[Use of dalargin in the complex treatment of complicated injuries of the thoraco-lumbar segments of the spine]

In the present report there has been pursued an object of studying the efficiency of the preparation dalargine (synthetic preparation, analogous to encephaline) in case of unstable spine and spinal cord injuries. Under the observation there were 32 operated patients. Dalargine was administered endolumbally by 2 mg, dissolved in 2 ml of physiologic salt solution. The results were evaluated by several categories: locomotive function, sensitivity, pelvic organ function, pain, spasticity, trophic disturbances.

[Dumbbell type tumor of a nerve root treated surgically by vertical curvilinear approach]

A 42-year-old man was admitted for further examination of an abnormal shadow on the posterior mediastinum which was incidentally detected by a routine chest X-ray. Myelography followed by computerized tomographic scanning (CT) revealed that a dumbbell shaped tumor had developed in the paravertebral area adjacent to the vertebral canal through an intervertebral foramen. A vertical curvilinear incision centered at T-6 was made with the patient in a prone position. Total laminectomy or T-5 and T-6 and resection of the left 6th rib provided sufficiently wide exposure for a one-stage resection of the tumor. The dumbbell shaped tumor originated from the root of 6th spinal nerve but did not extend to the spinal cord. The extirpated tumor was diagnosed histologically as schwannoma. Because tumor location had been determined preoperatively by CT scanning after myelography, it was possible to perform complete extirpation of the tumor while avoiding the complications of laminectomy and unnecessary thoracotomy.

Treatment of spinal cord compression by epidural malignancy in childhood

Epidural spinal cord compression by a malignant tumor is a rare occurrence in children. Both the tumors involved and the extent of involvement of the vertebral column are different in children and adults. Often, the epidural tumor in a child is identified before significant spinal canal compromise has occurred, and these children frequently can be managed by radiation therapy and/or chemotherapy. There is a group of children, however, who have severe spinal canal encroachment by a tumor, as evidenced by a near complete or complete block on myelography. In this study, we report a group of patients with severe spinal cord compression, as documented by imaging studies. We compared the results of a decompressive laminectomy and subtotal tumor resection followed by adjuvant therapy with the results obtained with radiation therapy and/or chemotherapy alone. Thirty-three patients met the criteria for inclusion in the study. Twenty-six were treated with a laminectomy and adjuvant therapy, and 7 were treated without surgical intervention. With surgical therapy, 25 of 26 epidurals were either improved or stable, whereas 4 of 7 nonsurgical patients deteriorated. Especially notable was a decrease in pain in the operative patients immediately after their procedure. There was no surgical mortality or morbidity. The results of this study indicate that children with severe spinal cord compression as evidenced by a near complete or complete block on myelography or filling of 50% or more of the spinal canal on magnetic resonance imaging are best treated by a combination of surgical decompression and tumor removal followed by adjuvant therapy.

Minilaminotomy as an alternative to laminectomy or microdiskectomy: ten years' experience

Minilaminotomy as an alternative to microdiskectomy or standard laminectomy has been performed at two community hospitals on 1000 patients over a period of 10 years. The operative technique, employing simple prone positioning, a 4-cm incision, standard instruments, X-ray guidance, a fiberoptic head light, and 4.5 x binocular loupes, has not changed since 1986, when the initial series of 200 cases was published. The overall results in 800 additional patients continued to compare favorably to all reported series of microdiskectomy: minimal blood loss, less narcotic requirement, fewer days in the hospital, earlier return to normal activity, no wound infection, and low rate of second surgery.

Evaluation and treatment of intradural tumours located anterior to the cervicomedullary junction by a lateral suboccipital approach

Tumours located anterior to the cervicomedullary junction have been most commonly approached via one of two routes: anterior/transoral or posterolateral. Each of these surgical corridors can pose potential pitfalls. To circumvent these problems, a lateral suboccipital approach in conjunction with an upper cervical hemilaminectomy has been used. Selecting an appropriate surgical corridor between the lower cranial nerves (IX through XII), the vertebral artery, and the posterior inferior cerebellar artery has allowed satisfactory tumour removal. A three-dimensional picture of tumour location and relationship to surrounding neural and vascular structures is obtained preoperatively from computed tomography and magnetic resonance. Arteriography is essential to determine the origin, course, and relation of each vertebral to the tumour as well as the contribution of each vertebral to the basilar. In instances of abnormalities in the posterior circulation, evaluation of the carotid contribution to the basilar is crucial. The advantages of this approach are several. First, a direct view of the anterior surface of the lower brainstem und upper cervical cord is obtained. Second, surgery is undertaken in a sterile field in which the dura can be closed watertight. Third, neither mastoidectomy nor transposition of the vertebral artery is required. The major difficulty is the necessity to operate through narrow surgical corridors bounded by the lower cranial nerves, vertebral and posterior inferior cerebellar arteries, and the lower medulla and upper cervical cord. These structures provide the major obstacles to dissection as well as the primary causes of morbidity.

