Sexual function is an important determinant of quality of life, and factors such as surgical approach, performance of fusion, neurological function and residual pain can affect it after spine surgery. Our aim was to perform a systematic review to collate evidence regarding the impact of spine surgery on sexual function.
Methods
A systematic review of studies reporting measures of sexual function, and incidence of adverse sexual outcomes (retrograde ejaculation) after major spine surgery was done, regardless of spinal location. Pubmed (MEDLINE) and Google Scholar databases were queried using the following search words “Sex”, “Sex life”, “Sexual function”, “Sexual activity”, “retrograde ejaculation”, “Spine”, “Spine surgery”, “Lumbar surgery”, “Lumbar fusion”, “cervical spine”, “cervical fusion”, “Spinal deformity”, “scoliosis” and “Decompression”. All articles published between 1997 and 2017 were retrieved from the database. A total of 81 studies were included in the final review.
Results
Majority of the studies were retrospective case series and were low quality (Level IV) in evidence. Anterior lumbar approaches were associated with a higher incidence of retrograde ejaculation, especially with the utilization of transperitoneal laparoscopic approach. There is inconclusive evidence on the preferred sexual position following fusion, and also on the impact of BMP-2 usage on retrograde ejaculation/sexual dysfunction.
Conclusion
Despite limited evidence from high-quality articles, there is a general trend towards improvement of sexual activity and function after spine surgery. Future studies incorporating specific assessments of sexual activity will be required to address this important determinant of quality of life so that appropriate pre-operative counselling can be done by providers.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
Surgical correction of severe and rigid cervical kyphosis with chin-on-chest deformity poses significant challenges to both the patient and surgeon once surgery is considered as the treatment of choice.
Objectives
This article presents the current concepts of corrective surgery for patients with severe and rigid cervical kyphosis.
Material and methods
Narrative review and report of clinical experience.
Results
The treatment of severe cervical kyphosis indicates a dedicated deformity assessment, the analysis of regional and global imbalance, the identification of spinal sagittal plane compensation mechanisms, detailed radiographic and clinical planning of corrective surgery, and the meticulous performance of surgical correction. Most recent large-scale studies serve as evidence for the benefit of surgical correction and outline the complications that need to be targeted during and after surgery.
Conclusion
Surgical correction of severe cervical kyphosis can be a pleasant and life-changing event for the disabled patient.
The purpose of this study was to develop a simple and clinically useful morphological classification system for congenital lumbar spinal stenosis using sagittal MRI, allowing clinicians to recognize patterns of lumbar congenital stenosis quickly and be able to screen these patients for tandem cervical stenosis.
Methods
Forty-four subjects with an MRI of both the cervical and lumbar spine were included. On the lumbar spine MRI, the sagittal canal morphology was classified as one of three types: Type I normal, Type II partially narrow, Type III globally narrow. For the cervical spine, the Torg-Pavlov ratio on X-ray and the cervical spinal canal width on MRI were measured. Kruskal–Wallis analysis was done to determine if there was a relationship between the sagittal morphology of the lumbar spinal canal and the presence of cervical spinal stenosis.
Results
Subjects with a type III globally narrow lumbar spinal canal had a significantly lower cervical Torg-Pavlov ratio and smaller cervical spinal canal width than those with a type I normal lumbar spinal canal.
Conclusion
A type III lumbar spinal canal is a globally narrow canal characterized by a lack of spinal fluid around the conus. This was defined as “functional lumbar spinal stenosis” and is associated with an increased incidence of tandem cervical spinal stenosis.
Based on an interesting case of a medical evaluation, the possible association between a cervical spine strain trauma and an emerging symptomatic bleeding of a prior-existing intramedullary cavernoma is presented and discussed.
Materials and methods
Based on the criteria “course of events,” “behavior of the trauma patient,” “medical findings,” and “imaging results” pertaining to the initial situation as well as case progression, the basic principles and differential diagnostic steps of a medical evaluation of a correlation are demonstrated.
Results and discussion
Weighing up of pros and contras and the differentiation between essential and nonessential partial causes of a legal point of view leads to the conclusion that the present incriminated event can be regarded as the primary cause of the resulting physical injury.
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.
Robotic technology has been applied to colorectal surgery over the last decade. The aim of this review is to analyze the outcomes of robotic colorectal surgery systematically and to provide objective information to surgeons.
Methods
Studies were searched and identified using PubMed and Google Scholar from Jan 2001 to Feb 2013 with the search terms “robot,” “robotic,” “colon,” “rectum,” “colorectal,” and “colectomy.” Appropriate data in the studies about the outcomes of robotic colorectal surgery were analyzed.
