Transforaminal lumbar interbody fusion: clinical and radiographic results and complications in 100 consecutive patients

OBJECTIVE: We retrospectively reviewed the results of 100 consecutive transforaminal lumbar interbody fusions (TLIFs) performed at one institution. The preoperative diagnoses included degenerative disk disease (55), spondylolisthesis (41; 22 isthmic, 19 degenerative), and degenerative adult scoliosis (4). There were 64 single-level, 33 two-level, 2 three-level, and 1 four-level TLIF (140 levels). METHODS: The fusion mass was assessed by an independent observer using biplanar radiography, whereas clinical outcomes were assessed by means of several established outcome measures. RESULTS: By level, the posterolateral fusion was judged to be probably or definitely solid in 78% of levels, whereas the interbody fusion was radiographically solid in 88% of levels, for an overall 93% fusion success/patient (94%/level). All patients had >24 months of postoperative clinical follow-up, and 82 patients (82%) were available for outcome measure assessment at an average follow-up of 34 months (range 24-61 months) postoperatively. Eighty-one percent of these patients reported a >50% decrease in their symptoms, and 76% of patients were satisfied with their results to the degree that they would have the procedure again. However, a large percentage of patients experienced incomplete relief of their symptoms. Twenty patients sustained minor complications, and there were no major complications. CONCLUSIONS: We conclude that TLIF is a safe and effective method of achieving lumbar fusion with a 93% radiographic fusion success and a nearly 80% rate of overall patient satisfaction but frequently results in incomplete relief of symptoms. Complications resulting from the procedure are uncommon and generally minor and transient.     

Stabilization of the lower thoracic and lumbar spine with external skeletal fixation

For stabilization of the lower thoracic and lumbar spine, an external spinal skeletal fixation (ESSF) system has been developed and clinically used since 1977. The system consists of two pairs of Schanz screws and an adjustable external fixation device. The Schanz screws are firmly anchored through the pedicles into the vertebral bodies. Application of ESSF offers some unique characteristics beneficial in the treatment of unstable spinal injuries and spinal osteomyelitis. In contrast to other fixation systems, the number of vertebrae immobilized can be reduced with ESSF. Versatility of the system allows application in every type of spinal instability. Stability obtained with ESSF suffices for early mobilization without major external support in every instance. In laboratory investigation, ESSF proved to be more secure than rod distraction systems and plate fixation. Since 1977, 65 patients were treated with ESSF. All 52 patients who were at least one year postsurgery were personally examined. This group included 42 patients with acute spinal trauma and eight patients with spinal osteomyelitis. Results achieved with ESSF have been encouraging, with no serious complications to date. Future modifications of ESSF application could lead to simplification and facilitation of treatment.     

Analysis of intraoperative difficulties and management of operative complications in revision anterior exposure of the lumbar spine: a report of 25 consecutive cases

Purpose

After a first anterior approach to the lumbar spine, formation of adhesions of soft tissues to the spine increases the surgical difficulties and potential for iatrogenic injury during the revision exposure. The objective of this study was to identify the intraoperative difficulties and postoperative complications associated with revision anterior lumbar spine procedures in a single institution.

Methods

This is a retrospective review of 25 consecutive anterior revision lumbar surgeries in 22 patients (7 men and 15 women) operated on between 1998 and 2011. Patients with trauma or malignancies were excluded. The mean age of the patients at the time of revision surgery was 56 years (range 20–80 years). The complications were analyzed depending on the operative level and the time between the index surgery and the revision.

Results

Six major complications (five intraoperatively and one postoperatively) occurred in five patients (20 %): three vein lacerations (12 %) and two ureteral injuries (8 %), despite the presence of a double-J ureteral stent. The three vein damages were repaired or ligated by a vascular surgeon. One of the two ureteral injuries led to a secondary nephrectomy after end-to-end anastomosis failure; the other necessitated secondary laparotomy for small bowel obstruction.

Conclusions

Anterior revision of the lumbar spine is technically challenging and is associated with a high rate of vascular or urologic complications. Therefore, the potential complications of the procedure must be weighted against its benefits. When iterative anterior lumbar approach is mandatory, exposure should be performed by an access surgeon in specialized centers that have ready access to vascular and urologic surgeons.     

