Surgical management of patients with multilevel CSM aims to decompress the spinal cord and restore the normal sagittal alignment. The literature lacks of high level evidences about the best surgical approach. Posterior decompression and stabilization in lordosis allows spinal cord back shift, leading to indirect decompression of the anterior spinal cord. The purpose of this study was to investigate the efficacy of posterior decompression and stabilization in lordosis for multilevel CSM.
Methods
36 out of 40 patients were clinically assessed at a mean follow-up of 5, 7 years. Outcome measures included EMS, mJOA Score, NDI and SF-12. Patients were asked whether surgery met their expectations and if they would undergo the same surgery again. Bone graft fusion, instrumental failure and cervical curvature were evaluated. Spinal cord back shift was measured and correlation with EMS and mJOA score recovery rate was analyzed.
Results
All scores showed a significative improvement (p < 0.001), except the SF12-MCS (p > 0.05). Ninety percent of patients would undergo the same surgery again. There was no deterioration of the cervical alignment, posterior grafted bones had completely fused and there were no instrument failures. The mean spinal cord back shift was 3.9 mm (range 2.5–4.5 mm). EMS and mJOA recovery rates were significantly correlated with the postoperative posterior cord migration (P < 0.05).
Conclusions
Posterior decompression and stabilization in lordosis is a valuable procedure for patients affected by multilevel CSM, leading to significant clinical improvement thanks to the spinal cord back shift. Postoperative lordotic alignment of the cervical spine is a key factor for successful treatment.
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.
To evaluate the efficacy of single-stage posterior vertebral column resection for old thoracolumbar fracture–dislocations with spinal cord injury.
Methods
From January 2007 to June 2013, twelve male patients (average age, 32.6 years; range 19–57 years) with old fracture–dislocations of the thoracolumbar spine and spinal cord injury underwent single-stage posterior vertebral column resection and internal fixation. All patients were assessed for relief of the pain and restoration of neurologic function. Postoperative Cobb angle was measured and bone graft fusion was evaluated by X-ray. A systematic review of 25 studies evaluating surgical management of thoracolumbar fractures with spinal cord injuries was also performed.
Results
From our case series, six of the nine patients with Frankel grade A had significant improvement in urination and defecation after surgery. The three patients with Frankel grades B and C had progression of 1–2 grades after surgery. Bony fusion was achieved and local back pain was relieved in all patients after surgery. From our systematic review of 25 studies, the majority of patients had improved back pain, the postoperative kyphotic angle was significantly reduced compared with pre-operative kyphotic angle.
Conclusion
Single-stage posterior vertebral column resection and internal fixation for old thoracolumbar fracture–dislocations is an ideal treatment allowing for thorough decompression, relief of pain, correction of deformities, and restoration of spinal stability.
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.
This study was designed to evaluate the effect of preoperative pregabalin on intraoperative neurophysiological monitoring in adolescents undergoing surgery for spinal deformities.
Methods
Thirty-one adolescents undergoing posterior spinal fusion were randomized to receive preoperatively either pregabalin 2 mg/kg twice daily or placebo. The ability to make reliable intraoperative neurophysiological measurements, transcranial motor (MEPs) and sensory evoked potentials (SSEP) was evaluated.
Results
Two patients (pregabalin group) did not fulfil the inclusion criteria and one patient’s (placebo group) spinal monitoring was technically incomplete and these were excluded from the final data. In the rest, spinal cord monitoring was successful. Anaesthesia prolonged the latency of MEPs and increased the threshold current of MEP. The current required to elicit MEPs did not differ between the study groups. There were no statistically significant differences between the study groups regarding the latency of bilateral SSEP (N32 and P37) and MEP latencies at any time point.
Conclusions
Preoperative pregabalin does not interfere spinal cord monitoring in adolescents undergoing posterior spinal fusion.
Instrumented spinal fixations are an important tool in the management of traumatic conditions and delayed complications are rare.
Case report
We present a case of open reduction and fixation of traumatic C5/6 facet fracture dislocation with late complication in the form of intradural hardware migration.
Conclusion
To our knowledge, this is the first report of an intradural rod migration distant to the initial surgery in a patient without posterior decompression. This highlights the need for long-term follow-up of patients with spinal instrumentation.
The first purpose of this study is to confirm whether the spinal cord and the surrounding tissues can be visualized clearly after laminoplasty using percutaneous ultrasonography. And second purpose is to evaluate the changes in the status of the spinal cord over time.
Methods
Fifty patients who underwent cervical laminoplasty with suture anchors were evaluated using intraoperative ultrasonography and postoperative (1 week, 2 weeks, 3 months, 6 months, and 1 year) percutaneous ultrasonography. We classified the decompression status of the spinal cord into three grades and the pattern of the spinal cord pulsation into six categories. Clinical outcomes were evaluated using the Japanese Orthopaedic Association Score for cervical myelopathy, and the recovery rate was calculated.