Results
Sixty-nine publications were included in this review and composed of 39 case series, 29 comparative studies, and 1 randomized controlled trial. Most of the studies reported that robotic surgery showed a longer operation time, less estimated blood loss, shorter length of hospital stay, lower complication and conversion rates, and comparable oncologic outcomes compared to laparoscopic or open surgery.
Conclusion
Robotic colorectal surgery is a safe and feasible option. Robotic surgery showed comparable short-term outcomes compared to laparoscopic surgery or open surgery. However, the long operation time and high cost are the limitations of robotic surgery.
Aim of this study is to compare late degenerative MRI changes in a subset of patients operated on with ACDF to a second subset of patients presenting indication to ACDF but never operated on.
Methods
Patients from both subgroups received surgical indication according to the same criteria. Both subgroups underwent a cervical spine MRI in 2004–2005 and 10 years later in 2015. These MRI scans were retrospectively evaluated with a cervical spine ageing scale.
Results
Comparing the two subset of patients both suffering from clinically relevant single-level disease returns no statistically significant difference in the degenerative condition of posterior ligaments, presence of degenerative spondylolisthesis, foraminal stenosis, diameter of the spinal canal, Modic alteration, and intervertebral discs degeneration at 10-year follow-up.
Conclusions
The adjacent segment degeneration represents, in the present cohort, a result of the natural history of cervical spondylosis rather than a consequence of fusion.
Cervical spine alignment interests appeared recently and relationships between the pelvis and the cervical spine have been reported but remain unclear. In this study, postoperative changes for cranial, cervical, lumbar and sagittal balance parameters have been measured in adult scoliosis surgery without major sagittal malalignment to appreciate the adaptation of the cervical spine.
Methods
Twenty-nine consecutive patients with a surgical adult degenerative scoliosis treated with a T8–T11 to iliac fusion without PSO or multiple Ponte’s osteotomies had preoperative and postoperative full spine EOS radiographies to measure spino-pelvic parameters. Correlation analysis between the different parameters was performed.
Results
Lower cervical, lordosis, lumbar lordosis and thoracic kyphosis were increased in postoperative as no changes were observed for upper cervical lordosis. C1–C7 CL highly correlated (0.85 in preoperative and 0.87 in postoperative) with C7 slope, which highly correlated itself with global balance parameters (0.74 in preoperative and 0.71 in postoperative for CAM-PL) underlining the relationship between cervical spine alignment and global malalignment.
Conclusions
Modifications of lower CL are observed, as upper CL remains constant. If no correlation was found for LL, TK and CL changes, CL appears to be highly correlated with C7 slope, which highly correlated itself with sagittal global balance parameters. C7 slope appears as a base for CL influenced by the spine global alignment.
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.
Correction of rigid cervical deformities often requires osteotomies to realign the spine. Cervical pedicle subtraction osteotomy can be technically challenging due to the presence of cervical nerve roots and usually can only be performed at C7 or T1 due to the presence of vertebral arteries. In contrast, anterior cervical osteotomy can be performed throughout the cervical spine and is a safe and effective method for correction of both sagittal and coronal cervical deformities. We describe the anterior cervical osteotomy technique with a review of the pertinent literature.
Methods
A step-by-step technical guide for anterior cervical osteotomy is provided with a focus on surgical nuances and complication avoidance. Two illustrative cases of fixed sagittal and coronal deformities are included to demonstrate the substantial amount of deformity correction achievable using the anterior cervical osteotomy technique.
Results
Both patients in the illustrative cases had successful clinical and radiographic outcome following deformity correction utilizing the anterior cervical osteotomy technique.
Conclusion
Anterior cervical osteotomy is a safe and effective technique for correction of rigid cervical deformities. Spine surgeons should be familiar with this technique to optimize clinical outcome in patients undergoing cervical deformity correction.
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.
Even though internal fixation has expanded the indications for cervical spine surgery, it carries the risks of fracture or migration, with associated potential life threatening complications. Removal of metal work from the cervical spine is required in case of failure of internal fixation, but it can become challenging, especially when a great amount of scar tissue is present because of previous surgery and radiotherapy.
Case presentation
We report a 16 year old competitive basketball athlete who underwent a combined anterior and posterior approach for resection of an osteosarcoma of the sixth cervical vertebra. Fourteen years after the index procedure, the patient eliminated spontaneously one screw through the intestinal tract via an oesophageal perforation and developed a severe dysphagia. Three revision surgeries were performed to remove the anterior plate because of the great amount of post-surgery and post-irradiation fibrosis.
Conclusions
Screw migration and oesophageal perforation after cervical spine surgery are uncommon potentially life-threatening occurrences. Revision surgery may be challenging and it requires special skills.
The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra.
Objectives
To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction.
Materials and methods
The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity.
Results
The general rules of reconstruction that should be applied in each particular situation are described.
Conclusions
Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.