Intramedullary "holocord" oligodendroglioma: case report

Primary spinal cord oligodendrogliomas are rare tumours. Only 3 holocord cases have been reported in the literature. We present a primary intramedullary "holocord" oligodendroglioma in a 13 year-old male. Scoliosis was the initial symptom. Neurological deterioration prompted MRI, which demonstrated the lesion. Total removal was achieved. This case shows that meticulous surgery may obtain an optimal result in holocord oligodendrogliomas. 2 years after surgery, the young patient has made an excellent recovery.

[Operative therapy in tumor involvement of the spine]

We report on 56 patients, who underwent operative treatment of tumorous lesions of the spine. We indicated dorsal instrumentation in 14 cases, ventral tumorectomy in 11 cases and a combined dorsal and ventral instrumentation in 31 cases. The median survival time was 14.8 months. Reduction of pain and the improvement of the preexisting neurological symptoms were the most important postoperative factors. According to our follow-up study, the combined dorsal and ventral instrumentation seems to be the best method for an operative treatment of tumorous spine lesions.

Intraoperative dexamethasone irrigation in lumbar microdiskectomy

In 45 lumbar hemilaminectomy/microdiskectomy patients, a control group of 23 patients had the standard operative procedure. The remaining 22 patients were treated with intraoperative irrigation of long-acting dexamethasone before incision closure. Age, weight, gender ratio, mean postoperative hospital stay, mean in-hospital narcotics usage, and incidence of perioperative complications among the two groups were compared. Age and gender ratios were comparable, although the control group was significantly heavier in body weight than the steroid-irrigated group. The steroid-irrigated group had a significant reduction in hospitalization and a marked reduction in narcotics usage compared with the control group. Postoperative fever occurred in one patient in the steroid group. The control group had three postoperative complications. These preliminary observations suggest that dexamethasone irrigation during lumbar diskectomy is a safe and effective adjunct to surgical management.

Postlaminectomy ossified extradural pseudocyst. Case report

A large ossified spurious meningocele accompanied by recurrent lumbar disc herniation occurred 7 years after posterior intervention for laminectomy and discectomy in a 53-year-old man. The cyst wall, histologically composed of mature bone tissue, was sparsely covered with connective tissue and lined with fibrocyte- or fibroblast-like cells on the inside. The ossified pseudocyst was presumed to have originated from a minute defect in the dura mater which occurred at the time of the first operation.

Combined laminoplasty and posterolateral fusion for spinal canal surgery in children and adolescents

Spinal deformities, especially kyphosis and instability, after laminectomy for tumors and other diseases, are major clinical problems. Since 1981, combined laminoplasty and posterolateral fusion for the prevention of postlaminectomy spinal deformities was performed on eight male and two female patients aged two to 26 years (average, 13.9 years). The follow-up period was from six months to seven years and three months (average, three years and five months). Two patients died six and ten months postoperatively because of brain metastases (astrocytoma) and lung metastases (neuroblastoma), respectively. Good alignment with no instability of the cervical or thoracic spine was obtained for all patients, including the two who died. Laminoplasty combined with posterolateral fusion was found to be very effective in preventing the development of spinal deformities after spinal canal surgery for spinal cord tumors or other diseases in children and adolescents.

Diagnostic imaging and surgical treatment of dumbbell tumors of the mediastinum

We describe the diagnostic procedures and surgical approaches employed in 5 patients with dumbbell tumors of the mediastinum. Magnetic resonance imaging accurately described the existence and longitudinal extension of the intraspinal component of the tumor and assisted in choosing the appropriate surgical approach. Both the intrathoracic and intraspinal components of the tumor were resected at one time by a thoracic and neurosurgical team. We employed the Grillo technique three times and a separate laminectomy and thoracotomy approach. Magnetic resonance imaging proved the most useful diagnostic technique for suspected dumbbell mediastinal tumors. In our experience, the extended thoracotomy proposed by Grillo and co-workers worked well for small tumors involving only one foramen in which the intraspinal extension was limited to 2 to 3 cm, and when no more than two laminectomies were required. On the other hand, thoracotomy and a longitudinal paravertebral incision are preferable for larger tumors (more than 4 cm) involving more than one foramen in which the intraspinal extension exceeds 2 to 3 cm, for tumors requiring multiple laminectomy, and when bony infiltration is present.