Operative neurological complications resulting from thoracic and lumbar spine internal fixation

Of 2023 patients treated for acute spinal injuries, 729 sustained acute injuries in thoracic and lumbar regions; 295 surgically treated patients were reviewed for evidence of postoperative neurological complications. Of the 295 patients, 150 were intraoperatively monitored using somatosensory-evoked potentials (SSEP). Six patients (4%) revealed intraoperative deterioration of the SSEP; however, only one of the six revealed a new postoperative neurological deficit (0.7%). The remaining 145 patients were included in the unmonitored or wake-up test group in which ten (6.9%) demonstrated new postoperative deficits. Of the 11 patients with new postoperative neurological deficits, eight patients demonstrated motor weakness, two had radiculopathy, and one had bowel-bladder incontinence. The intraoperative use of SSEP was not able to identify subtle alterations in neurological function; however, due to early warning, SSEP appears capable of preventing profound surgically induced neurological alterations. A new protocol is designed for the management of intraoperative neurological deterioration as detected by SSEP.     

Temporo-mesial epilepsy surgery: outcome and complications in 100 consecutive adult patients

Summary Background. We studied the surgical outcome, and the complications in a group of 100 consecutive adult patients with medically refractory epilepsy arising from the temporo-mesial structures. Methods. Hundred patients were treated surgically between 1994 and 2003 for drug-resistant epilepsy involving the temporo-mesial structures. All of them underwent a comprehensive noninvasive presurgical evaluation. Fourty-eight of them underwent depth electrodes recordings (according to the Talairach’s StereoElectroEncephaloGraphic (SEEG) methodology) because the noninvasive investigations were not congruent enough to identify the epileptic zone. The patients presenting with any space-occupying lesion, or with a cavernoma, or with a strictly lateral neocortical epileptic focus, were excluded. The MRI-examination was abnormal in 87 cases, displaying a hippocampal atrophy in 69 cases. The extent of temporal resection was planned according to the results of the presurgical investigation in each particular patient. Consequently, this “tailored” resection varied from selective amygdalo-hippocampectomy (6 cases), to anterior temporal lobectomy (76 cases), or to total temporal lobectomy (18 cases). Findings. The mean post-operative follow-up period was 53 months. 85 patients were found to be in Engel’s class I post-operatively (free of disabling seizures), among them 74 were in class Ia (totally seizure free). Nine patients were in Engel’s class II and six were in Engel’s class III or IV (failures). There was no surgical mortality. Three patients had a postoperative hematoma; two patients required a shunt insertion; in three patients meningitis occured; and two patients had postoperative ischaemia of the anterior choroidal artery territory, which resulted in a mild permanent hemiparesis. Neuropsychological complications are not addressed in detail in this article. Conclusions. These data indicate that “tailored” resective surgery for temporo-mesial epilepsy can be performed with a low rate of morbidity, and is highly efficacious. The use of invasive presurgical investigation (SEEG) may explain this high rate of success.     

Translaminar screw fixation of the lumbar spine

Summary Lower lumbar spinal fusion was carried out in 72 patients by a technique which involved screw fixation of the facet joints. Stability was achieved and mobilisation was allowed immediately. Radiographs after operation showed bony fusion in 94.5%. Pain was diminished and 76% of the patients would undergo the same treatment again. There were no neurological complications. The technique is useful and safe for the fusion of short segments of the lumbar spine.

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Résumé Une arthodèse du rachis lombaire a été réalisée chez 72 patients selon la technique décrite par Magerl, dont le principe est une fixation des articulations interapophysaires par deux vis. Les indications de cette intervention sont les lésions dégénératives, les anomalies congénitales, l'hypermobilité segmentaire ou les déformations post-traumatiques. Chez 37 patients l'arthrodèse a porté sur un niveau, chez 34 sur deux niveaux et chez 3 sur trois niveaux. Une décompression du canal vertébral a été effectuée dans 56 cas. Une fusion radiologique sans déplacement des vis a été obtenue dans 94.5% des cas. Les douleurs pré-opératoires, évaluées en moyenne à 7.7 sur une échelle de 0 à 10, sont tombées à 2.9 aprés l'intervention. 76% des patients accepteraient le même traitement si cela était nécessaire. Le vissage translaminaire offre une stabilité post-opératoire satisfaisante et permet une mobilisation immédiate. Aucune complication neurologique n'a été observée. Au vu de ces résultats nous pouvons conclure que cette technique est efficace et peu dangereuse pour stabiliser de petits segments de la colonne lombaire ou lombo sacrée.

     

Rate of complications due to neuromuscular scoliosis spine surgery in a 30-years consecutive series

Purpose

The aim of this study was to evaluate the rate of intraoperative and postoperative complications in a large series of patients affected by neuromuscular scoliosis.