A number of prominent surgical trials and clinical guidelines regard length of hospital stay and rates of daycase surgery as being of upmost importance following cholecystectomy. However, it is unclear whether these outcomes also matter to patients. This study aimed to identify the factors patients regard as most important when admitted with acute gallstone pathology.
Methods
A 41-item survey was produced by combining outcomes assessed in recent clinical trials with results from a preliminary patient questionnaire. This was then given out prospectively to patients presenting with acute gallstone pathology, prior to their cholecystectomy. Patients were asked to read an information sheet about laparoscopic cholecystectomy and then complete the survey, scoring each item out of 100 in terms of importance to them.
Results
Fifty-six patients completed the survey (43 females; median age 51 years). Diagnoses were: cholecystitis (28 patients), biliary colic (13), pancreatitis (10), common bile duct stones (3) and cholangitis (2). The top-scoring survey item was “long-term quality of life after surgery”, with a median value of 97 out of 100. Other high-scoring items included “cleanliness of the ward environment” and “pain control after surgery” (both 96). The lowest-scoring item was “being treated as a daycase” (54).
Conclusion
Patients with acute gallstone pathology view long-term quality of life after surgery as the most important factor and daycase surgery as the least important. These results should be considered when planning future surgical trials and clinical guidelines.
Lower urinary tract symptoms (LUTS) are common in middle-aged men and could be consequences of multiple etiologies responsible for bladder outlet obstruction (BOO), detrusor underactivity (DUA) and/or overactive bladder. When LUTS are suggestive of BOO secondary to benign prostatic hyperplasia, a surgical treatment can sometimes be consider. Even if multichannel urodynamic study (UDS) is currently the gold standard to properly assess LUTS, its use in non-neurogenic men is still a matter of controversy. Here, we aim to explore the evidence supporting or not the use of systematic multichannel UDS before considering an invasive treatment in men LUTS.
Methods
The debate was presented with a “pro and con” structure. The “pro” side supported the systematic use of a multichannel UDS before considering a surgical treatment in men LUTS. The “con” side successively refuted the “pro” side arguments.
Results
The “pro” side mainly based their argumentation on the poor correlation of LUTS and office-based tests with BOO or DUA. Furthermore, since a multichannel UDS could allow selecting men that will most benefit of a surgical procedure, they hypothesized that such an approach could reduce the overall morbidity rate and cost associated with. The “con” side considered that, in most cases, medical history and symptoms were reliable enough to consider surgery. Finally, they underlined the UDS limitations and the frequent lack of alternative to surgery in this context.
Conclusions
Randomized clinical trials are being conducted to compare these two approaches. Their results would help the urological community to override this debate.
We evaluated the trajectory and the entry points of anterior transpedicular screws (ATPS) in the cervicothoracic junction (CTJ).
Objective
This study aimed at investigating the feasibility of ATPS fixation in the CTJ.
Summary of background data
Application of an ATPS in the lower cervical spine has been reported; however, there were no reports exploring the feasibility of anterior transpedicular screw fixation in the CTJ.
Methods
CT scans were performed in 50 cases and multiplanar reformation was used to measure the related parameters on pedicle axis view at C6–T2. Transverse pedicle angle, outer pedicle width, pedicle axis length, distance transverse intersection point (DtIP), sagittal pedicle angle, anterior vertebral body height, outer pedicle height, and distance sagittal intersection point (DsIP) were measured. The prozone of CTJ was divided into three different regions, which were named as the “manubrium region”, the region “above” and “below” the manubrium. The distribution of the trajectory of sagittal pedicle axes was recorded in the three regions and the related data were statistically analyzed.
Results
There was no statistical difference in gender (P > 0.05). The transverse pedicle angle decreased from C6 (46.77° ± 2.72°) to T2 (20.62° ± 5.04°). DtIP increased from C6 to T2. DsIP was an average of 7.17 mm. The sagittal pedicle axis lines of the C6 and C7 were located in the region above the manubrium. T1 was mainly in the manubrium region followed by the region above the manubrium. T2 was mainly located in the manubrium region followed by the region below the manubrium.
Conclusion
Implantation of ATPS at C6, C7, and some T1 is feasible through the low anterior cervical approach, while it is almost impossible to approach T2 that way.
The impoverished West African country of Niger has high rates of obstetric fistula. We report a 6-month postoperative follow-up of 384 patients from the Danja Fistula Center and assess factors associated with operative success or failure.
Methods
The medical records of 384 women who had completed a 6-month follow-up after fistula surgery were reviewed. Cases were categorized as “easy,” “of intermediate complexity,” or “difficult” based on a preoperative points system. Data were analyzed using simple chi-squared statistics and logistic regression.
