10 Levels thoracic no-intrumented laminectomy for huge spontaneous spinal subdural hematoma removal. Report of the first case and literature review

IntroductionSpontaneous idiopathic acute spinal subdural hematoma (SSDH) is a rare cause of acute back pain followed by signs and symptoms of nerve root and/or spinal cord compression, frequently associated with coagulopathies, blood dyscrasias and arterio-venous malformations. Standard management includes non-operative treatment and timely (within 24 h) surgical decompression.Presentation of caseWe report on the case of a huge 10 levels SSDH treated with decompressive thoracic no-instrumented laminectomy in a 45-year-old woman with good neurological recovery (from ASIA A to D).DiscussionSpontaneous SSDHs without detectable structural lesion or anticoagulant therapy are very rare. Among 26 cases documented the literature harbouring SSDHs, the thoracic spine was found to be the preferred site, and the compression was usually extending over several vertebral levels. Nonoperative treatment for SSDH may be justified in presence of minimal neurologic deficits, otherwise, early decompressive laminectomy along with evacuation of hematoma are considered the treatment of choice in presence of major deficits.ConclusionTo our knowledge, the present case is the most extensive laminectomy for a SSDH removal never described before. No postoperative instability occurs in 10 levels thoracic laminectomy in case the articular processes are spared. When major neurological deficits are documented, early decompressive laminectomy with evacuation of hematoma should be considered the best treatment for SSDH.     

Acute non-traumatic extensive subdural spinal hematoma

Acute spinal subdural hematoma is a somewhat rare pathology. Its severity comes from the constitution of an acute spinal cord compression. In many cases MRI is useful for the differential diagnosis with the epidural hematoma. A 79-year-old patient was referred for emergency neurosurgery for acute spinal cord compression. The vascular risk in this patient was significant: hypertension, oral anticoagulants. Clinically, acute non-traumatic subdural spinal hematoma was suspected. The spinal cord MRI was in favor of the diagnosis which was confirmed intraoperatively. The surgical procedure revealed an extensive hematoma which infiltrated the spinal cord. The diagnosis of nontraumatic subdural spinal hematoma may be difficult in some cases and correctly established only during the surgical procedure. In comparison with reports in the literature, we discuss the underlying mechanisms of this hematoma. Spinal subdural haematoma must be considered in patients taking anticoagulant therapy or with a coagulation disorder who present signs of acute spinal cord compression. MRI sagittal T1 and T2-weighted images are adequate and reliable for diagnosis of spinal subdural hematoma. Prompt surgical evacuation of this hematoma is crucial.     

Osteoporotic spinal deformity: a biomechanical rationale for the clinical consequences and treatment of vertebral body compression fractures

This review article develops a biomechanical rationale for the clinical consequences and treatment of osteoporotic vertebral body compression fracture. In patients with osteoporotic vertebral fractures and spinal deformity, altered spinal biomechanics and global spinal imbalance are important factors in the increased morbidity and mortality reported in this population. Severe spinal deformity impairs physical functioning, health, and quality of life. The spinal deformity itself, independent of pain, is a significant cause of disability. Spinal deformity is also an independent risk factor for hip fracture. Treatments directed at osteoporotic vertebral compression fractures should ideally address spinal deformity as well as pain. Balloon kyphoplasty, the minimally invasive technique of reduction and internal fixation of osteopenic vertebral body compression fractures that addresses pain and spinal deformity, is discussed.     