Results
In all cases and all periods, we could observe the status of the spinal cord using percutaneous ultrasonography after cervical laminoplasty. The decompression status of the spinal cord improved until 3 months postoperatively, and the clinical outcomes improved up to 6 months postoperatively. Although the pulsation pattern of the spinal cord varied in each individual and in each period, spinal pulsation itself was observed in all cases and all periods, except one, when an epidural hematoma caused quadriplegia and a revision surgery was needed. Decompression status and pulsation pattern of the spinal cord were not associated with clinical outcomes as far as pulsation was observed.
Conclusions
Percutaneous ultrasonography was very useful method to evaluate the postoperative status of the spinal cord, particularly in the diagnosis of the postoperative epidural hematoma.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
To compare the clinical effectiveness of decompression plus fusion and decompression alone for patients with degenerative lumbar spondylolisthesis, a systematic review and meta-analysis of all available evidence was performed.
Methods
A search of the literature was conducted on PubMed/MEDLINE, EMBASE, and the Cochrane Collaboration Library. Relevant studies comparing decompression plus fusion and decompression alone were selected according to eligibility criteria. Predefined endpoints were extracted and meta-analyzed from the identified studies.
Results
Four randomized controlled trials and 13 observational studies were eligible. The pooled data revealed that fusion was associated with significantly higher rates of satisfaction and lower leg pain scores when compared with decompression alone. However, fusion significantly increased the intraoperative blood loss, operative time and hospital stay. Both techniques had similar ODI, back pain scores, complication rate, and reoperation rate.
Conclusions
Based on the available evidence, decompression plus fusion maybe be better than decompression alone in the treatment of degenerative spondylolisthesis. Fusion had advantages of improvement of clinical satisfaction, as well as reduction of postoperative leg pain, with similar complication rate to decompression alone.
Recently, strategies aimed at optimizing provider factors have been proposed, including regionalization of surgeries to higher volume centers and adoption of volume standards. With limited literature promoting the regionalization of spine surgeries, we undertook a systematic review to investigate the impact of surgeon volume on outcomes in patients undergoing spine surgery.
Methods
We performed a systematic review examining the association between surgeon volume and spine surgery outcomes. To be included in the review, the study population had to include patients undergoing a primary or revision spinal procedure. These included anterior cervical discectomy and fusion (ACDF), anterior/posterior cervical fusion, laminectomy/decompression, anterior/posterior lumbar decompression with fusion, discectomy, and spinal deformity surgery (spine arthrodesis).
Results
Studies were variable in defining surgeon volume thresholds. Higher surgeon volume was associated with a significantly lower risk of postoperative complications, a lower length of stay (LOS), lower cost of hospital stay and a lower risk of readmissions and reoperations/revisions.
Conclusions
Findings suggest a trend towards better outcomes for higher volume surgeons; however, further study needs to be carried out to define objective volume thresholds for individual spine surgeries for surgeons to use as a marker of proficiency.
The pathogenesis of cervical spondylotic myelopathy (CSM) is often multifactorial. Hence, the treatment of this disease requires a differentiated surgical approach in order to adequately address the underlying pathology.
Purpose
The aim of this review is to identify factors that influence the choice of treatment strategy and to summarize them in an algorithm that serves as a decision aid in choosing the optimal indication for surgical treatment. An attempt is made to define the threshold values for the indication of surgical treatment and to discuss the ideal timing for performing surgery.
Materials and methods
On the basis of the published data, the influencing factors on the prognosis of CSM, as well as surgical approaches are discussed.
Results
Circumferential spinal cord compression, a sharply defined myelopathy signal in the T2-weighted MRI sequence, and segmental instability at the level of the myelopathy signal mean an unfavorable prognosis for the worsening of CSM. The most important factors that influence the choice of the surgical access point are the sagittal profile of the cervical spine, the extent of myelopathy, the extent of stenosis, and the location of the myelopathy-inducing pathology. Previously existing neck pain and prior cervical surgery must also be considered.
Discussion
On the basis of the research carried out, we developed an algorithm that could serve as an aid in choosing the right treatment in the setting of cervical spondylotic myelopathy.
Osteoblastoma is a rare and benign tumor which requires early diagnosis and surgical excision. Scoliosis is a common presentation following osteoblastoma. It is considered due to pain-provoked muscle spasm on the side of the lesion. Few researches about osteoblastoma combined with severe scoliosis have been reported.