Results
The patients were predominantly of Hausa ethnicity (73%), married young (average 15.9 years), had teenage first pregnancies (average first delivery 16.9 years), and experienced prolonged labor (average 2.3 days) with poor outcomes (89% stillbirth rate). The average parity was four. Patients commonly developed their fistula during their first delivery (43.5%), but over half sustained a fistula during a subsequent delivery (56.5%). Prior fistula surgery elsewhere (average 1.75 operations) was common. The overall surgical success (“closed and dry”) was 54%. When the 134 primary operations were analyzed separately, the overall success rate was 80%. Increasing success was seen with decreasing surgical difficulty: 92% success for “easy” cases, 68% for “intermediate” cases, and 57% success for “difficult” cases. Success decreased with increasing numbers of previous attempts at surgical repair.
Conclusions
These data provide further evidence that clinical outcomes are better when primary fistula repair is performed by expert surgeons in specialist centers with the support of trained fistula nurses.
Since the late 1960s aesthetic surgery has also been a topic in the humanities and social sciences.
Objective
How is aesthetic surgery viewed from a cultural scientific perspective?
Material and methods
This article describes the evaluation of the surgical literature, literature on the humanities and social sciences, a discussion on narrative terminology and an analytical discourse on pictorial science and feminist history.
Results
The term “aesthetics” is a diffuse term, which is used in the cultural construction of policies also for human beauty, not for specific policies. In the surgical literature it is used with very different objectives, which leads to the fact that it does not describe any clearly differentiated category. References to artistic policies only provide surgery with rough guides and often serve the authorization of surgeons. In feminist criticism, aesthetic surgery is interpreted as (self)submission and in the more recent literature as a possibility for self-optimization. The recognition of aesthetics as cultural construction and the disclosure of one’s own working principles enables patients to have a greater self-determination.
To review relevant data for the management of esophageal perforation after anterior cervical surgery.
Methods
A case of delayed esophageal perforation after anterior cervical surgery has been presented and the relevant literature between 1958 and 2014 was reviewed. A total of 57 papers regarding esophageal perforation following anterior cervical surgery were found and utilized in this review.
Results
The treatment options for esophageal perforation after anterior cervical surgery were discussed and a novel management algorithm was proposed.
Conclusion
Following anterior cervical surgery, patients should be closely followed up in the postoperative period for risk of esophageal perforation. Development of symptoms like dysphagia, pneumonia, fever, odynophagia, hoarseness, weight loss, and breathing difficulty in patients with a history of previous anterior cervical surgery should alert us for a possible esophageal injury. Review of the literature revealed that conservative treatment is advocated for early and small esophageal perforations. Surgical treatment may be considered for large esophageal defects.
Surgical treatment of hematogenous pyogenic spondylitis and spondylodiskitis includes anterior debridement, stabilization, and fusion. Titanium mesh cage (TMC) has been advocated to immediately correct deformity and eradicate infection with low recurrence rates. There are no comprehensive reviews on TMC.
Purpose
To evaluate recorded information regarding surgical outcome with the use of TMC for treating patients with pyogenic spinal infection.
Study design
Comprehensive review.
Methods
The terms “titanium cage”, “spine”, “infection” were searched. A total of 486 peer-reviewed papers published from 2002 to 2012 were obtained from PubMed search. Fifteen Level IV articles with 363 patients were enrolled for consideration. Finally, 192 (53 %) patients who received TMC were eligible and included in this review. Age, comorbidities, indications for surgery, abscess formation, time lapsed between symptoms initiation and surgery, microbiology, radiological spine restoration, neurological outcome, and complications following surgery are evaluated.
Results
The average age at the index surgery was 57 years, range 15–85 years. The reported time lapsed from symptoms presentation to diagnosis varied significantly from 1 week to 2 years. On admission, there reported paravertebral and/or epidural abscess in 48 % and neurological impairment in 51 % of the patients. One hundred and seventy-seven comorbidities were recorded in 192 patients. Bone biopsy and culture revealed gram (+) bacteria in 71 %, gram (?) in 24 %, and multiple bacteria in 1 %, while it was negative in 3.1 % of the patients. TMC was most commonly (49 %) implanted in the lumbar spine. The follow-up observation following surgery averaged 26 months, range 10–116 months. Most of the studies reported decrease in segmental kyphosis and neurological improvement in incomplete lesions postoperatively. TMC was primarily revised for early dislodgment or cage misplacement in 3.2 % of the patients. Infection recurrence was recorded in two patients (1.3 %), but revision surgery needed in one (0.65 %) patient. Mortality was reported in 5.8 % of the patients.
Conclusions
TMC offers an advantageous and safe technique for spinal debridement and fusion for hematogenous spinal infection. TMC safeguarded medium-term spinal stability with low infection recurrence rates, which were independent form causative pathogen, age, and comorbidities.