Spinal subdural haematoma as a complication of cranial surgery

Summary ?Background. Spinal subdural haematoma is a rare condition usually associated with several precipitating factors including coagulopathy, lumbar puncture, trauma, vascular malformation and previous spinal surgery. In this paper we report spinal subdural haematoma related to cranial surgery which is a previously unknown precipitating factor. Method. The medical records of six patients in whom spinal subdural haematoma developed after cranial surgery was reviewed retrospectively for clinical presentation, radiological findings, treatment, and outcome. Findings. Six patients presented with low back pain and radiculopathy in the lower extremity after surgery for intracranial lesions. Symptom onset was between 2 and 9 days after cranial surgery. Initial cranial procedures were craniotomy and tumour removal in 1 patient, clipping of aneurysm in 1, temporal lobectomy for epilepsy in 4. None of the patients had previously known precipitating factors for spinal subdural haematoma. In all of them, the diagnosis was confirmed by magnetic resonance (MR) imaging and the spinal segment involved was the lower lumbar and sacral level except for one patient with a wide distribution of haematoma over the thoracolumbar region. All patients recovered completely without surgical intervention. Interpretation. Spinal subdural haematoma is a rare but possible complication of cranial surgery. It should be considered in patients with back pain and radiculopathy in the lower extremity developing after surgery for intracranial lesions. Unlike spontaneous spinal subdural haematoma with other precipitating factors, spinal subdural haematoma developing after cranial surgery takes a benign clinical course and resolves spontaneously over several days to 2 weeks without surgical intervention. Published online May 19, 2003     

Novel options for patients with lumbar spinal stenosis: Minimally invasive lumbar decompression and other strategies

As the population ages, spinal stenosis is becoming a more common condition. Often, elderly patients suffer from comorbidities that may increase the risks associated with general anesthesia or extensive surgeries. Unfortunately, with limited conservative treatment options, surgical decompression often becomes the only alternative. Recently a percutaneous minimally invasive lumbar decompression technique has emerged as a safe and highly successful therapeutic option for this group of patients. In this review, I present the current evidence in support of minimally invasive lumbar decompression as a novel therapeutic option for the growing population with lumbar spinal stenosis.     

Thoracoscopic debridement and stabilization of pyogenic vertebral osteomyelitis

The role of surgical debridement and internal fixation in treatment of vertebral osteomyelitis has been evolving. The standard surgical approach to thoracolumbar vertebral osteomyelitis requiring extensive thoracotomy or retroperitoneal exposure carries significant associated morbidity and postoperative pain. Minimally invasive thoracoscopic spine surgery is designed to improve postoperative morbidity associated with the traditional open surgery. We report a case of a 70-year-old man who developed T11-T12 pyogenic vertebral osteomyelitis 3 months after undergoing posterior laminectomy and microsurgical excision of a herniated thoracic disc. The patient underwent minimally invasive thoracoscopic radical debridement and anterior spinal reconstruction and fusion. Patients with vertebral osteomyelitis may benefit from the decreased postoperative morbidity that is associated with minimally invasive thoracoscopic spinal surgery.     

Avoidable factors that contribute to complications in the surgical treatment of chronic subdural haematoma

Summary The results of a personal series of 44 consecutive patients undergoing burrhole evacuation and closed system suction drainage for chronic subdural haematoma are presented. 43 patients made a complete recovery and one was left with moderate disability. Contralateral weakness in one patient, recurrence of haematoma in another, and a new contralateral haematoma in a third were the only complications.The operative procedures responsible for the rather low complication rate in this series are described. It is concluded that to avoid complications following surgical treatment of chronic subdural haematoma, attention must be paid to the following factors: evacuation of the haematoma through two burrholes overlying the subdural collection; attention to ensure free communication through the subdural space between the two burrholes; identification and opening of additional loculations overlying the cortex; irrigation of the subdural space to ensure as complete an evacuation of the subdural collection as possible and the use of closed system suction drainage, nursing the patient flat, and intravenous hydration of the patient for three days. In addition, in patients with coagulopathy, correction of these disorders before surgery is most essential.     

Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma

Summary Background. Chronic subdural haematoma is one of the most common entities encountered in daily practice. Many methods of treatment have been reported, each with its own advantages and disadvantages. Method. The authors present a novel technique for the management of chronic subdural haematoma which is a variation of a closed drainage system. After evacuation of the haematoma through a single burr hole, we inserted a Jackson Pratt drain into the subgaleal space, with suction facing the burr hole, allowing for continuous drainage of the remaining haematoma. Findings. We used the method for over 4 years to treat 224 patients. Seventeen patients (7.6%) needed a second operation for a recurrence of the haematoma no patient required a third operation. Postoperative complications developed in 3 patients. Two patients died while in the hospital, a mortality rate of 0.9%. Conclusions. The use of suction assisted evacuation, is followed by results that compare satisfactorily to reports of previous methods, with a low rate of recurrence and complications. It is relatively less invasive and can be used in high risk patients.     

