Thoracoscopic interbody fusion with percutaneous posterior stabilization for thoracic and thoracolumbar injuries

Background context

Traumatic thoracolumbar discoligamentous injuries and partial burst fractures are commonly managed through posterior-only stabilization. Many cases present later with failure of posterior implant and progressive kyphotic deformities that necessitates major surgeries. Anterior interbody fusion saves the patients unnecessary long-segment fixation and provides a stable definitive solution for the injured segment.

Purpose

The purpose of this study is to assess the clinical and radiographic outcomes of combined minimal invasive short-segment posterior percutaneous instrumentation and anterior thoracoscopic-assisted fusion in thoracolumbar partial burst fractures or discoligamentous injuries.

Study design

Prospective observational study.

Patient sample

Thirty patients with acute thoracic or thoracolumbar injuries operated upon between December 2007 and January 2009.

Outcome measures

Oswestry Disability Index (ODI), clinical and neurological examination for clinical assessment. Plain X-ray for radiological evaluation.

Methods

Preoperative evaluation included clinical and neurological examination, plain X-rays, computed tomography (CT), and magnetic resonance imaging (MRI). Posterior short-segment percutaneous stabilization plus anterior thoracoscopically assisted fusion in prone position were done. The minimum follow-up period was 2 years (range 24–48 months).

Results

The mean age was 44 years. The commonest affected segment was between T10 and L1 (22 patients, 73 %). The mean total operative time was 103 min. The mean operative blood loss was 444 ml. Interbody fusion cage was used in 28 patients while iliac graft in two cases. Fusion rate at the final follow-up was 97 % (29 patients); one patient did not show definitive fusion although he was clinically satisfied. The mean final follow-up ODI was 12 %. The mean preoperative kyphosis angle was 22° improved to 6.5° postoperatively and was 7.5° at final follow-up. There were no major intraoperative or postoperative complications.

Conclusion

Combined anterior thoracoscopic fusion and short-segment posterior percutaneous instrumentation showed good clinical and radiographic outcomes in cases of thoracolumbar injuries through limiting the instrumented levels and preventing progress of posttraumatic kyphosis.     

Modified one-stage posterior/anterior combined surgery with posterior pedicle instrumentation and anterior monosegmental reconstruction for unstable Denis type B thoracolumbar burst fracture

Purpose

This study aimed to evaluate the clinical and radiological results in patients with unstable Denis type B thoracolumbar burst fractures treated by modified one-stage posterior/anterior combined surgery.

Methods

Thirty-one patients with unstable Denis type B thoracolumbar burst fractures were enrolled in this study. The patients underwent one-stage posterior/anterior combined surgery with posterior instrumentation using pedicle screws and anterior monosegmental reconstruction utilizing titanium mesh cages. The mean follow-up period was 38.3 months. Clinical outcomes, radiological parameters, and treatment-related complications were assessed.

Results

The mean age of the patients was 36.4 years. The mean operative time and blood loss were 230 min and 645 ml, respectively. The VAS pain score was significantly improved after surgery, and the improvement was maintained until the final follow-up. In 23 patients with neurologic dysfunction, 20 (87 %) patients had improvement after surgery. By the final follow-up, 27 patients had returned to work; 18 of the 27 patients returned to a similar job. The mean sagittal kyphosis was corrected from 21.2° preoperatively to 2.5° postoperatively, which increased slightly to 4.3° at the final follow-up. Minimal subsidence and tilt of the titanium mesh cage were observed during the follow-up period. Solid bony fusion was achieved in all patients. One patient developed a posterior surgical site infection, which was resolved by antibiotic treatment and surgical debridement.

Conclusion

Modified one-stage posterior/anterior combined surgery for Denis type B unstable thoracolumbar burst fractures can produce good clinical and radiological outcomes.

     

Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion

Background

There is significant controversy surrounding the ideal management of thoracolumbar burst fractures. While several treatment and management algorithms have been proposed, the ideal treatment strategy for these fractures remains unsettled. The authors review their experience with short-segment posterior fusion followed by anterior thoracoscopic corpectomy for the treatment of unstable thoracolumbar burst fractures.