Case presentation
A 14-year-old girl presents with progressive scoliosis deformity for 3 years, with gradually appeared low back pain and numbness of left leg. Radiographic results showed osteoblastic mass at the left side of L3-L4 with severe scoliosis deformity, pelvic obliquity and spinal imbalance. The patient underwent posterior tumor excision, spinal decompression, scoliosis correction, spinal fusion with auto-graft and instrumentation from T8-S1. The mass was found to be osteoblastoma. The patient had a full neurological recovery with no aggravate of scoliosis or spinal imbalance during the follow-up.
Conclusions
This case emphasizes the importance of early diagnosis and surgical treatment of osteoblastoma. Early surgical excision will not only prevent neurological deficit but also the progression of scoliosis. Atypical scoliosis presence without pain requires carefully examination of whether a tumor exists.
To present cases of spinal tuberculosis in advanced pregnancy treated on anti-tuberculous drug regimen with successful outcome and proposing alternative paradigm to surgical decompression. A case series of five patients in stages of advanced pregnancy with neurologic deterioration and spinal tuberculosis were reported and treated.
Methods
Five patients with backache in advanced stages of pregnancy were reported. Patients were diagnosed as cases of spinal tuberculosis on further imaging studies. Patients were treated and followed up till complete clinical and radiological recovery.
Results
Four out of five patients were treated conservatively on ATT and rest. One patient underwent decompression without instrumentation. All patients recovered neurologically. There were foetal complications in two cases with foetal demise. One patient who underwent surgical decompression had preterm labour with still birth, apparently due to adverse reactions with anaesthetic drugs.
Conclusion
Spinal tuberculosis in pregnancy is a rare occurrence. Hesitation in performing radiographs complicates the outcome with delay in diagnosis and neurological compromise. There are no clear guidelines for treatment of such cases. Conservative treatment with ATT in pregnant patients may be a viable approach. Neurological compromise does not mandate surgical decompression, which in itself is not devoid of complications. Concern of foetal complications is high in surgical treatment.
The aim of this study is to compare the clinical, radiological and functional outcome of anterior versus posterior surgical debridement and fixation in patients with thoracic and lumbar tuberculous spondylodiscitis.
Patients and methods
A total number of 42 patients with tuberculous spondylodiscitis of the thoracic and lumbar spine treated surgically were included in this study. Twenty patients (group A) underwent anterior debridement, decompression and instrumentation by anterior approach. Twenty-two patients (group B) were operated by posterolateral (extracavitary) decompression and posterior instrumentation. Operative parameters, clinical, radiographic and functional results for the two groups were analyzed and compared.
Results
The average follow-up period was 15 months (range 12–24) in both groups. The average operative time, blood loss and blood transfusion of anterior group were significantly less than the posterior one. There was significant better back pain relief, kyphotic angle correction and less angle loss in the posterior group than anterior. There was no significant difference between the two groups regarding neurological recovery, functional outcome and fusion rate.
Conclusion
Both anterolateral and posterolateral approaches are sufficient for achieving the goals of surgical treatment of thoracic and lumbar Pott’s disease but posterolateral approach allows significant better kyphotic angle correction, less angle loss, better improvement in back pain but unfortunately more operative time and blood loss.
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.
Surgical site infection is a catastrophic complication after spinal surgery, which seriously affects the progress of rehabilitation and clinical outcome. Currently the clinical reports on spinal surgical site infections are mostly confined to the surgical segment itself and there are few reports on adjacent segment infections after spinal surgery.
Study design
Case report.
Objective
To report a clinical case with adjacent level infection after spinal fusion.
Methods
We report the case of a 68-year-old woman who underwent posterior lumbar 4?5 laminectomy, posterolateral fusion and internal fixation. The patient showed signs of surgical site infection, such as surgical site pain, high fever and increase of the inflammatory index 1 week after the operation. Magnetic resonance imaging (MRI) confirmed the diagnosis of adjacent intervertebral disc infection. The patient received early combined, high-dose anti-infection treatment instead of debridement.
Results
After the conservative treatment, the infection was controlled and the patient subsequently enjoyed a normal daily life.
Conclusion
Adjacent level infections can occur after spinal surgery. Early diagnosis and anti-infection treatment played an important role in the treatment of this kind of complication.
Septic cervical facet joints arthritis is a rare pathology, usually revealed by fever and neck pain. As symptoms may be indolent, a high index of suspicion needs to be maintained. Magnetic resonance imaging (MRI) is effective for early diagnostic, looking for local spread and guiding potential preoperative planning. We present a case exhibiting an uncommon pathology with possible significant morbidity if misdiagnosed.
Methods
A 75-year-old woman presented with fever, neck stiffness and torticollis accompanied with altered level of consciousness.
Results
The diagnosis was established by computed tomography and MRI, identifying atlantoaxial facet joint destruction with para spinal muscles and epidural abscesses. A surgical treatment consisting in posterior decompression of the spinal canal and atlantoaxial pars articularis fixation known as Harms technique, associated with a targeted antibiotic therapy, succeeded in obtaining favorable clinical course.