Minimally invasive surgery prior to radiation therapy for metastatic spine disease: Decision making and technique

Spinal metastatic disease is a challenging but increasingly common occurrence in oncology patients. Novel radiation techniques and minimally invasive surgical techniques have changed treatment paradigms over the past two decades. Spinal decompression may be indicated with or without concomitant stabilization. In the absence of spinal cord compression, prophylactic stabilization may be considered depending on the host bone quality, tumor location, and planned radiation. Minimally invasive surgery has decreased the need for open, morbid approaches to achieve spinal decompression and stabilization.     

Acute idiopathic spinal subdural hematoma: What to do in an emergency?

Acute spinal cord compression usually results from trauma, infection, or cancer. Spinal subdural hematoma is an uncommon cause of spinal cord compression that occurs after spine trauma or spinal invasive procedure, especially in context of coagulopathy. In the following reported case, an 82-year-old woman with a history of rapidly progressive paraparesis after a sudden middle back pain, with no previous trauma or coagulopathy, due to an acute spontaneous spinal subdural hematoma. In fact, the main difficulty was to determine, in an emergency situation, the right strategy to identify both the lesion and its cause to adapt therapeutics. This case not only provides an illustrative unusual condition in an emergency department but also a challenging discussion to choose the right treatment for a sudden neurological impairment. According to a literature review of the idiopathic cases of spinal subdural hematomas without coagulopathy, the clinical outcome depends on severity of neurological impairment. MRI is the main examination to perform in an emergency. Thus surgical evacuation should be performed in emergency in patients presenting with severe neurological impairment.     

Spontaneous resolution of a paraparesis due to a dorsolumbar epidural haematoma associated with subarachnoid anaesthesia and postoperative analgesia using an epidural catheter

Spinal epidural haematoma after neuroaxial anaesthesia is a rare but serious complication. Most cases are attributed to anticoagulant therapy or bleeding tendency. It presents as an acute spinal cord compression and usually requires emergency surgical decompression. The interval between the onset of clinical signs and surgical evacuation is very important, influencing the neurological prognosis. We report a case of a spinal epidural haematoma after epidural analgesia in a patient who was treated with low molecular weight heparin for thrombo-prophylaxis in the perioperative period. In some cases, such as the one reported here, good neurological recovery can be achieved with conservative management.     

The clinical features of,and microendoscopic decompression for,extraforaminal entrapment of the L5 spinal nerve

Objective: To evaluate the clinical results of, and surgical techniques for, microendoscopic (METRx) decompression of extraforaminal entrapment of the L5 spinal nerve at the lumbosacral tunnel. Methods: Five patients with extraforaminal entrapment of the L5 spinal nerve in the lumbosacral tunnel were treated in our department, including three men and two women. The average age was 65.6 years. All patients suffered severe leg pain and neurological deficits compatible with L5 radiculopathy. Minimally invasive decompression of the L5 spinal nerve was performed under METRx intertransverse decompression. Results: With an average follow‐up of 17.8 months, clinical results were assessed based on Nakai criteria and Visual Analogue scale (VAS). All patients experienced immediate pain relief postoperatively. Clinical outcomes were excellent in three patients and good in two. The average intraoperative blood loss was 59 ml, with an average operative time of 103 min. Average post‐operative stay in bed was 7 days, and average cost was $1860. Conclusion: Extraforaminal entrapment of the L5 spinal nerve in the lumbosacral tunnel can cause L5 radiculopathy. METRx partial resection of the L5 transverse processes, sacral ala and osteophytes of L5‐S1 vertebral bodies to relieve extraforaminal entrapment of the L5 spinal nerve is a very effective and minimally invasive surgical option.     

