical spine, caused by hypertrophic transverse ligament of atlas (TLA), dysplasia of the posterior arch of atlas, disc herniation, hypertrophic ligamentum flavum and osteophytes.Methods
We present such two cases with clinical, imageological presentations, and describe the surgical procedure, to which both patients responded favorably.Results
The neurological functions of both patients gradually improved according to the JOA scores and VAS scores in preoperative clumsiness and gait disturbance during the mean follow-up period lasted for 18 months. The latest plain radiographs and computed tomography (CT) revealed good fusion without instrumental failure and magnetic resonance imaging (MRI) showed good decompression of C1–7 spinal cord of both patients. Both patients are progressively followed-up.Conclusion
Posterior surgical approach as C1–7 laminectomy with fixations or occipital-cervical fusions may obtain better reconstructions of the cervical spine and good neurological recovery for the patients with complex CSM we present. However, the incidence and ethnic predisposition for the patients with complex CSM are still unclear.19.
Purpose
Aim of this study is to compare late degenerative MRI changes in a subset of patients operated on with ACDF to a second subset of patients presenting indication to ACDF but never operated on.Methods
Patients from both subgroups received surgical indication according to the same criteria. Both subgroups underwent a cervical spine MRI in 2004–2005 and 10 years later in 2015. These MRI scans were retrospectively evaluated with a cervical spine ageing scale.Results
Comparing the two subset of patients both suffering from clinically relevant single-level disease returns no statistically significant difference in the degenerative condition of posterior ligaments, presence of degenerative spondylolisthesis, foraminal stenosis, diameter of the spinal canal, Modic alteration, and intervertebral discs degeneration at 10-year follow-up.Conclusions
The adjacent segment degeneration represents, in the present cohort, a result of the natural history of cervical spondylosis rather than a consequence of fusion.20.