Methods

We identified all patients treated by a single surgeon at our institution from 2002 to 2009 with short-segment posterior fusion followed by anterior thoracoscopic corpectomy for unstable thoracolumbar junction burst fractures. Demographic data, mechanism of injury, classification of fracture, Cobb angle, American Spinal Injury Association score, associated injuries, tobacco use, follow-up duration, and radiographic studies were all collected. Outcomes were assessed for fracture alignment (preoperative, postoperative, and long-term follow-up kyphosis), rate of fusion, neurological outcome, and treatment complications.

Results

Thirty-two patients with burst fracture of the thoracolumbar junction defined as T10 to L1 were included. At a mean follow-up of 20.4 months, 90 % of patients had demonstrated radiographic evidence of fusion and 91 % retained the correction of their kyphotic deformity. There were three complications in the series.

Conclusions

Short-segment posterior fusion with thoracoscopic anterior corpectomy represents an alternative to traditional open treatment of thoracolumbar burst fractures. A thoracoscopic approach allows for a short-segment posterior fusion, reducing the loss of adjacent motion segments, minimizes morbidity associated with traditional open anterior approaches, allows for anterior and posterior column stabilization, and is associated with a high rate of bony fusion.     

Thoracoscopically assisted corpectomy and percutaneous transpedicular instrumentation in management of burst thoracic and thoracolumbar fractures

Study design

This is a prospective observational study.

Purpose

The aim of this study was to determine whether the combination of thoracoscopically assisted corpectomy with posterior percutaneous transpedicular instrumentation in prone position achieves treatment goals in burst thoracic or thoracolumbar fractures and minimizes the associated morbidities.

Methods

Between December 2007 and December 2008, 26 patients with acute burst spinal fractures were operated upon in our hospital. Those patients underwent posterior percutaneous stabilization plus anterior thoracoscopically assisted corpectomy and fusion in prone position. Clinical and radiological outcomes of these patients were evaluated after a minimum follow-up period of 2 years. The Oswestry Disability Index (ODI) combined with clinical examination was used for clinical evaluation. Plain X-ray in two views was used for the radiological evaluation.

Results

The mean operative time was 248 min. The average blood loss was 765 ml. Ten patients had preoperative neurological deficits ranging from Frankel A to D. One patient did not show any neurological improvement at the final follow-up. The mean ODI at final follow-up was about 7. The mean preoperative kyphosis angle was 25.58°, improved to 9.2° postoperatively and to 13.8° at the final follow-up. No cases of implant failure were reported at the final follow-up.

Conclusions

Minimal invasive spinal techniques including thoracoscopic decompression and fusion and short segment posterior percutaneous instrumentation showed good clinical outcomes and can be considered as alternative to open procedures with decreased rates of morbidities in managing burst thoracic and thoracolumbar fractures.     

Results of fusion and instrumentation of thoracic and lumbar vertebral fractures in children: a prospective ten-year study

Background

Researches on the results of surgical treatment of thoracolumbar spine fractures are infrequent. The aim of this study was to determine midterm outcomes of surgical treatment of these fractures in a prospective survey.

Methods

A case series study on pediatric patients with the diagnosis of thoracic and/or lumbar vertebral fractures was conducted over a ten-year period. Surgically treated patients were evaluated in the follow-up period, based on back pain, independent function, neurological status, and radiographic indices.

Results

There were 102 pediatric individuals, 61 boys and 41 girls, aged 3–17 years (mean 12 years of age) with thoracic and/or lumbar spinal fractures. Motor vehicle accident was the most common mechanism of injury (45.0 %). L1 was the most frequent level of fractured vertebra (24.4 %), and pelvic fracture was the most common associated orthopedic injury (21.5 %). Totally, 20 patients underwent surgery, but only fifteen (14 boys and one girl) participated in follow-up (mean 49 months; range 12–81 months). Posterior spinal fusion and instrumentation was accomplished in 12 cases. Three patients were operated by anterior approach and fusion followed by posterior fusion and instrumentation because of delay in diagnosis. There were no major perioperative complications. Two cauda equina syndromes and two incomplete spinal cord injuries improved back to normal. Five cases (33.3 %) reported occasional back pain, and all patients were functionally independent. Radiographic indices improved significantly.

