胸椎后纵韧带骨化的临床特点及治疗策略

目的回顾研究手术治疗胸椎后纵韧带骨化症(OPLL)的临床特点及治疗方法。方法1991至2005年手术治疗胸椎OPLL55例,男19例,女36例;年龄35～73岁,平均51.9岁。均伴有脊髓损害。手术方式包括单纯椎管后壁切除术34例、前方OPLL切除减压术15例以及前后路联合手术6例。结果55例中36例(65.5%)合并胸椎黄韧带骨化(OLF),18例(32.7%)合并颈椎OPLL。单纯发生于上胸椎的OPLL13例(23.6%),中胸椎12例(21.8%),下胸椎及胸腰段17例(30.9%),广泛分布者13例(23.6%)。43例获得随访,平均随访时间47.1个月(6～168个月)。37例神经功能有改善,改善率为76.6%,无改善2例,加重4例。前方入路获随访者13例,其中3例症状加重,余改善率平均为82.9%(42.9%～100%)。后路椎管后壁切除术获随访者25例,1例无改善,1例加重,余改善率平均为72.6%(22.2%～100%)。前后路联合手术获随访5例,1例无改善,余改善率平均为83.9%。结论胸椎OPLL常合并胸椎OLF及颈椎OPLL。上胸椎OPLL合并颈椎管狭窄可一期行颈后路单开门及上胸椎椎管后壁切除术。两个节段以内的OPLL且不合并有造成脊髓压迫的胸椎OLF可行前路OPLL切除减压术,否则行后路椎管后壁切除术。单节段的OPLL合并胸椎OLF可行前后路联合手术。     

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.     

Oesophageal perforation following cervical spinal surgery with instrumentation: A case report on primary repair with pedicled sternocleidomastoid muscle flap reinforcement and review of the literature

Anterior cervical spine fusion and stabilisation is an entrenched procedure for managing traumatic spinal fracture. Oesophageal perforation by spinal hardware after cervical spinal fusion surgery is a rare complication that can be life-threatening. We present a case with a complication of oesophageal perforation following anterior and posterior spinal fusion with instrumentation performed 7 years ago with a review of literature.     

Pitfalls of spinal deformities associated with neurofibromatosis in children

A study of 116 patients younger than 12 years of age conclusively diagnosed as having neurofibromatosis was undertaken to determine the incidence of significant orthopedic problems. Deformities of the spine comprised the most common skeletal problem. Seventy-four patients (64%) had spinal deformities. Forty-six patients were treated by posterior spinal fusion. Ten required exploration for pseudarthrosis; six were found to have pseudarthrotic defects in the fusion mass. Eight patients had more kyphosis than scoliosis. Only three patients with kyphoscoliosis obtained a solid posterior spinal fusion after multiple surgical procedures. Anteroposterior and lateral roentgenograms of the cervical spine are recommended at the time of initial evaluation of all spinal deformities. Four patients had severe cervical spine deformities, only one of whom was initially identified as having a cervical spine disorder while under treatment for scoliosis. Three of these patients were seen by other surgical services for neck masses. Following removal of posterior elements, the osseous structures were unstable. Only one patient developed spondylolisthesis. Because of the exceedingly high incidence of pseudarthrosis and spinal instability following attempts at spinal fusion, certain guidelines have evolved for the management of these deformities. High-volume computed tomographic myelography in the prone, lateral, and supine positions or magnetic resonance imaging should be performed on all patients prior to surgical treatment. Anterior disc excision and bone graft followed by posterior arthrodesis with instrumentation are indicated if the kyphotic angle is greater than 50 degrees or if scoliosis is greater than 80 degrees. Even combined anterior and posterior arthrodesis operations did not guarantee successful permanent spinal stability in young patients with neurofibromatosis.     

Single-staged double anterior and posterior spinal reconstruction for rigid adult spinal deformity: a report of four cases.