Expansive laminoplasty for lumbar spinal stenosis

Expansive laminoplasty, a procedure used for cervical myelopathy, was carried out in 4 patients with degenerative lumbar spinal stenosis. The method was used in relatively young patients with severe low back and sciatic pain who had intraspinal ossification at multiple segments, with or without developmental spinal stenosis. The advantages of osteoplastic enlargement of the lumbar spinal canal with reinforcement of spinal stability are confirmed by our follow up of 2 to 5 1/2 years. The results were very satisfactory in each case. The indications and operative technique are described.

[Reconstruction instead of resection: laminotomy and laminoplasty]

Spinal instability and deformity have to be kept in mind when performing laminectomies. The procedure described (laminotomy) results in a stable bony reconstruction of the spinal canal, which in addition may be enlarged (laminoplasty): Laminotomy is performed by means of an oscillating saw just medial of the pedicles, preserving the yellow and interspinous ligaments. The laminotomy specimen is removed en bloc. It can be refixed by means of vitallium plates, bridging the corresponding laminae and pedicles.

Multiple thoracic disc herniations

Multiple thoracic disc herniation is a rare disease. There are only 12 cases reported in the literature. They were treated surgically. Two cases of multiple thoracic disc herniations subjected to laminectomy without discectomy are presented in this report.

Neurophysiologic monitoring during surgery of peripheral and cranial nerves, and in selective dorsal rhizotomy

Physiologic monitoring may warn of impending neural damage and intraoperative assessment may provide critical information used to direct the surgical procedure itself. Intraoperative techniques utilize methods modified from the diagnostic neurophysiologic laboratory. Simultaneous multimodality recording of different signal sources is of particular value for several types of procedures. Intraoperative studies must be tailored to each patient's clinical condition and to the specific surgical risks. Since studies have supported the benefits of intraoperative monitoring for peripheral nerve and cranial nerve surgery, monitoring is not likely to be subjected to the rigors of a randomized controlled study for these procedures.

Solitary spinal cord metastasis of Wilms' tumor

Wilms' tumor metastasis to the spinal cord is very rare at any age. We recently encountered a case of a 4-year-old girl, who had a solitary lumbar spinal cord metastasis about 1 year following the initial nephrectomy and an incomplete course of chemotherapy for a stage I Wilms' tumor. The patient recovered uneventfully after decompressive laminectomy, removal of the extradural spinal cord tumor, adjuvant chemotherapy, and radiotherapy according to the National Wilms' Tumor Study (NWTS)-IV protocol.

Use of Vicryl (polyglactin 910) mesh to limit epidural scar formation after laminectomy

A variety of substances have been used at laminectomy sites to prevent postoperative epidural scarring. Free grafts of autologous subcutaneous fat are commonly used both clinically and experimentally. The free fat grafts usually survive, but decrease in size by about 50%. Postoperatively, subcutaneous seroma has been observed with the use of fat grafts, as well as recurrent symptoms of neural compression by the graft that required additional operations. When compared to the use of free grafts after laminectomy in dogs, Vicryl mesh produced slightly more scarring, but consistently less than that observed in control animals. The Vicryl mesh was resorbed by a minimal chronic inflammatory response over about 45 days. Seven of 11 fat-grafted zones showed signs of necrosis, at times with a greater collection of inflammatory cells than that associated with the Vicryl mesh. Of the 4 fat-grafted zones that showed good survival, 2 had gross evidence of neural compression. No surgical zone treated with Vicryl mesh exhibited evidence of neural compression. In view of these results, the use of Vicryl mesh at laminectomy sites may be a safer method of limiting postoperative epidural scar formation.

Fat graft for the prevention of scar formation after laminectomy (macroscopic and microscopic findings in a case report)

Over recent years attempts have been made to prevent scar formation after laminectomy by placing biological and non-biological material between the dura mater and nervous structures and the paravertebral muscles. The author discusses his personal use of and preference for fat graft, and reports the surgical and histological findings in a patient submitted to surgery for a herniated disc 3 months previously.

Histological differences between rootlets sectioned during selective posterior rhizotomy by two surgical techniques

During selective posterior rhizotomy, for the treatment of spasticity in infantile cerebral palsy, the rootlets to be divided are chosen by the type of electromyographic response elicited by intraoperative electrical stimulation. Two different surgical techniques were used for exposing the lumbar roots. The first approach was to expose the conus medullaris through a T 12-L 1 laminectomy, while the other approach to the dorsal roots was distally in the cauda equina through a L 2-L 3 to S1 laminectomy. Although the clinical results obtained with either of them are not very different, there is anatomical evidence that suggests that the histological structure of the divided rootlets may be different in the two techniques. We designed our study to determine of a significant difference in the number of large myelinated fibers was found between rootlets divided close to the conus medullaris and those divided distally in the cauda equina. Two groups of five children with spasticity secondary to cerebral palsy where randomly designed to be operated upon by one of the techniques. The divided rootlets were processed with standard histological techniques and the large myelinated fibers were counted on enlarged (40 x) photomicrograph of the rootlet. A significantly (p less than 0.001) larger number of large myelinated axons was found in the rootlets dissected and divided close to the conus medullaris.