Conclusions

Spinal fusion and instrumentation in pediatric patients with unstable thoracolumbar vertebral fractures with or without spinal cord injuries have favorable radiographic and functional outcomes.     

Recurrent adamantinoma in the thoracolumbar spine successfully treated by three-level total en bloc spondylectomy by a single posterior approach

Purpose

Adamantinoma is a low-grade primary malignant bone tumour with slow growth and local recurrence. Its occurrence in the spine is extremely rare, particularly with multilevel involvement. This paper wants to present the first case involving a patient with recurrent thoracolumbar spinal adamantinoma, who underwent a successful three-level spondylectomy for en bloc resection.

Methods

A 24-year-old man with osteolytic masses of T11 and T12 vertebral bodies was performed curettage by a posterior approach in 2008. The pathology report showed the excised neoplasm was a rare adamantinoma. This patient underwent a tumorectomy again because of its local recurrence nearly 3 years later. In 2012, it was unfortunately revealed that the excised tumour had relapsed and had spread to the L1 vertebral body. Due to its repeated recurrence and aggressive lesion, total en bloc spondylectomy (TES) for this malignant tumour was thought to be the best option for preventing repeated recurrence and possible cure. TES for T11–L1 thoracolumbar spine was performed and spinal reconstruction was completed with instrumentation and a titanium mesh cage through a one-stage single posterior approach.

Results

After three-level TES, neurological deficits of the patient demonstrated good recovery and no evidence of adamantinoma recurrence or deformity was found at 2-year follow-up.

Conclusions

This is the first case involving multilevel thoracolumbar spinal adamantinoma with repeated recurrence to be successfully treated by three-level TES by a single posterior approach.

     

Posterior short-segment instrumentation and limited segmental decompression supplemented with vertebroplasty with calcium sulphate and intermediate screws for thoracolumbar burst fractures

Purpose

Thoracolumbar burst fractures treated with short-segment posterior instrumentation without anterior column support is associated with a high incidence of implant failure and correction loss. This study was designed to evaluate the clinical and radiographic results following posterior short-segment instrumentation and limited segmental decompression supplemented with vertebroplasty with calcium sulphate and intermediate screws for patients with severe thoracolumbar burst fractures.

Methods

Twenty-eight patients with thoracolumbar burst fractures of LSC point 7 or more underwent this procedure. The average follow-up was 27.5 months. Demographic data, radiographic parameters, neurologic function, clinical outcomes and treatment-related complications were prospectively evaluated.

Results

Loss of vertebral body height and segmental kyphosis was 55.3 % and 20.2° before surgery, which significantly improved to 12.2 % and 5.4° at the final follow-up, respectively. Loss of kyphosis correction was 2.2°. The preoperative canal encroachment was 49 % that significantly improved to 8.8 %. The preoperative pain and function level showed a mean VAS score of 9.2 and ODI of 89.9 % that improved to 1.4 and 12.9 % at the final follow-up, respectively. No implant failure was observed in this series, and cement leakage occurred in two cases without clinical implications.

Conclusions

Excellent reduction and maintenance of thoracolumbar burst fractures can be achieved with short-segment pedicle instrumentation supplemented with anterior column reconstruction and intermediate screws. The resultant circumferential stabilization combined with a limited segmental decompression resulted in improved neurologic function and satisfactory clinical outcomes, with a low incidence of implant failure and progressive deformity.     

Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage

Purpose

Retrospective analysis of the clinical efficacy and feasibility of patients with thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.

Method

A total of 18 patients with thoracolumbar tuberculosis (TB), between February 2007 and February 2011, underwent one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. And the clinical efficacy was evaluated based on surgery duration time, the blood loss, the postural drainage of time, neurological status that was recorded by American Spinal Injury Association (ASIA) Impairment Scale, the fate of bone graft fusion, kyphosis angle, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which were collected at certain time.