BACKGROUND CONTEXT: Sequential anterior/posterior spinal reconstruction for rigid adult spinal deformity has become a standard operative option. Single-staged double anterior/posterior spinal reconstruction for rigid double major curvature has not been reported in the literature to date. PURPOSE: To report a previously unreported approach for rigid double major curvature of the thoracic and thoracolumbar spine with emphasis on indications and avoiding complications. STUDY DESIGN: Four cases of sequential double anterior/posterior spinal reconstruction are reported. METHODS: Single-staged double anterior spinal reconstruction was performed on four adult patients with rigid thoracic and thoracolumbar scoliosis. Osteotomies were performed by the anterior and posterior approach and followed by posterior instrumentation. A right thoracotomy and left retropleural/retroperitoneal approach was performed for each patient followed by the posterior approach in a single stage. RESULTS: Only one complication occurred, a posterior dural tear, treated without incident. A high level of patient satisfaction and return to activity was noted. Solid arthrodesis with good coronal and sagittal balance occurred in all patients. CONCLUSIONS: Single-staged double anterior/posterior spinal reconstruction for rigid adult deformity can be performed safely and effectively with good patient outcome. The procedure should be reserved only for those patients with severe double major curvature of similar magnitude and rigidity.     

Aneurysmal bone cyst of the second cervical vertebrae causing multilevel upper cervical instability

OBJECTIVE: Aneurysmal bone cyst (ABC) is a rare expansile osteolytic lesion of bone comprising proliferating vascular tissue lining blood-filled cystic cavities. ABCs occur most frequently in patients under age 20 and are uncommon after 30 years of age. Three to 20% of cases occur in the spine, and upper cervical involvement is rare. Lesions may grow rapidly and attain considerable size. When involving the spine, ABCs may result in instability and neurologic compromise, making prompt diagnosis and treatment imperative. We present a report of a 6-year-old child with an ABC of the second cervical vertebrae causing atlantoaxial and C2-C3 instability, treated successfully with curettage, decompression, and anterior and posterior arthrodesis with posterior instrumentation. METHODS: The patient underwent a staged procedure consisting of posterior instrumentation from occiput to C4 and curettage of the lesion followed by anterior cervical discectomy and fusion of C2-C4. The diagnosis, surgical treatment, and outcome of the case are described and relevant literature reviewed. RESULTS: The patient sustained no lasting neurologic deficits and was disease-free at 3 years of follow-up. CONCLUSIONS: ABC is a rare but potentially devastating cause of upper cervical spine instability. Prompt detection and treatment with curettage, decompression, and fusion can produce a satisfactory result and prevent spinal cord injury.     

Bone morphogenetic protein in complex cervical spine surgery: A safe biologic adjunct?

The advent of recombinant DNA technology has substantially increased the intra-operative utilization of biologic augmentation in spine surgery over the past several years after the Food and Drug Administration approval of the bone morphogenetic protein (BMP) class of molecules for indications in the lumbar spine. Much less is known about the potential benefits and risks of the “off-label” use of BMP in the cervical spine. The history and relevant literature pertaining to the use of the “off-label” implantation of the BMP class of molecules in the anterior or posterior cervical spine are reviewed and discussed. Early prospective studies of BMP-2 implantation in anterior cervical spine constructs showed encouraging results. Later retrospective studies reported potentially “life threatening complications” resulting in a 2007 public health advisory by the FDA. Limited data regarding BMP-7 in anterior cervical surgery was available with one group reporting a 2.4% early (< 30 d) complication rate (brachialgia and dysphagia). BMP use in the decompressed posterior cervical spine may result in neurologic or wound compromise according to several retrospective reports, however, controlled use has been reported to increase fusion rates in select complex and pediatric patients. There were no cases of de novo neoplasia related to BMP implantation in the cervical spine. BMP-2 use in anterior cervical spine surgery has been associated with a high early complication rate. Definitive recommendations for BMP-7 use in anterior cervical spine surgery cannot be made with current clinical data. According to limited reports, select complex patients who are considered “high risk” for pseudoarthrosis undergoing posterior cervical or occipitocervical arthrodesis or children with congenital or traumatic conditions may be candidates for “off-label” use of BMP in the context of appropriate informed decision making. At the present time, there are no high-level clinical studies on the outcomes and complication rates of BMP implantation in the cervical spine.     