Management of an extensive spinal epidural abscess from C-1 to the sacrum. Case report

The authors report a rare case of extensive spinal epidural abscess in an immunocompromised young woman. The patient presented with low-grade fever, back pain, and progressive lower limb weakness. The MR imaging of her whole spine revealed an epidural abscess extending from C-1 to the sacrum. She was treated using a minimally invasive surgical technique and showed excellent recovery. The authors review the current literature along with different modes of surgical treatment available for this unusual clinical entity.     

Comparison of techniques for decompressive lumbar laminectomy: the minimally invasive versus the "classic" open approach.

OBJECT: Decompressive laminectomy offers an effective surgical treatment of lumbar spinal stenosis. The purpose of this study was to compare the elements of treatment commonly associated with successful outcomes in the assessment of laminectomies - operating room times, estimated blood loss, length of stay, and complications - of the minimally invasive and open approach laminectomies. METHODS: We retrospectively reviewed the medical records and relevant imaging of 126 patients who underwent surgical decompression for lumbar stenosis. Thirty-eight patients underwent bilateral decompression via a unilateral minimally invasive technique, while 88 patients underwent bilateral decompression via a standard open technique. A chart review was performed to determine intraoperative blood loss, length of operative time, length of hospital stay, and number and nature of complications. RESULTS: The minimally invasive lumbar laminectomy (MID) patients had shorter operating room times, less estimated blood loss, shorter length of stay, and fewer complications. CONCLUSIONS: Bilateral decompression of lumbar spinal stenosis via a unilateral approach involves shorter operating times and less blood loss, less muscle dissection, fewer and less severe complications, and better mobility in the immediate postoperative period than open decompressive techniques. In addition, this technique is very similar to the commonly performed microendoscopic discectomy and is easily mastered over time.     

症状性椎体血管瘤的外科治疗

目的：探讨症状性椎体血管瘤通过多途径外科治疗的适应证及效果.方法：症状性胸段椎体血管瘤患者8例,男6例,女2例.表现为单纯疼痛的2例患者行经皮穿刺椎体成形术;表现为脊髓压迫的6例患者根据压迫部位的不同分别采用：1）前方经胸腔椎体切除＋内同定2例;2）后方减压＋椎体内骨水泥注射3例;3）后方减压＋椎体内骨水泥注射＋后方内固定1例.6例有脊髓压迫患者中5例手术前行脊髓血管造影,4例成功栓塞.结果：随访4～40个月,平均14个月,表现为局部疼痛的2例患者术后第1d症状即完全缓解;脊髓压迫的6例患者术后早期恢复不明显,但无加重,随访期间,除1例手术前即已经完全截瘫的患者外,其余5例患者的运动功能障碍均完全恢复正常.5例患者在随访期间行MRI检查,未见肿瘤复发.结论：症状性椎体血管瘤应根据不同症状选择不同的手术方式,以改善症状为主,而不是强求肿瘤全切.     

Spontaneous spinal epidural haematoma causing rapid flaccid paraplegia in a healthy 25-year-old patient

Although clinical presentation of a spinal epidural compressive haematoma is well recognized, causing acute radicular pain shortly followed by cord compression syndrome, its aetiology may pose a quandary. Rare and most commonly seen after trauma, spinal surgery, epidural anaesthesia, anticoagulation therapy, vascular malformation or coagulopathy (haemophilia), spinal epidural haematoma (SHE) can be spontaneous. Surgical decompression remains the mainstay treatment especially when the prognosis depends on the interval to surgery and the severity of preoperative neurological deficit. We report the case of a healthy 25-year-old man who presented, three days after an acute back pain, a flaccid paraplegia with urinary retention. Magnetic resonance imaging of the spinal column identified a compressive SHE extending from T3 to T6, requiring an early laminectomy. After decompression, clinical outcome revealed a complete recovery excepted some mild sensibility trouble remains.     