Results

The average follow-up period was 34 months (range 18–48 months). 18 patients suffered from seriously neurological deficits pre-operatively, of which 16 patients returned to normal at final follow-up. The surgery duration time was 197 ± 37.9 min, and the blood loss was 815 ± 348.5 ml. The postural drainage of time was 7.2 ± 2.7 days. The psoas abscesses disappeared in all cases, within the time range of 6–9 months (mean 7.4 ± 1.2 months). All patients of the grafted bones were thoroughly fused, with a fusion time ranging from 4 to 12 months (mean 7.8 months). Kyphosis angle was 44.32 ± 7.26° on average pre-operative and returned to 11.72 ± 2.85° at 6 weeks after operation; kyphosis angle was 13.10 ± 2.39° at final follow-up. The values of ESR and CRP were significant declined at 6 weeks post-operative, and returned to normal levels at final follow-up.

Conclusion

With standardized anti-TB chemotherapy, thoracolumbar spinal tuberculosis with psoas abscesses could be effectively treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.     

Comparison of alcohol ablation with repeated thermal radiofrequency ablation in medial branch neurotomy for the treatment of recurrent thoracolumbar facet joint pain

Purpose

Chemical denervation is not recommended as part of the routine care of chronic non-cancer pain. Physicians face a dilemma when it comes to repeated interventions in cases of recurrent thoracolumbar facet joint pain after successful thermal radiofrequency ablation (RFA) in medial branch neurotomy. This study was performed to compare the effects of alcohol ablation (AA) with thermal RFA in patients with recurrent thoracolumbar facet joint pain after thermal RFA treatment.

Methods

Forty patients with recurrent thoracolumbar facet joint pain after successful thermal RFA defined as a numeric rating scale (NRS) score of ≥7 or a revised Oswestry disability index (ODI) of ≥22 % were randomly allocated to two groups receiving either the same repeated RFA (n = 20) or AA (n = 20). The recurrence rate was assessed with NRS and ODI during the next 24 months, and adverse events in each group were recorded.

Results

During the 24-month follow-up after RFA and AA, one and 17 patients, respectively, were without recurring thoracolumbar facet joint pain. The median effective periods in the RFA and AA groups were 10.7 (range 5.4–24) and 24 (range 16.8–24) months, respectively (p < 0.000). No significant complications were observed with the exception of injection site pain, which occurred in both groups.

Conclusion

In our patient cohort, alcohol ablation in medial branch neurotomy provided a longer period of pain relief and better quality of life than repeated radiofrequency medial branch neurotomy in the treatment of recurrent thoracolumbar facet joint pain syndrome after successful thermal RFA without significant complications during the 24-month follow-up.     

Combined spinal arthrodesis with instrumentation for the management of progressive thoracolumbar kyphosis in children with mucopolysaccharidosis

Purpose

To evaluate the outcome and complications of a novel technique for the treatment of progressive thoracolumbar kyphosis in children with mucopolysaccharidosis (MPS).

Methods

The medical records and spinal imaging of four consecutive paediatric patients who underwent a single stage anteroposterior spinal fusion with segmental pedicle screw instrumentation were reviewed.

Results

Patients underwent spinal deformity correction at the mean age of 3 years (2.4–3.7) with mean clinical follow-up of 3.2 years (2.1–4.5) and mean postoperative radiographic follow-up was 2.4 years (0.8–3). Preoperative kyphosis was corrected from a mean angle of 65º (63º–70º) to 6.5º (–12º–13º). Vertebral subluxation at the apex of the deformity was corrected from an average 64 % (56–83 %) to 12 % (0–24 %). Spinal cord monitoring with somatosensory evoked potentials (SSEP) was successfully obtained and stable throughout surgery. No instrumentation failure, loss of correction or junctional problems occurred at final follow-up.