内固定应用于脊柱结核治疗的安全性探讨

目的 探讨内固定应用于脊柱结核治疗的安全有效性.方法 1985年4月至2005年5月,51例脊柱结核患者行一期或二期病灶清除、植骨及前路或后路钉棒系统内固定术,男25例,女26例;年龄2～80岁,平均44.8岁.病灶分布:C3～S1,其中颈椎6例,胸椎19例,胸腰段16例,腰骶椎10例.单节段6例,双节段30例,三节段11例,四节段及以上4例.神经功能按Frankel分级:B级2例,C级8例,D级36例,E级5例.所有患者术前均行至少两周的抗结核治疗.手术清除脓液,刮除干酪样坏死物,摘除椎间盘,用骨刀切除坏死骨质直至有正常血运的骨组织.使用内固定Luque 6例,Z-plate 3例,TSRH 8例,Ventrofix 5例,Kenada 4例,Moss-Miami 5例,Isola 6例,CDH 3例,Caspaz 2例,C-D 2例,Zielke、Dick、Oriell、Ozion、Zephir、Tenor、USS各1例.术后继续三联抗结核治疗1年.结果 术后患者腰背部疼痛明显缓解,术前有神经损害的患者术后均有不同程度的恢复.1例术后复发.经清创及调整药物治疗后未再复发.1例胸椎结核术后伤口延迟愈合,出现脓肿窦道,经长期换药后愈合.1例T10椎体结核,术前双下肢肌力3级,术后降为0级,经保守治疗2周后双下肢肌力逐渐恢复至术前水平.所有患者均获得随访,随访时间3.2～23.5年,平均813年.所有患者植骨均融合.24例术前伴后凸畸形的患者,后凸角从入院时平均34.17°矫正至术后平均10.45°,末次随访矫形平均丢失3.2°.结论 内固定应用于脊柱结核的治疗安全、有效.     

The surgical management of congenital kyphosis and kyphoscoliosis.

STUDY DESIGN: A retrospective study of surgery for congenital kyphosis and kyphoscoliosis. OBJECTIVE: To assess the effectiveness of different types of spine surgery in the management of congenital kyphosis and kyphoscoliosis. SUMMARY OF BACKGROUND DATA: Congenital kyphosis and kyphoscoliosis are much less common than congenital scoliosis but potentially more serious, because these curves can progress rapidly and Type I deformities can lead to spinal cord compression and paraplegia. No one operative procedure can be applied to all types and sizes of deformity. The method of surgical treatment depends on the age of the patient, the type and size of the deformity, and the presence or absence of spinal cord compression causing a neurologic deficit. METHODS: Sixty-five patients with a congenital kyphosis (n = 14) or kyphoscoliosis (n = 51) were treated by five different methods of spine arthrodesis: prophylactic posterior arthrodesis before age of 5 years (n = 11), posterior arthrodesis after age 5 years without instrumentation (n = 26) and with instrumentation (n = 12), combined anterior and posterior arthrodesis without instrumentation (n = 7) and with instrumentation (n = 9). Six patients had preoperative lower limb spastic paraparesis caused by spinal cord compression. The mean age at surgery was 9 years 6 months (range, 11 months to 25 years), and all 65 patients were observed for a minimum of 2 years (mean 6 years 6 months, range 2 to 18 years). Fifty-seven patients reached skeletal maturity. RESULTS: A posterior arthrodesis performed before the age of 5 years resulted in a gradual reduction of the kyphosis by a mean 15 degrees in 9 of the 11 patients, followed up for a mean of 11 years, whose initial kyphosis was less than 55 degrees. Patients treated after the age of 5 years by a posterior arthrodesis followed by cast application had poor correction and a high incidence of pseudarthrosis. This was not significantly improved by the addition of posterior instrumentation. For curves greater than 60 degrees, the most successful results were achieved by an anterior spinal release and arthrodesis with strut graft correction followed by posterior arthrodesis with instrumentation (if possible). CONCLUSION: All patients with a Type I or Type III congenital kyphosis or kyphoscoliosis should be treated by a posterior arthrodesis before the age of 5 years and before the kyphosis exceeds 50 degrees. A kyphosis that does not reduce to less than 50 degrees as measured on the lateral spine radiograph made with the patient supine requires an anterior release and arthrodesis with strut grafting followed by posterior arthrodesis with instrumentation (if possible).     