Clinical results of the foraminotomy as described by Frykholm for the treatment of lateral cervical disc herniation

During the period between 1980 and 1989, foraminotomy as described by Frykholm was performed on 230 patients suffering from lateral cervical disc herniation with exclusively radicular symptomatology. Following an average postoperative period of 3.5 years, the subjective alleviation of symptoms and the neurological symptomatology were examined in 161 patients. The mortality was nil; the morbidity was 5%, with a rapid full recovery in 4% of cases. In addition to the intra-operative findings of soft and hard disc lesions, a third group with combined findings was created. Excellent or good results were obtained in 98% of the patients with soft disc lesions, in 91% of the patients with combined findings, and in 84% of those with hard disc lesions. In 93% of the cases, there was a complete or marked improvement of paresis; in 82%, of the sensory deficits. A total of 92% of the patients were able to carry out their previous occupation to the full extent. The high efficacy of foraminotomy and the low incidence of complications described in previous studies was thereby confirmed.

[Surgically stabilizing "complex therapy" of unstable injury of the lower cervical spine]

Numerous assessments of the stability of screws within the cervical vertebral bodies after strong mechanical loading showed that spondylodesis can be considered as a stable fixation whether it is performed as a ventral, dorsal of combined procedure. Luxation fractures of the cervical spine, however, often do not only show lesions of the osteo-ligamentary structures, but are also accompanied by lesions of the spinal marrow. In addition to surgical measures, the self-destructing fermentative processes occurring in the mechanically injured spinal marrow have to be and can be eliminated or at least reduced by chemotherapy. The immediate simultaneous chemotherapeutic and surgical treatment is presented as "complex therapy" and recommended because of its good results.

A neurosurgical approach to far-lateral disc herniation. Technical note

A technique for exposing far-lateral intervertebral disc herniations without disrupting the facet is described. This technique is a simple modification of the standard neurosurgical approach.

Far-lateral disk herniation: treatment by automated percutaneous diskectomy

Automated percutaneous diskectomy has certain advantages over other surgical approaches to the treatment of far-lateral disk herniation; primarily, the procedure can be performed under local anesthesia without soft-tissue disruption. We describe four patients with far-lateral herniations who were successfully treated with the procedure.

[Destruction of the entry zone of the posterior roots combined with selective rhizotomy in pain syndromes due to a lesion of the brachial plexus]

Pain syndromes caused by traumatic preganglionic avulsion of roots forming the brachial plexus are among the most severe forms which do not respond to nonoperative treatment. According to the data in the literature and our experience, operation for destruction of the posterior root entry zones is the most substantiated and effective method for the management of these pain syndromes. In this operation, however, poor results and recurrences are encountered in some cases. In view of this, the authors suggest combining destruction of the entry zone of the posterior roots with posterior selective rhizotomy. These combined operations are indicated in prevalent spreading of the pain syndrome in the limb dermatomes related to the torn roots. Operations were carried out on 85 patients. They are followed up since 1982. Among 48 patients treated by destruction of the posterior root entry zones 40 had a good result, i.e., practically complete regression of the pain syndrome occurred in 5 patients, the result was moderate--the pain syndrome abated approximately by 50%, in 3 patients the result was poor, the pain syndrome regressed by 25% and less. Destruction of the entry zones of the posterior root was combined with posterior selective rhizotomy in 37 patients. In 35 of them the result was good, in 2--moderate. Thus, destruction of the entry zones of the posterior roots in combination with posterior selective rhizotomy is a substantiated and effective method for the management of the pain syndrome in traumatic affections of the brachial plexus.

Vertebro-PICA aneurysms: midline suboccipital approach and laminectomy of the atlas

Vertebro-PICA aneurysms represent a particular technical challenge because of the extremely narrow operative field and the presence of numerous vital neural and vascular structures. The lack of exposure still remains the limiting factor in most cases. During the 9-year period from January 1980 to October 1989, 8 vertebro-PICA aneurysms have been treated microsurgically. Of these, 2 underwent a pure suboccipital approach while 6 underwent a midline suboccipital approach with deliberate removal of the arch of the atlas in the park bench position. Seven patients did well and regained full activities while one patient died from complications related to vasospasm with brainstem infarction. One patient developed symptomatic obstructive dilation of the fourth ventricle requiring ventriculo-cisternostomy. The authors recommend the midline suboccipital approach with deliberate C1-laminectomy in ventrolateral decubitus for vertebro-PICA aneurysms. The main advantages are: constant access to the proximal vertebral artery, less medullary retraction in ventrally located aneurysms, improved exposure of the laterobulbar cisterns and the lateromedullary and tonsillar segments of the PICA, thus facilitating dissection of the aneurysm.