脊柱转移瘤减压手术的研究进展

脊柱是恶性肿瘤骨转移最常发生的部位,其中约10%的脊柱转移瘤患者会出现硬膜外脊髓压迫。姑息性放疗和单纯椎板切除减压术曾是转移性脊髓压迫的主要治疗方式,而前者对放疗不敏感肿瘤无效且疗效具有延后性,后者还常常损害脊柱稳定性。随着近年来手术技术和内固定器械的不断改进,脊柱转移瘤的治疗模式也发生了很大改变。减压手术经历了开放性手术减压、分离手术减压、微创手术减压和激光间质热消融减压等手术方案。但无论采取何种手术方案,都应根据患者的具体情况精确评估,尽量减少手术风险,以确保后续放疗的顺利开展。本文就脊柱转移瘤减压手术的研究进展作一综述。     

Cranial subdural haematoma after spinal anaesthesia

Intracranial subdural haematoma is an exceptionally rare complicationof spinal anaesthesia. A 20-yr-old male underwent appendicectomyunder partial spinal and subsequent general anaesthesia. A weeklater, he presented with severe headache and vomiting not respondingto bed rest and analgesia. Magnetic resonance imaging showeda small acute subdural haematoma in the right temporo-occipitalregion. The patient improved without surgical decompression.The pathogenesis of headache and subdural haematoma formationafter dural puncture is discussed and the literature brieflyreviewed. Severe and prolonged post-dural puncture headacheshould be regarded as a warning sign of an intracranial complication. Br J Anaesth 2001; 86: 893–5     

Managements of osteoporotic vertebral compression fractures: A narrative review

Osteoporotic vertebral compression fractures (OVCFs) are the most common fragility fracture and significantly influence the quality of life in the elderly. Currently, the literature lacks a comprehensive narrative review of the management of OVCFs. The purpose of this study is to review background information, diagnosis, and surgical and non-surgical management of the OVCFs. A comprehensive search of PubMed and Google Scholar for articles in the English language between 1980 and 2021 was performed. Combinations of the following terms were used: compression fractures, vertebral compression fractures, osteoporosis, osteoporotic compression fractures, vertebroplasty, kyphoplasty, bisphosphonates, calcitonin, and osteoporosis treatments. Additional articles were also included by examining the reference list of articles found in the search. OVCFs, especially those that occur over long periods, can be asymptomatic. Symptoms of acute OVCFs include pain localized to the mid-line spine, a loss in height, and decreased mobility. The primary treatment regimens are pain control, medication management, vertebral augmentation, and anterior or posterior decompression and reconstructions. Pain control can be achieved with acetaminophen or nonsteroidal anti-inflammatory drugs for mild pain or opioids and/or calcitonin for moderate to severe pain. Bisphosphonates and denosumab are the first-line treatments for osteoporosis. Vertebroplasty and kyphoplasty are reserved for patients who have not found symptomatic relief through conservative methods and are effective in achieving pain relief. Vertebroplasty is less technical and cheaper than kyphoplasty but could have more complications. Calcium and vitamin D supplementation can have a protective and therapeutic effect. Management of OVCFs must be combined with multiple approaches. Appropriate exercises and activity modification are important in fracture prevention. Medication with different mechanisms of action is a critical long-term causal treatment strategy. The minimally invasive surgical interventions such as vertebroplasty and kyphoplasty are reserved for patients not responsive to conservative therapy and are recognized as efficient stopgap treatment methods. Posterior decompression and fixation or Anterior decompression and reconstruction may be required if neurological deficits are present. The detailed pathogenesis and related targeted treatment options still need to be developed for better clinical outcomes.     

Endoscopic approaches to metastatic thoracic disease

Traditional approaches to thoracic metastases and spinal cord compression have been well worked out and validated in the literature. Anterior decompression is clearly superior to laminectomy; vertebrectomy and reconstruction are indicated for sagittal collapse, instability, and pain; and surgical decompression is necessary in cases of bony impingement. The role of endoscopic and minimally invasive techniques in treatment of metastatic disease is evolving. Dr. Lieberman advocates the use of thoracoscopic anterior approaches as the principal application in these patients, whereas Dr. McLain has found that endoscopic assistance has vastly improved his results with posterolateral decompression. The two authors weigh the relative advantages and disadvantages of these approaches for the selected patient with metastatic thoracic disease.