Bone screw osteosynthesis of dens fractures. Technical surgical aspects and results

Twenty cases of Anderson and d'Alonzo type II and "shallow" type III fractures of the dens were treated by anterior screw fixation: the results were reviewed and compared with previously published results obtained in series of such fractures treated non-surgically, by posterior C1-C2 arthrodesis or anterior screw fixation. The complication rate of 25% in our series is comparable to those reported in a previously published review of studies on posterior wiring for C1-C2 arthrodesis. Three of our cases in which complications occurred (15%) were recognized in retrospect as inappropriate for the use of this technique: in one of these patients there was confirmed non-union, and the other two had markedly osteoporotic bone. A meticulous operative technique and the use of special instruments may improve the success rate. The anterior screw fixation method, however, allows for maximal post-treatment cervical motion, since it makes arthrodesis unnecessary and minimizes the degree and duration of postoperative external immobilization. It also reduces the iatrogenic trauma since an anterior rather than a posterior cervical approach is taken and supplementary bone grafting is not required. Anterior screw fixation of type II dens fractures appears to be the ideal method of treatment for these injuries, but since it is difficult to perform its use should be limited only to experienced spine surgeons with access to the appropriate surgical facilities.     

Posterior Vertebral Column Resection for VATER/VACTERL Associated Spinal Deformity: A Case Report

The VATER/VACTERL association is a syndrome notable for congenital vertebral malformations, anal atresia, cardiovascular anomalies, tracheoesophageal fistula, esophageal atresia, and renal or limb malformations. Vertebral malformations may include the entire spectrum of congenital spinal deformities, including kyphosis, as was seen in this case. A 14-year-old girl presented to our institution with severe rigid sagittal deformity in the thoracolumbar spine that had recurred following three prior spinal fusion surgeries: the first posterior only, the second anterior and posterior, and the third a posterior only proximal extension. These surgeries were performed to control progressive kyphosis from a complex failure of segmentation that resulted in a 66° kyphosis from T11 to L3 by the time she was 9 years old. Our evaluation revealed solid arthrodesis from the most recent procedures with resultant sagittal imbalance, and surgical options to restore balance included anterior and posterior revision spinal fusion with osteotomies, multiple posterior extension osteotomies with circumferential spine fusion, and posterior vertebral column resection with circumferential spine fusion. She was advised that multiple posterior extension osteotomies would likely be insufficient to restore sagittal balance in the setting of solid arthrodesis from anterior and posterior surgery, and that the posterior-only vertebral column resection would provide results equivalent to revision anterior and posterior surgery, without the morbidity of the anterior approach. She successfully underwent posterior vertebrectomy and circumferential spinal fusion with instrumentation and is doing well 2 years postoperatively. Severe rigid sagittal deformity can be effectively managed with a posterior-only surgical approach, vertebrectomy, and circumferential spinal fusion with instrumentation. An erratum to this article can be found at     

Surgical correction of spinal deformities following spinal cord injury occurring in childhood

This article reports on the surgical treatment of 14 consecutive patients with paralytic spinal deformities secondary to spinal cord injury occurring in childhood. Eleven patients underwent a posterior spinal fusion and three patients underwent a combined anterior and posterior spinal arthrodesis. Luque rods were used in all but one patient. The spinal fusion extended to the sacrum in 10 patients. No patient developed postoperative wound infections or medical complications. Four patients (28.6%) who underwent initially a posterior spinal arthrodesis developed pseudarthrosis. This was treated successfully by a combined anterior and posterior spinal fusion in two patients. The remaining patients underwent a revision posterior spinal fusion with recurrence of the nonunion in one patient. A combined anterior and posterior spinal arthrodesis could be considered the treatment of choice for patients with severe deformities who can tolerate anterior surgery. If pseudarthrosis develops following posterior spinal fusion, this can be best treated by a combined anterior and posterior revision procedure with instrumentation.     