Conclusions

Anterior and posterior spinal arthrodesis with segmental pedicle screw instrumentation is a safety and reliable technique for the treatment of severe thoracolumbar kyphosis in children with MPS. This technique achieves excellent correction of the deformity with adequate decompression of the spinal canal. The fusion is limited to the thoracolumbar junction and interferes minimally with the longitudinal growth of the thorax. No neurological complications or intraoperative spinal cord monitoring events occurred. No loss of correction or junctional kyphosis was observed.     

Digastric trochanteric flip osteotomy and surgical dislocation of hip in the management of acetabular fractures

Objectives

To assess the efficacy and safety of digastric trochanteric flip osteotomy technique in the management of acetabular fractures and to evaluate surgical outcome in terms of fracture reduction, femoral head viability of selected acetabular fractures treated operatively using a digastric trochanteric flip osteotomy and a modified Kocher–Langenbeck approach with surgical dislocation of the femoral head.

Design

Prospective.

Patients

Eighteen patients predominantly with combined transverse and posterior wall fractures or multifragmentary posterior wall fractures.

Outcome evaluation

Clinical and radiographic analysis after a minimum 18 months follow-up.

Methods

A single modified approach involving digastric trochanteric flip osteotomy and a modified Kocher–Langenbeck approach with anterior (n = 14) or posterior (n = 4) surgical dislocation of the femoral head, was done for one or more of following reasons: intra-articular assessment of reduction in fractures with comminution, marginal impaction and involvement of the anterior column, removal of intra-articular fragments, and confirmation of extra-articular screw placement.

Results

At a mean follow-up of 26 months (18–40 months), the 17 patients presented with a good to excellent clinical result according to the d’Aubigné score. In all subjects, anatomical reduction was achieved during surgery. The osteotomy site healed at an average of 7 weeks and all the patients recovered abductor strength at 12 weeks. One avascular necrosis occurred in a case of posterior column plus wall fracture (who presented to us after 3 weeks). No heterotopic ossification interfering with hip function was found.

Conclusion

This technique gives good exposure (especially in posterior wall, dome area, posterior fracture-dislocation with intra-articular fragments/femoral head fractures and T-fractures), preservation of abductor strength (which may be lost with excessive retraction of abductors to see dome area in classical posterior approach), reliable healing of osteotomy (in contrast to conventional trochanteric osteotomy) without risking the vascularity of femoral head.     

One-stage anterior debridement,bone grafting and posterior instrumentation vs. single posterior debridement,bone grafting,and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis

Purpose

The aim of this study was to compare single posterior debridement, interbody fusion and instrumentation with one-stage anterior debridement, interbody fusion and posterior instrumentation for treating thoracic and lumbar spinal tuberculosis.

Method

From January 2006 to January 2010, we enrolled 115 spinal tuberculosis patients with obvious surgical indications. Overall, 55 patients had vertebral body destruction, accompanied by a flow injection abscess or a unilateral abscess volume greater than 500 ml. The patients underwent one-staged anterior debridement, bone grafting and posterior instrumentation (group A) or single posterior debridement, bone grafting and instrumentation (group B). Clinical and radiographic results for the two groups were analyzed and compared.

Results

Patients were followed 12–36 months (mean 21.3 months), Fusion occurred at 4–12 months (mean 7.8 months). There were significant differences between groups regarding the post-operative kyphosis angle, angle correction and angle correction rate, especially if pathology is present in thoracolumbar and lumbar regions. Operative complications affected five patients in group A, and one patient in group B. A unilateral psoas abscess was observed in three patients 12 months postoperatively. In one of them, interbody fusion did not occur, and there was fixation loosening and interbody absorption. All of them were cured by an anterior operation.

Conclusion

Anterior debridement and bone grafting with posterior instrumentation may not be the best choice for treating patients with spinal tuberculosis. Single posterior debridement/bone grafting/instrumentation for single-segment of thoracic or lumbar spine tuberculosis produced good clinical results, except in patients who had a psoas abscess.     