Methods

It was a monocentric retrospective study. In this study have been considered complications those events that significantly affected the course of treatment, such as getting the hospital stay longer, or requiring a subsequent surgical procedure, or corrupting the final result of the treatment.

Results

Of the 358 patients affected by neuromuscular scoliosis treated from January 1985 to December 2010, 185 that met the inclusion criteria were included in the study. There were recorded 66 complications in 55/185 patients. Of that 66 complications, 54 complications occurred in 46/120 patients with Luque’s instrumentation, while only 12 complications occurred in 9/65 patients with hybrid instrumentation and this difference was statistically significant (p < 0.05); 11/126 patients with pelvic fixation and 5/59 without pelvic fixation, as well as 45/156 patients treated by posterior approach alone and 10/29 patient that underwent combined anterior–posterior approach suffered complications but both this did not result in a statistical significant difference (p > 0.05).

Conclusions

The surgical treatment in neuromuscular scoliosis is burdened by a large number of complications. An accurate knowledge of possible complications is mandatory to prepare strategies due to prevent adverse events. A difference in definitions could completely change results in good or bad as well as in our same series the adverse events amounted at almost 30% of cases, but complications that due to complete failure would amount at 9.19% of patients.

     

微创腰椎360°固定术

目的评估微创腰椎360°固定术的疗效。方法从2002年5月至2005年5月,应用微创腰椎360°固定术治疗患者25例,其中男11例,女14例;年龄45~67岁,平均56岁。腰椎滑脱16例,其中Ⅰ度13例、Ⅱ度3例;腰椎不稳7例;椎间盘源性腰痛2例。行L4,5节段融合14例,L5~S111例。功能评估采用Oswestry D isab ility Index(OD I),统计患者术前、术后2周、3、6、12个月的OD I评分。术后即刻、3、6、12个月摄X线片,观察椎体的融合情况和融合器(cage)有无下沉。结果手术时间从110~180 m in。术中发生1例下腔静脉破裂出血。术后全部病例获得随访,随访时间12~35个月,平均22.3个月。OD I评分手术前为34.15±5.17,术后2周为43.27±10.43,术后3个月为46.14±6.85,术后6个月为44.97±3.65,术后12个月为46.38±4.48,与术前相比有显著差异(P<0.05)。25例植骨手术后3个月融合。1例患者术后3个月X线片显示相邻椎体滑移2 mm,6个月时融合。2例患者发生椎间高度丢失1 mm。无一例发生内置物松动、滑落及逆向射精等并发症。结论微创腰椎360°固定术适用于腰椎不稳、局限节段椎间盘变性及Ⅱ度以下腰椎滑脱伴神经根管狭窄患者。手术出血少、损伤小,但操作时应特别注意大血管的暴露和牵开。     

Internal fixation of the lumbar spine. The Hartshill rectangle

The Hartshill rectangle fixation is a modification of the Luque system of segmental spinal instrumentation. The rectangle is formed from a 3/16-in stainless steel rod and incorporates a roof that allows it to fit snugly against the lamina and provides good rotational stability. The rectangle is secured to the spine by means of doubled 0.91-mm-diameter stainless steel wires. The technique of the Hartshill system in the lumbar spine is described in detail. The system has been used in 71 patients with good relief of pain and without major complication. In the first 45 cases, a simple, flat, unwelded rectangle was used, and in the last 26 the Hartshill rectangle was employed.     

Translaminar screw fixation in lumbar spine pathology

Summary Two technical variations of the method of translaminar screw fixation for unstable lumbar and lumbosacral segments are presented. Distraction-arthrodesis with intraarticular bone grafts allows definitive enlargement of narrowed foramina with consecutive root decompression as well as repositioning and intracanalicular decompression in cases of instability after lumbar disc surgery and in degenerative spondylolisthesis. Reconstruction of a hemilamina after hemilaminectomy and facet reduction allows reconstitution of the spinal canal and its posterior parts as well as direct treatment of intraforaminal pathology.     

Spontaneous effect of increased stability of the lower lumbar spine in cases of severe chronic back pain. The answer of an external transpeduncular fixation test

Eighteen patients with severe low-back pain of long duration were externally stabilized over selected segments of the lumbar spine to evaluate the pain relieving effect of increased stability. Five millimeter Schantz screws were driven into the vertebral body transpeduncularly by a closed technique using an image intensifier. A modified Hoffmann fixation device with possibilities to compress and distract was used for external stabilization. The results were recorded by means of pain area sketches and pain lines. All but one patient experienced remarkable relief of low-back pain and often of pain radiating into the lower extremities. No serious complications were seen. Of eight patients with residual severe pain after fusions, five were considered healed using radiologic techniques and three were improved by external stabilization. This test could be used to identify candidates, select levels for lumbar fusion, and evaluate the stability of previous fusions.     