颈前路手术早期并发症的防治

目的总结分析颈椎前路手术早期并发症，探讨其防治策略。方法1998年11月-2006年12月，采用前路手术治疗颈椎疾患363例，其中男268例，女95例；年龄17～79岁，中位年龄50．6岁。颈椎病224例，颈椎间盘突出症39例，颈椎外伤87例，颈椎肿瘤9例，颈椎结核4例。采用前路减压、自体髂骨融合治疗48例，前路减压、植骨融合联合带锁钢板内固定132例，前路减压、钛网植入联合带锁钢板内固定183例。结果术后282例获随访3个月～5年，平均1年11个月。手术相关并发症23例，发生率为8．16％。喉上神经损伤3例，经禁流质饮食及补液治疗，术后3～7d症状消失；喉返神经损伤2例，行发音训练，3个月后恢复正常；脊髓损伤1例，经抗炎脱水治疗，下肢肌力6个月后恢复至术前水平；硬脊膜撕裂2例，经皮肤肌肉严密缝合，切口适度加压包扎后愈合；内固定相关并发症10例，其中1例螺钉拔出，因吞咽困难行再次手术，余行对症治疗、头颈胸石膏固定，3～18个月后固定节段融合：颈部血肿形成4例，其中1例因抢救方法不当死亡；植骨区及创口感染1例。结论充分的术前准备、熟悉颈前路解剖以及严格规范化操作，是预防颈椎前路手术早期并发症的关键。     

The double approach in recent cervical injury. Indications apropos of 15 cases and a review of the literature

The authors presented 15 cases of recent spinal cervical injuries treated with double approach procedure. Neurological disorders were variable but instability was severe in all cases. In 11 cases with severe neurological disorders the anterior procedure was made immediately, in 4 cases secondary with one or two sequences. In all cases was made discectomy and arthrodesis or removal vertebral body and arthrodesis associated with a posterior stabilization using generally bilateral plates of Roy-Camille. The functional spinal results were excellent with immediate or early mobilisation. In 4 cases with incomplete quadriplegia was observed favorable recovery. In 9 cases with complete quadriplegia two excellent recovery are obtained.     

Biomechanical evaluation of methods of posterior stabilization of the spine and posterior lumbar interbody arthrodesis for lumbosacral isthmic spondylolisthesis. A calf-spine model

In order to evaluate biomechanically the efficacy of four types of posterior instrumentation for the stabilization of isthmic spondylolisthesis of the lumbosacral spine, mechanical non-destructive cyclic testing in axial compression, flexion, extension, and rotation was performed on six fresh lumbosacral spines from calves. Each segment contained four motion segments, including the lumbosacral junction. Isthmic spondylolisthesis was created by sectioning the pars interarticularis of the sixth lumbar vertebra and all posterior ligaments between the fifth and sixth lumbar levels. Eight constructs were tested sequentially: (1) the intact spine, (2) the destabilized spine, (3) the spine fixed with Harrington double-distraction rods, (4) the spine treated with transpedicular Cotrel-Dubousset instrumentation with a transverse approximating device, (5) the spine treated with Steffee transpedicular screws and plates, (6) the spine treated with posterior lumbar interbody arthrodesis, (7) the spine treated with Cotrel-Dubousset instrumentation and posterior lumbar interbody arthrodesis, and (8) the spine treated with Steffee instrumentation and posterior lumbar interbody arthrodesis. One motion segment was involved in each construct, except for the spine that was fixed with Harrington instrumentation, which involved three segments. Strain across the supraspinous and anterior longitudinal ligaments was measured with two extensometers that were attached at the spondylolisthetic level and at the intact motion segments adjacent to the fixed level. Harrington instrumentation was the least rigid construct under any type of loading except axial compression (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Iatrogenic fractures in ankylosing spondylitis—a report of two cases

Study design: Two cases of intraoperative, iatrogenic cervical spine fractures in patients with ankylosing spondylitis are reported. Objective: To describe the uncommon complication of iatrogenic cervical spine fractures occurring during spine surgery in patients with ankylosing spondylitis. Summary of background data: To our knowledge, this is the first report on this rare complication. Methods: A 39-year-old patient (1) with ankylosing spondylitis was operated on for cervical stenosis due to C1/2 anterolisthesis. Fifteen hours postoperatively, he developed acute quadriplegia. MRI revealed a fracture/dislocation of C6 on C7 and compression of the spinal cord at this level. Revision was performed with decompression and instrumentation from the occiput to T3. A 55-year-old patient (2) with ankylosing spondylitis and thoracic hyperkyphosis underwent a correction procedure consisting of costotransversectomy, anterior cage implantation at T8/9, and posterior instrumentation from T4 to L1. Halo traction was temporarily applied for correction. At the end of the operation, with the patient still under anesthesia, increased mobility of the cervical spine was noticed. Emergent MRI revealed a fracture of the anterior structures of C6/7. Posterior instrumentation from C5 to T1 was then performed. Results: Quadriplegia persisted in patient 1 until his death secondary to further complications. Patient 2 was mobilized without any neurologic deficits. The fracture healed in good alignment. Conclusions: Iatrogenic fractures of the cervical spine during surgery in ankylosing spondylitis patients are a rare but potentially severe complication. Early diagnosis and therapy are necessary before dislocation, cord compression, and subsequent neurologic impairment occur.     