Posterior instrumentation, anterior column reconstruction with single posterior approach for treatment of pyogenic osteomyelitis of thoracic and lumbar spine

Purpose

Surgical treatment of thoracolumbar osteomyelitis consists of radical debridement, reconstruction of anterior column either with or without posterior stabilization. The objective of present study is to evaluate a case series of patients with osteomyelitis of thoracic and lumbar spine treated by single, posterior approach with posterior instrumentation and anterior column reconstruction.

Methods

Seventeen patients underwent clinical and radiological evaluation pre and postoperatively with latest follow-up at 19 months (8–56 months) after surgery. Parameters assessed were site of infection, causative organism, angle of deformity, blood loss, duration of surgery, ICU stay, deformity correction, time to solid bony fusion, ambulatory status, neurologic status (ASIA impairment scale), and functional outcome (Kirkaldy-Willis criteria).

Results

Mean operating time was 207 min and average blood loss 1,150 ml. Patients spent 2 (1–4) days in ICU and were able to walk unaided 1.6 (1–2) days after surgery. Infection receded in all 17 patients postoperatively. Solid bony fusion occurred in 15 out of 17 patients (88 %) on average 6.3 months after surgery. Functional outcome was assessed as excellent or good in 82 % of cases. Average deformity correction was 8 (1–18) degrees, with loss of correction of 4 (0–19) degrees at final follow-up.

Conclusions

Single, posterior approach addressing both columns poses safe alternative in treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine. It proved to be less invasive resulting in faster postoperative recovery.     

Modified LigaSure hemorrhoidectomy for the treatment of hemorrhoidal crisis

Purpose

This study aimed at reporting a modified LigaSure technique for the treatment of acute hemorrhoidal crisis.

Methods

Consecutive patients with an acute hemorrhoidal crisis received a modified LigaSure hemorrhoidectomy. After removing the hemorrhoidal tissues above the welding line, scissors were used to undermine the anoderm to excise residual thrombosed hemorrhoidal tissue. The wound was approximated with a continuous 4-0 vicryl suture.

Results

Forty patients (mean age, 47.5 years; range 22.0–76.0 years) were included. The mean duration of the crisis, length of the operation, and follow-up were 2.0 days (range 1.0–5.0 days), 35.6 min (range 15.0–60.0 min), and 13.2 months (range 6–24 months), respectively. At the final follow-up, all patients were continent and there were no cases with anal stenosis, recurrent bleeding, prolapse, or thrombus. The mean pain score before surgery was 8.3, and was 4.4 and 3.2 on postoperative days 1 and 7, respectively. Complications within 30 days of surgery included two cases of urine retention, two cases bleeding, one wound infection and one case of fecal impaction, which all resolved with conservative treatment. The only late complication was one case of residual skin tags.

Conclusions

The modified LigaSure hemorrhoidectomy offers rapid pain relief, early recovery, and low morbidity for patients with an acute hemorrhoidal crisis.     

The complement of the load-sharing classification for the thoracolumbar injury classification system in managing thoracolumbar burst fractures

Background

The classification and therapeutic strategy for thoracolumbar burst fractures are controversial. The load-sharing classification (LSC) and thoracolumbar injury classification system (TLICS) are both quantitative evaluation systems for thoracolumbar burst fractures. We hypothesized that their combination would be helpful not only for surgical indications but also for deciding on the surgical approach. However, no reports have evaluated the relationship between them. The purpose of this study was to clarify the relationship between the LSC and TLICS and investigate the clinical usefulness of their combination.

Methods

This study included 100 consecutive patients surgically treated for thoracolumbar burst fractures (71 men and 29 women; mean age 36 years). Clinical and radiographical data as well as thoracolumbar injury classification systems were evaluated.

Results

LSC and TLICS scores were found to be statistically correlated. The mean LSC score with a TLICS score of 5 or more (surgical treatment recommended) was 7.3 ± 1.2 points, and the mean LSC score with a TLICS score of 3 or less (conservative treatment recommended) was 6.1 ± 1.3 points. The mean TLICS score with an LSC score of 7 or more (additional anterior reconstruction recommended) was 6.6 ± 2.7 points, and the mean TLICS score with an LSC score of 6 or less (expectation of good clinical results with posterior short fusion) was 5.0 ± 2.5 points. The TLICS score was 3 or less, and the LSC score was 7 or more in 13 patients (13 %).