Synchronous vertebral decompression and posterior stabilization in the treatment of spinal malignancy

Thirty-four patients with metastatic tumors of the spinal column exhibiting vertebral collapse and posterior element disease were treated by a single-stage operation combining decompression of the vertebral body with posterior spinal instrumentation. Attention is drawn to the use of computed tomographic scanning in planning the operative approach. The indications for surgery were neurological deficit in 32 patients and pain in 2; 14 patients received preoperative radiotherapy. Of the 21 patients who were nonambulant preoperatively, 67% walked again, 21% regained sphincter control, and 68% had less pain. The surgical mortality was 12%; wound infection and dehiscence occurred in 15%. These results indicate that a single-stage decompression and posterior stabilization may improve neurological function dramatically in patients with malignant cord compression. The operative morbidity and mortality is comparable to that of laminectomy.

Posterior extensive simultaneous multisegment decompression with posterolateral fusion for cervical myelopathy with cervical instability and kyphotic and/or S-shaped deformities

From June 1978 to May 1988, posterior decompression with posterolateral fusion was performed at Tenri Hospital on 63 cases of cervical myelopathy with instability and/or malalignment including kyphotic and/or S-shaped deformities. Among 46 cases followed up for more than 1 year, 41 cases (89.1%) improved; 21 cases (45.7%) were rated excellent, six (13%), good; 14 (30.4%), fair; one (2.2%), unchanged; and four (8.7%), poor. On x-ray examination, bone consolidation at the bone implanted area was satisfactory in 30 cases (65.2%). Cervical instability disappeared at 55 cervical interspaces of 40 cases (78.6%). Displacement at unstable interspace disappeared or improved at 49 of 61 cervical interspaces (80.3%). Although cervical kyphosis or S-shaped deformity could not be improved, accelerated progression of these deformities appeared to be prevented.

[Surgical tactics in gunshot wounds of the spine and spinal cord]

Based on literature data and personal experiences with treatment of patients with this pathology the author considers the sequence of diagnostic measures, describes his experience with contrast examinations of the vertebral canal in the acute period. The volume of the infusion-transfusion therapy was determined. Details of the surgical tactics were outlined with a reference to the character of the injury. A brief analysis of lethality during first six months after injury is given.

[Diagnosis and treatment of dermal sinus in children]

The article acquaints the reader with a rare developmental anomaly of the spine which hazards life seriously. Seven cases with dermal sinus are analysed. All of the patients were admitted to the clinic with an erroneous diagnosis; the duration of the disease ranged from one to 14 years during which some of them underwent surgical interventions to no purpose. Variants of the clinical course of dermal sinus are shown and concomitant skin changes and spinal anomalies, which make the diagnosis obvious, are described. The role of survey radiography, fistulography, and ultrasonic examination in the diagnosis of dermal sinus is determined. Arguments are given in favour of obligatory operative treatment of the anomaly immediately after the diagnosis is established and operative techniques are recommended.

Dome-like expansive laminoplasty for the second cervical vertebra

The second cervical vertebra (C2) is in a pivotal position for the alignment and stability of the cervical vertebrae as a whole. Since its spinal canal is wider at the cranial and narrower at the caudal end, a dome-like excision of the inner side of the spinal canal from the caudal toward the cranial end results in the decompression of the lesion, preserving the dorsal part of the C2. The authors performed this C2 dome-like expansive laminoplasty on 33 patients (25 cases of the ossification of the posterior longitudinal ligament, six of developmental spinal canal stenosis, and two of spondylosis) and kept them under follow-up observation, which ranged from 1 to 7 years (mean, 3.5 years). The result was satisfactory in terms of the decompression and stability of the cervical vertebrae: even 5 years after the operation, no osteogenesis was noted in the expanded spinal canal to induce compression again. It thus may be concluded that this method is good enough to replace conventional laminectomy.

[Reconstructive surgery in complicated trauma of the thoracic and lumbar segments of the spine]

The article presents an analysis of reconstructive operations on the spinal cord in 176 patients with traumas of the thoracic and lumbar parts of the vertebral column. The operative treatment in acute period consisted in end-to-end anastomosis of the horse's tail roots, in late period of trauma disease of the spinal cord--in reconstruction of the spinal cord defects with intercostal nerves by the type of "collateral anastomosis" or free transplants from the peripheral nerve. The operations performed resulted in an improvement of sensitivity, movement, functions of pelvic organs in part of the patients.