Delayed subarachnoid hemorrhage following failed odontoid screw fixation

Iatrogenic vascular injury is a rare but potentially devastating complication of cervical spine instrumentation. The authors report on a patient who developed an anterior spinal artery pseudoaneurysm associated with delayed subarachnoid hemorrhage after undergoing odontoid screw placement 14 months earlier. This 86-year-old man presented with spontaneous subarachnoid hemorrhage (Fisher Grade 4) and full motor strength on neurological examination. Imaging demonstrated pseudarthrosis of the odontoid process, extension of the odontoid screw beyond the posterior cortex of the dens, and a pseudoaneurysm arising from an adjacent branch of the anterior spinal artery. Due to the aneurysm's location and lack of active extravasation, endovascular treatment was not attempted. Posterior C1-2 fusion was performed to treat radiographic and clinical instability of the C1-2 joint. Postoperatively, the patient's motor function remained intact. Almost all cases of vascular injury related to cervical spine instrumentation are recognized at surgery. To the authors' knowledge, this is the first report of delayed vascular injury following an uncomplicated cervical fixation. This case further suggests that the risk of this phenomenon may be elevated in cases of failed fusion.     

Posterior compact Cotrel-Dubousset instrumentation for occipitocervical, cervical and cervicothoracic fusion

The authors report on 32 consecutive patients with instability at the craniocervical, cervical and cervicothoracic regions suffering from various pathologies, who were treated with posterior instrumentation and fusion using the posterior hooks-rods-plate cervical compact Cotrel-Dubousset (CCD) instrumentation alone or, in three patients, in combination with anterior operation. The patients were observed postoperatively for an average of 31 months (range 25-44 months) and evaluated both clinically and radiographically using the following parameters: spine anatomy and reconstruction, sagittal profile, neurologic status, functional level, complications and status of arthrodesis. All patients but one (who died) achieved a solid arthrodesis based on plain and flexion/extension roentgenograms. Cervical lordosis (skull-C7) and cervicothoracic kyphosis (C7-T2) was improved by instrumentation towards a physiological lateral curve by an average of 33% (P<0.05) and 28% (P<0.05) respectively. Anterior vertebral olisthesis was reduced in the craniocervical and cervicothoracic region, by 73% and 90% respectively. At final follow-up there was an improvement of the neurologic Frankel status by an average of 1.2 grades and of myelopathy in 75% of the operated patients. Good to excellent functional results were seen in 77% of the operated patients, while acute and chronic pain was reduced by an average of 2.4 grades, on a scale of 0-3, in operated patients. No neurovascular or pulmonary complications arose from surgery. There was no significant change in lateral spine profile and olisthesis at the latest follow-up evaluation. There were no instrument-related failures. One patient requested hardware removal in the hope of reducing postoperative pain in the cervicothoracic region. The poor and fair results were related to the lack of improvement of neurologic impairment and myelopathy. The results of this study demonstrate that cervical CCD instrumentation applied in the region of the skull to the upper thoracic region for various disorders is a simple and safe instrumentation that restores lateral spine alignment, improves the potential for a solid fusion and offers sufficient functional results in the vast majority of the operated patients. However, the use of hooks in spinal stenosis is contraindicated.     