Conclusion

Although the TLICS scores correlated with the LSC scores, a single application of TLICS might not be sufficient to identify those patients who have a TLICS score of 3 or less and an LSC score of 7 or more as surgically indicated. However, an additional LSC evaluation avoided deviations as the two classifications complemented each other, and it was useful in determining the best treatment options for thoracolumbar burst fractures.     

Extreme Lateral Interbody Fusion (XLIF) in the Thoracic and Thoracolumbar Spine: Technical Report and Early Outcomes

Background

Previous studies have demonstrated the distinct advantages of thoracoscopically assisted spinal fusion compared to traditional open thoracotomy. However, these techniques are limited by a steep learning curve, prolonged operative time, and lack of three-dimensional visualization of the surgical field.

Objective

The objective of this study was to describe our initial experience with an adaptation of the extreme lateral interbody fusion (XLIF) technique allowing access to the anterior aspect of the thoracic and thoracolumbar spine with specific reference to (1) early pulmonary complications, (2) non-pulmonary complications, and (3) ability of this technique to successfully achieve spinal decompression and fusion at the operative level.

Methods

Clinical and radiographic data were reviewed for the entire perioperative period. A total of 18 patients (72% females; mean age, 56.8 years) underwent a thoracic XLIF procedure for spinal pathologies including disc herniation, fracture, tumor, pseudoarthrosis, and proximal junctional kyphosis. A total of 32 levels were treated, with the majority located at the thoracolumbar junction. Twelve of the procedures were done as part of a combined anterior/posterior surgery.

Results

The mean estimated blood loss was 577 ml and the mean length of stay was 12 days. At a mean follow-up of 14 months, all patients except for one (who died of widely metastatic disease) had achieved radiographic evidence of fusion. Two patients developed pulmonary effusions requiring medical intervention. Six patients had seven non-pulmonary complications: incidental durotomy (two), infection (one), instrumentation pullout (one), cardiac arrhythmia (two), and death from metastatic disease (one).

Conclusions

The XLIF technique can be utilized for access to the anterior column of the thoracic and thoracolumbar spine. The advantages of this minimally invasive technique include avoidance of the need for an access surgeon and for lung deflation during surgery as well as excellent visualization of the spinal pathology.     

Removal of thoracic dumbbell tumors through a single-stage posterior approach: its usefulness and limitations

Background

The purpose of this study was to evaluate the surgical results of the single-stage surgery only from posterior approach for the management of thoracic dumbbell tumor and to discuss its usefulness and limitations.

Methods

Sixteen cases of large thoracic dumbbell tumor (11 men and 5 woman, mean age, 44 years) were analyzed retrospectively. Pathologic findings included schwannoma in 10 patients, neurofibroma in 2 patients (Recklinghausen in 1 patient), meningioma in 2 patients, myxolipoma in 1 and ganglioneuroma in 1. They underwent single-stage removal of dumbbell tumor using the posterior approach followed by laminectomy and often costotransversectomy combined with instrumentation. Clinical and radiologic outcomes are reviewed.

Results

The mean follow-up period for clinical and radiographic outcome variables was 66 months (range, 24–120 months). Operative time ranged from 185 to 420 min (mean, 320 min), with estimated blood loss ranging from 71 to 1830 ml (mean, 540 ml). Postoperative complications were pleural injury during the enucleation of paravertebral tumors, which could be repaired, and the chest tube was detained to prevent postoperative pneumothorax. Postoperative complications included atelectasis in one case. All patients had tumors successfully removed with no neurological deterioration. One patient underwent both posterior and anterior surgery because of attachment to and compression of an artery. We were not able to diagnose this case preoperatively, although a biopsy had been performed.

Conclusions

Single-stage surgery may be a useful method for removing thoracic dumbbell tumors without the combined anterior approach, unless they are attached to and compressing the artery and the diagnosis cannot be made preoperatively.     