[Lumbar disk hernia: microsurgery--yes or no?]

Microsurgery has been performed in about three-quarters of 5,000 patients operated on since 1973 for herniation of a lumbar disc. The findings obtained in two groups of patients who had undergone primary surgery, in the one group by classical methods, in the other by microsurgery, are compared. The two groups were similar in respect of age and sex distribution, localisation of the discal hernia, duration of signs and symptoms and follow-up time. Results classified "very good" were seen more often in the microsurgery group, where no improvement or postoperative aggravation of the signs was relatively rare. The difference compared with the group treated by conventional surgery was mainly in respect of appearance of a postoperative vertebral syndrome, and not so much with regard to the radicular pain syndrome and radicular motor deficits. Unlike some other researchers, we found no difference between the two groups in respect of frequency of local reoperation or of spondylodiscitis. In patients whose disc hernia is mainly of a soft consistency, unilateral and at a single level only, microsurgery requires a shorter access, involves less damage to tissues, allows a better haemostasis and good surgical visualisation. The operation is minimally invasive, the area involved more or less extensive depending on the individual pathology. Magnification under good lighting is indicated in all cases.

[A case of dumb-bell-like neurilemmoma of the posterior mediastinum]

A 56 year-old female was pointed out an abnormal shadow on chest X-ray film for the lung cancer screening study. Chest X-ray film showed a round mass shadow at the right superior mediastinum. Chest CT scan revealed the mass was in the paravertebral area abutting on the 2nd thoracic vertebral body and had extended into the intervertebral foramen. Preoperative diagnosis was a dumb-bell-like neurogenic tumor. Operation was carried out by posterior approach in the prone position. At first thoracotomy was done by removing the paravertebral portion of the 2nd and 3rd ribs, and then hemilaminectomy was added. Both the intrathoracic and intraforminal portions of the tumor were completely exposed, and excised. Pathological examination demonstrated the tumor was a typical neurilemmoma originating from the 2nd intercostal nerve. When a neurogenic tumor of the posterior mediastinum has an intraspinal extension, a posterior approach by a simultaneous thoracotomy and laminectomy will be useful to remove the tumor at one sitting.

Intervertebral disc herniation at D3-4 Case report

The authors report a case of intervertebral disc herniation at D3.4 which they removed surgically from a posterior approach. They emphasize the extreme rarity of this localisation. The hernia was calcified, extruded and displaced posterolaterally and medially, causing pressure on the anterior aspect of the spinal cord with neurological signs of the pareto-spastic type. The operation was successful, with relief of pain and regression of the neurological symptoms.

[Surgical treatment of herniation of lumbar intervertebral disks]

An analysis of outcomes of treatment of 288 patients has shown that using the microsurgical technique when removing hernias of lumbar disks allows to perform more sharing manipulations with the roots, vessels and disk, gives favorable results of treatment. Good outcomes were obtained in 68 patients, satisfactory--in 12 patients, bad--in 2 patients. The period of the intrahospital treatment became shorter.

L4-5 degenerative spondylolisthesis. The results of treatment by decompressive laminectomy without fusion

The results of the treatment of L4-5 degenerative spondylolisthesis by decompressive laminectomy and partial facetectomy without fusion are presented. Patients who met the following criteria were studied: 1) A slip of at least 10%; 2) No compensation/litigation issues involved; 3) No prior surgery; and 4) Follow-up of at least 18 months. Twenty-four patients with an average follow-up of 34 months (range, 18 to 71 months) are reported. The average preoperative slip measured 7 mm (17%; range, 4-12 mm). Sixteen patients, including all patients less than 60 years of age, underwent preoperative supine lateral flexion-extension radiographs for evaluation of instability. No patient had greater than 2 mm of increase in slip on flexion-extension testing. During decompression, the structural integrity of the pars interarticularis and facet joints are preserved. There were 20 good, three fair, and one poor results. The average postoperative slip measured 8 mm (20%; range, 4-11 mm), and no patient had an increase in slip of greater than 4 mm. In the absence of objective instability on preoperative flexion-extension lateral radiographs in L4-5 degenerative spondylolisthesis, decompressive laminectomy with preservation of the structural integrity of the pars interarticularis and articular processes does not require routine spinal fusion and produced satisfactory clinical results.