Lateral lumbar spine roentgenograms: potential role in complications of lumbar disc surgery

Penetration into the abdominal cavity with injury to visceral, vascular, or neural structures is a potentially life-threatening complication of lumbar disc exploration. In this report, we used reconstructed computed tomographic measurements of the L3-L4, L4-L5, and L5-S1 intervertebral discs to show that lateral spine roentgenograms contain an unavoidable magnification error that makes accurate measurement of minimal depth to penetration impossible. This magnification error may mislead the unwary surgeon into an overestimation of actual disc size. Moreover, the "safe distances" that have been published for the avoidance of penetration at the L3-L4, L4-L5, and L5-S1 intervertebral levels would have been excessive for 22.2%, 19.4%, and 8.3%, respectively, of the 26 patients in our study.     

Flow-regulated external lumbar drain: applications and complications

Background

A novel flow-regulated external drain (FRED) was devised to overcome the problems of the pressure-regulated systems and serial lumbar taps.

Methods

Eleven patients who underwent lumbar external drainage received a flow-regulated system using simple and inexpensive materials available in most hospital settings.

Results

The system proved to be reliable at removing a set amount of cerebrospinal fluid (CSF). We did not encounter any serious complications in its application.

Conclusions

The FRED system offered better patient compliance and comfort, providing them with greater mobility, while maintaining a safer steady removal of a set amount of CSF. In opposition to the pressure-regulated systems, we describe the possible indications, advantages and disadvantages of a flow regulated device. Extensive clinical trials are needed to study the use of FRED in patients with different CSF circulation physiology, pressure and composition.     

Transpedicular screw fixation of the lumbar spine: review and technique

Transpedicular fixation of the lumbar spine is an integral element in the surgical management of fractures, spondylolysthesis, neoplasms, scoliosis, and various other spine conditions. Experience over the past 15 years has better defined the indications, limitations, and potential risks of this surgical technique. Although segmental fixation using pedicle screws has many advantages, meticulous attention to detail and advanced training is required to avoid serious complications. This article outlines the pertinent clinical anatomy, preoperative evaluation, and surgical technique for transpedicular fixation of the lumbar spine.     

The role of transpedicular fixation systems for stabilization of the lumbar spine

Transpedicular fixation devices are extremely useful tools to achieve stabilization of the lumbosacral spine. The indications for the use of these systems are still evolving. These systems are able to obtain rigid fixation in vertebra lacking posterior elements, obtain solid sacral fixation, connect vertebra without distraction and maintain lordosis, fuse short spinal segments, and preserve motion segments. Stable, short segment constructs can be achieved even in the face of the most radical decompressions and vertebral resection. This technique is not, however, without risks. A thorough understanding of pedicle anatomy, pedicle screw insertion technique, fusion biology, and biomechanical considerations are paramount to achieve safe stabilization of the lumbosacral spine with this technique.     

Sexual complications of anterior fusion of the lumbar spine

Recently, there is renewed interest in anterior fusion for spondylolisthesis and congenital and paralytic scoliosis with pelvic obliquity. Some of the candidates are prepubertal boys. Sterility after surgery in urogenitally normal prepubertal boys will not be determined until these patients mature. A worldwide survey of 20 surgeons with 15-20 years of experience (4,500 cases) reports the frequency of sterility (retrograde ejaculation) to be 19 cases (0.42%) and impotence 20 cases (0.44%). One-fourth of the retrograde ejaculation cases resolved and became normal. Impotence is non-organic. The complication of retrograde ejaculation does not appear to be related to approach, though it was related to technique. While the complications of sterility and impotence following anterior fusion have been over-exaggerated, caution and informed consent from adult males and parents of prepubertal male children is advisable.     

Osteoradionecrosis of the lumbar spine 25 years after radiotherapy

Osteoradionecrosis is a rare but recognised complication of radiotherapy. Cases have been described in the cervical spine following treatment for head and neck malignancies up to 25 years after administration of radiotherapy. We present a rare case of osteoradionecrosis affecting the L5 and S1 vertebral bodies in a 58-year-old woman who presented with low back pain 25 years after undergoing a hysterectomy with adjuvant radiotherapy for cancer of the cervix.