The treatment of type III acromioclavicular dislocations with a modified Cadenat procedure: surgical technique and mid-term results

Introduction

The treatment of type III acromioclavicular injuries is controversial. Both conservative and surgical approaches have been successful. Aim of the present study was to prospectively evaluate the results of the modified Cadenat procedure in subjects with type III acromioclavicular joint injuries.

Methods

Twenty-eight patients with acute type III acromioclavicular joint dislocations (mean age 31 years) were prospectively enrolled in the present study. The delay between the injury and the surgery varied between 4 and 19 days, with an average of 8.3 days. All patients were evaluated both preoperatively and postoperatively with radiographs and clinically with visual analog scale and Constant score. A modified Cadenat procedure was performed in all cases.

Results

Twenty-five patients were evaluated at an average follow-up of 72 months. One patient had a re-dislocation 3 years after surgery. At the last follow-up, average visual analog scale score of was 0.96 (range 0–3), while mean constant score was 94.32 (range 90–99) and 92 % of patient were very happy or happy with their functional result. Radiographs showed complete reduction in 22 patients and loss of reduction in two cases. No major complications were recorded.

Interpretation

This is the first clinical report on a modified Cadenat procedure. This operation has a reduced morbidity if compared to other techniques involving autologous grafts. Moreover, it yielded good functional results, with complete pain relief, and full strength recovery at mid-term follow-up. No major loss of reduction or recurrence of instability was observed.

Level of evidence

4, Case series.     

Is section of the sympathetic rami communicantes by laparoscopy in patients with refractory low back pain efficient?

Objective

The objective of this prospective innovative treatment is to section the pain pathways carried by sympathetic lumbar rami communicantes to achieve lasting pain relief of refractory low back pain.

Methods

From December 2005 to September 2008, nine patients were operated by bilateral section of rami communicantes for a refractory low back pain. As a diagnostic and predictive test, all patients had, before surgery, a local anaesthetic infiltration of the sympathetic trunk at L2 performed with computed tomography guidance. Surgery is indicated if the tests lead to a reduction in pain of at least 50 %. The procedure, using a retroperitoneal laparoscopic approach, consisted to identify the sympathetic trunk and to section all lumbar rami communicantes from L1 to L2.

Results

No intraoperative complications were observed. The mean postoperative follow-up was 29 ± 15 months. At the last follow-up, only 22 % (2/9) patients had an improvement of their low back pain with this surgery but with a minimal effect (30 and 50 % reduction of pain). An improvement of quality of life was observed in 33 % (3/9) of cases. Due to persistent pain, four patients had a spinal cord stimulation after this surgery.

Conclusions

Section the pain pathways carried by sympathetic lumbar rami communicantes for refractory low back pain improved 22 % of patients at the last follow-up of 29 months.     

Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosis without anterior instrumentation and without anterior or posterior bone grafting

Purpose

The aim of this prospective study is the analysis of the clinical and radiological outcomes of active thoraco-lumbar spinal tuberculosis treated with isolated posterior instrumentation without any posterior bone grafting or anterior inter-body bone grafting or anterior instrumentation.

Methods

The study was a prospective follow-up of 25 patients with active thoraco-lumbar spinal tuberculosis who underwent posterior spinal instrumentation with pedicle screws and rods. These patients had posterior stabilization of the involved segment of the spine without anterior or posterior bone grafting. The mean duration of follow-up was 3.3 years and the minimum duration of follow-up was 2 years.

Results

The mean kyphotic angle improved from 32.4° pre-operatively to 7.2° in the early follow-up period. Following a minor loss of correction during follow-up, the mean kyphotic angle settled at 11.5° at the time of final follow-up. Inter-body bony fusion was noticed at the final follow-up in all patients despite the absence of anterior bone grafting or cages.

Conclusion

Posterior instrumented stabilization followed by chemotherapy seems to be adequate for obtaining satisfactory healing of the lesions. Anterior inter-body bony arthrodesis occurs despite the absence of anterior bone grafts or cages. Careful patient selection is critical for successful outcome with this technique.