[Current trends in surgery of the spine]

This paper is based on an invited lecture given at the SICOT 87 meeting in Munich. The topics discussed include: selective spinal arteriography in the management of tumours, which enables definition of the vascular supply of the cord and of the tumour and may facilitate preoperative embolisation; MRI, which allows visualisation of both bone and soft tissue; the pathogenesis of transverse fractures of the upper sacrum; the management of malunion of fractures of the thoracolumbar spine by a three stage procedure, in which an initial posterior approach allows osteotomy and definition of the pedicle, a second anterior procedure for correction of the deformity by appropriate resection of the vertebral body, and a final posterior operation in which internal fixation is carried out using pedicular screws and plates. Operation on extradural tumours of the spine is usually palliative for metastases and aims to decompress the cord by laminectomy, stabilising the spine by osteosynthesis. Total removal of a vertebral body may be needed; percutaneous resection is being used increasingly for lumbar disc resection; the development of the Cotrel-Dubousset system and the use of long transpedicular plates allows better reduction of the deformity in scoliosis.

[Lumbar diskectomy without or with spondylodesis? Revival of an old dilemma]

Indications for spine fusion in combination with removal of a lumbar intervertebral disc are not as well defined or as widely accepted. Extreme opinions have been expressed on both side of this issue, but it seems unreasonable that every segment should be fused after removal of a disc or that none should be. The indication for fusion or for no fusion is often based on the specialist to whom the patient is referred. Orthopedists perform often fusion, neurosurgeons rarely. The problem is not the superiority of combined operation or simple disc excision, but the right indication for one or other procedure. It is clear that for the patient with acute disc displacement with leg-pain as the predominant symptom, simple laminectomy and disc excision will yield good results in most cases. Basically the are two indications for combined operation: the first of this is a strong history of instability troubles prior to the disc prolapse; second indication is the bilateral hemilaminectomy and discectomy, which can lead the spine quite instable. Indication for secondary spinal fusion are: 1) the presence after disc excision of complain of pain in the back with relatively little sciatic radiation, sometimes as intermittent claudication; 2) the overproduction of scar tissue is seen very often in instable segment after disc excision and partial or complete facetectomy. Decompression of the nerve root and fusion may result in a great benefit. Finally we recall the possibility to perform simple fusion in flexion without excision of the disc and without laminectomy in cases with median protrusion of the disc, seen in CT in patients with chronic low back pain and inconstant radicular pain radiation. We describe our own technic of combined operation.

Cranial subluxation of the odontoid process in rheumatoid arthritis

In eighteen patients who had long-standing severe rheumatoid polyarthritis, cranial subluxation of the odontoid process was caused by erosion and collapse of both the occipitocervical and the atlantoaxial facet joints. In five of the patients, the subluxation caused impairment of cranial nerves. One patient was tetraparetic. Six patients had a posterior fusion of the spine; of these, three also had laminectomy of the atlas. Operative treatment seemed to arrest the subluxation, but there was appreciable functional improvement in only four of the six patients. During an average of four years of follow-up, in the twelve conservatively treated patients, the cranial subluxation of the odontoid process progressed, on average, from 8.6 to 10.5 millimeters.

Critical analysis of extensive cervical laminectomy

Conventional extensive laminectomy has been widely performed to reduce spinal cord compression, and is greatly facilitated by the use of an air drill. Laminectomy is recognized, however, as the occasional cause of problems after surgery, such as spinal instability or deformity, acceleration of spondylotic change, constriction of the dura mater caused by extradural scar formation, and lack of posterior bony protection for the spinal cord. In an effort to eliminate these negative aspects of conventional laminectomy, a surgical technique called suspension laminotomy has been used. Fifty-five patients treated with conventional extensive laminectomy and 55 others treated with suspension laminotomy were followed up clinically and compared. Flexibility and alignment of the cervical spine were assessed by plane radiographs, and dural configuration by computed tomographic scans. Neurologic improvement was also evaluated. Decrease of spinal movement after laminectomy was observed, notably during extension, probably as a result of functional insufficiency of paraspinal muscles. The incidence of postoperative spinal deformity was lower and the relief of dural constriction better in the patients treated with suspension laminotomy than in those treated with conventional laminectomy. Neurological recovery was significantly better in fully decompressed cases than in insufficiently decompressed cases.

Diagnostic and therapeutic technology assessment. Percutaneous lumbar diskectomy for herniated disks

Percutaneous diskectomy, particularly using Onik's nucleotome, has promise. It is too early, however, to decide if the percutaneous approach to reducing lumbar disk herniation will achieve a permanent place in the surgical armamentarium. Nevertheless, it is clear that patient selection is important. At the minimum, an adequate trial of conservative therapy must be followed by diagnostic imaging that documents a herniation that can be treated in this fashion and correlates with the patient's neurological signs and symptoms. If free fragments are found, a laminectomy of some sort will be required to remove the offending material. Patients who are at risk for general anesthesia or may be allergic to chymopapain were mentioned by the panel as special subpopulations for whom the procedure may be indicated despite the lack of wide experience with it. The rapidly rising popularity of automated percutaneous lumbar diskectomy via the nucleotome will hopefully be followed in the near future with larger studies with long-term follow-up.