Perioperative complications of posterior lumbar decompression and arthrodesis in older adults

BACKGROUND: Lumbar arthrodesis is commonly done in elderly patients to treat degenerative spine problems. These patients may be at increased risk for complications because of their age and associated medical conditions. In this study, we examined the rates of perioperative complications associated with posterior lumbar decompression and arthrodesis in patients sixty-five years of age or older. METHODS: We reviewed the hospital records of ninety-eight patients who were sixty-five years of age or older when they had a posterior decompression and lumbar arthrodesis with instrumentation, between 1993 and 1995, to treat degenerative disease of the spine. The average age was seventy-two years (range, sixty-five to eighty-four years). RESULTS: Perioperative complications occurred in seventy-eight patients. Twenty-one patients had at least one major complication, and sixty-nine had at least one minor complication. Forty-nine patients had more than one complication. The most common major complication was wound infection (prevalence, 10%), and the most common minor complication was urinary tract infection (prevalence, 34%). The complication rate increased with older age, increased blood loss, longer operative time, and the number of levels of the arthrodesis. CONCLUSIONS: Surgeons should be vigilant about perioperative complications in elderly patients treated with multi-level lumbar decompression and arthrodesis with instrumentation. Elderly patients should be made aware that they are at increased risk for surgical complications because of their age. Attention should be paid to controlling blood loss and limiting operative time.     

Simultaneously anterior decompression and posterior instrumentation by extrapleural retroperitoneal approach in thoracolumbar lesions

Background:

Anterior decompression with posterior instrumentation when indicated in thoracolumbar spinal lesions if performed simultaneously in single-stage expedites rehabilitation and recovery. Transthoracic, transdiaphragmatic approach to access the thoracolumbar junction is associated with significant morbidity, as it violates thoracic cavity; requires cutting of diaphragm and a separate approach, for posterior instrumentation. We evaluated the clinical outcome morbidity and feasibility of extrapleural retroperitoneal approach to perform anterior decompression and posterior instrumentation simultaneously by single “T” incision outcome in thoracolumbar spinal trauma and tuberculosis.

Patients and Methods:

Forty-eight cases of tubercular spine (n = 25) and fracture of the spine (n = 23) were included in the study of which 29 were male and 19 female. The mean age of patients was 29.1 years. All patients underwent single-stage anterior decompression, fusion, and posterior instrumentation (except two old traumatic cases) via extrapleural retroperitoneal approach by single “T” incision. Tuberculosis cases were operated in lateral position as they were stabilized with Hartshill instrumentation. For traumatic spine initially posterior pedicle screw fixation was performed in prone position and then turned to right lateral position for anterior decompression by same incision and approach. They were evaluated for blood loss, duration of surgery, superficial and deep infection of incision site, flap necrosis, correction of the kyphotic deformity, and restoration of anterior and posterior vertebral body height.

Results:

In traumatic spine group the mean duration of surgery was 269 minutes (range 215–315 minutes) including the change over time from prone to lateral position. The mean intraoperative blood loss was 918 ml (range 550–1100 ml). The preoperative mean ASIA motor, pin prick and light touch score improved from 63.3 to 74.4, 86 to 94.4 and 86 to 96 at 6 month of follow-up respectively. The mean preoperative loss of the anterior vertebral height improved from 44.7% to 18.4% immediate postoperatively and was 17.5% at final follow-up at 1 year. The means preoperative kyphus angle also improved from 23.3° to 9.3° immediately after surgery, which deteriorated to 11.5° at final follow-up. One patient developed deep wound infection at the operative site as well as flap necrosis, which needed debridement and removal of hardware. Five patients had bed sore in the sacral region, which healed uneventfully. In tubercular spine (n=25) group, mean operating time was approximately 45 minutes less than traumatic group. The mean intraoperative blood loss was 1100 ml (750–2200 ml). The mean preoperative kyphosis was corrected from 55° to 23°. Wound healing occurred uneventful in 23 cases and wound dehiscence occurred in only 2 cases. Nine out of 11 cases with paraplegia showed excellent neural recovery while 2 with panvertebral disease showed partial neural recovery. None of the patients in both groups required intensive unit care.

Conclusions:

Simultaneous exposure of both posterior and anterior column of the spine for posterior instrumentation and anterior decompression and fusion in single stage by extra pleural retroperitoneal approach by “T” incision in thoracolumbar spinal lesions is safe, an easy alternative with reduced morbidity as chest and abdominal cavities are not violated, ICU care is not required and diaphragm is not cut.