Conclusion
Atlantoaxial septic arthritis is an under reported and severe infection. Early use of MRI should avoid delayed diagnosis and would guide the practitioner in choosing an appropriate therapy. Early surgical treatment for uncontrolled sepsis is also a critical element of the prognosis.
Contemporary minimally invasive techniques have evolved to enable direct access to the anterior spinal column via the extreme lateral approach. We have employed this access approach to treat selected burst fractures. We report our technique. Thoracolumbar burst fractures that require surgical intervention have traditionally been managed with anterior, posterior, or combined approaches.
Methods
We have applied the minimally invasive extreme lateral approach to perform vertebral corpectomy, cage placement, and lateral instrumentation to treat burst fractures. Indications for surgery were incomplete spinal cord injury with persistent neural element compression due to ventral fracture fragments in the canal. We present the technical nuances of this surgical approach for the treatment of thoracolumbar burst fractures with two case illustrations.
Results
There were no peri- or intra-operative complications. Both patients in our series remained neurologically intact at their last follow-up (11 and 29 months, respectively), and maintained their correction of kyphosis.
Conclusion
The minimally invasive extreme lateral approach is an effective treatment option for the management of thoracolumbar burst fractures.
Radiofrequency ablation (RFA) and percutaneous vertebroplasty (PVP) are used independently and in combination to treat metastatically involved vertebrae with the aim of relieving pain, reducing tumour burden and providing bony mechanical stabilization.
Purpose
The aim of this work was to characterize the effect of two bone-targeted RFA devices, alone and in combination with PVP, to improve strength and mechanical stability in vertebrae with osteolytic metastatic disease.
Methods
Simulated spinal metastases (n = 12) were treated with one of two bone-targeted RFA devices (bipolar cooled or bone coil RF electrodes), followed by PVP. Under axial compressive loading, spinal canal narrowing was measured in the intact specimen, after tumour simulation, post-RFA and post-PVP.
Results
RFA alone resulted in successful tumour shrinkage and cavitation, but further increased canal narrowing under loading. RFA combined with PVP significantly reduced posterior wall stability in samples where sufficient tumour shrinkage and cavitation were coupled with a pattern of cement deposition which extended to posterior vertebral body.
Conclusions
RFA combined with cement deposition in the posterior vertebral body demonstrates significantly more stable vertebrae under axial loading.
The purpose of this study is to justify a new concept of the pathogenesis of secondary changes in the cervical spinal cord, and its correlation with the depth of development of neurological disorders in spinal injury.
Methods
Standard magnetic resonance imaging examination and angiography of the cervical and vertebral arteries of four patients were performed to diagnose the prevalence rate of ischemia and edema, and examine the spinal cord vasculature. Correlation of the data obtained with the neurological status was performed.
Results
Collateral circulation is most apparent in the upper-cervical region, above the C4 vertebra. Following occlusion of the vertebral artery, the circulation above the C4 vertebra is performed by collaterals of the ascending cervical artery. With extensive damage to the spinal cord, the intensity of edema and ischemia can be regarded as the effect of damage to radicular medullary arteries, which are injured in the intervertebral foramen. Secondary changes of the spinal cord are most apparent by impaired circulation in the artery of cervical enlargement.
Conclusions
Collateral circulation is a significant factor that limits the damage to the cervical spinal cord. Impaired circulation in the artery of cervical enlargement is significant in extension of perifocal ischemia. The appearance of early arteriovenous shunting in the region of a primary spinal cord injury (contusion focus) by angiography is pathognomonic. The data obtained open a perspective for the endovascular treatment of spinal cord injury.
To document a rarely reported complication associated with spinal instrumentation and to evaluate the current literature on spinal metallosis and spinal metalloma.
Methods
A local case report is presented. EBSCOhost, PubMed and ScienceDirect databases were used to conduct a systematic review for articles describing spinal metallosis and spinal metalloma.
Results
A total of 836 articles were identified using the terms “metalloma” or “metallosis”. Exclusion of arthroplasty-related abstracts retrieved 46 articles of which 3 full text articles presenting spinal metalloma as a causative pathological finding responsible for neurological signs and symptoms in patients with previous spinal fusion instrumentation were reviewed. Our case is the first described with titanium-composed posterior instrumentation and fifth reported, demonstrating the phenomena of neurological symptoms and signs attributed directly to neural tissue compression by spinal metalloma after spinal instrumentation.
Conclusion
Spinal metallosis can present weeks to years after spinal instrumentation surgery and is a potential cause of neural compression. This process appears to be independent of the instrument composition as metallosis has now been demonstrated in both titanium and stainless steel constructs.