[Pathogenetic aspects of decompression interventions in complicated injuries of the spine]

The paper is based on the analysis of the results of clinical, pathophysiological and roentgenological examinations and on the data of surgical verification of the causes of neurologic deficiency in 163 patients. Proceeding from the condition that the principal operations in cases of complicated fractures of the spine are decompression and stabilization interventions, the authors have elaborated a system of such interventions and stated the main principles of choice of the methods of decompression. In particular they have proposed the following extents of decompression interventions: decompression of the contents of the vertebral canal, decompression of the contents of the dural sac and intratrunk decompression of the spinal cord. The methods of decompression interventions may be correction, correction and stabilization, resection and resection and stabilization. The proposed scheme allows to eliminate the existing terminological discord and provides for objective evaluation of the efficiency of the intervention.

Limited surgical discectomy and microdiscectomy. A clinical comparison

This study was performed in an attempt to determine if there was any clinical or cost benefit of microdiscectomy over surgical discectomy. Each patient was asked to rate his pain or neurologic deficit on a scale from 1 to 10 (1 = no pain or deficit and 10 = the most severe pain or deficit). Thirty patients underwent microdiscectomy. Average preoperative back pain was rated 8.03 and leg pain 8.53. Preoperative numbness was rated 5.29 and weakness 5.38. The median time off work preoperatively was 4 weeks. The mean hospitalization was 2 days, and a postoperative median of 8 weeks for returning to work. Average follow-up was 17.4 months. Mean back pain was 1.8, with 57% having no back pain at follow-up. Mean leg pain at follow-up was 1.3, with 67% having no leg pain. Numbness was rated 0.97, with 85% having none at follow-up. Weakness was rated 1.4, with 76% having none at follow-up. Thirty-four patients underwent surgical discectomy. Average preoperative back pain was rated 7.56 and leg pain 9.32. Preoperative numbness was rated 6.94 and weakness 5.88. The median time off work preoperatively was 6 weeks. The mean hospitalization was 7 days, and a median of 7 weeks postoperative before returning to work. Average follow-up was 18.5 months. The mean pain rating for back pain was 1.09, with 74% having no back pain at follow-up. The average leg pain was 1.09, with 74% having no leg pain at follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Cervical laminoplasty (Hattori's method). Procedure and follow-up results

Posterior decompression plus posterior reconstruction (laminoplasty) is a useful surgical method for treatment of cervical compressive myelopathy. There are many laminoplasty procedures. This paper describes the Z-shaped laminoplasty developed by Hattori in 1971, and presents a clinical follow-up of the authors' experience with 130 patients. The procedure involves grinding the laminae down with an air drill and making a Z-shaped cut into the thinned laminae without excising the laminae. This technique enlarges the spinal canal. The purpose of this technique is to decompress the spinal cord and at the same time maintain clinical stability. Postoperative results were satisfactory without any major complication. Follow-up study was conducted in 78 cases with a minimal follow-up period of more than 2 years. Satisfactory clinical results were maintained for long periods postoperatively, and the enlargement of the spinal canal was well maintained as demonstrated on follow up X-ray study.

[Hemilaminectomy in the removal of spinal cord tumors]

From experience in operations on 19 patients the authors show that hemilaminectomy provides for an adequate approach to spinal cord tumors of various localization and histostructure. In all 10 patients benign extradural tumors were totally removed. Removal of intramedullary tumors is also possible. Some advantages of hemilaminectomy over routine laminectomy are pointed out.

The surgical management of cervical spinal stenosis, spondylosis, and myeloradiculopathy by means of the posterior approach

No firm statistical evidence exists establishing the superiority of the anterior or the posterior approach in the management of spondylostenosis, although some sense of order is evolving. In general the consensus suggests that in spondylostenosis, the anterior approach may be preferred for disc or segmental osteophyte intrusions limited to one or two levels. Laminectomy is the preferred procedure in patients with a narrowed canal and multiple level involvement. The surgeon's personal preference and experience remains the dominant factor. Patients with congenital stenosis involving all of the major segments, with or without superimposed developmental changes, require more extensive laminar decompression with proper attention to the craniocervical junction where anomalies may occur. The success of laminectomy is dictated by the preservation of cervical lordosis. In patients with major dorsally located abnormalities such as hyperlordosis, shingling, and arthrosis with hypertrophy of the yellow ligaments, posterior decompression is essential. Subsequent stabilization is rarely required with proper surgical and postoperative care. Both an anterior and posterior approach may be indicated in unique circumstances of spondylostenosis complicated by subluxation and instability.