Perioperative management of a patient with Coffin-Lowry syndrome complicated by severe obesity: A case report and literature review

RATIONALE

Coffin-Lowry syndrome (CLS) is a rare inherited disease with specific clinical features, such as mental retardation, facial dysmorphism, and cardiac abnormality. In particular, the characteristic facial features of CLS, including retrognathia and large tongue, are associated with difficult ventilation and/or intubation, which is a serious problem of anesthesia management. However, case reports on anesthesia management of CLS are very limited as there are only two published English reports till date. In this case report, we discuss anesthetic and postoperative considerations in patients with CLS, focusing on difficult airway management, and summarize past reports including some Japanese articles.

PATIENT CONCERNS

A 25-year-old man with CLS was planning to undergo laminectomy because of progressive quadriplegia caused by calcification of the yellow ligament. We suspected difficulty in airway management because of several factors in his facial features, short thyromental and sternomental distances in computed tomography, severe obesity, and sleep apnea syndrome.

DIAGNOSES

Difficult airway was suspected. However, because of mental retardation, awake intubation was considered difficult.

INTERVENTIONS

We selected bronchofiberscope-guided nasotracheal intubation, maintaining spontaneous breathing under moderate sedation with a propofol target-controlled infusion.

OUTCOMES

Airway management was safely performed during anesthesia induction.

LESSONS

In many patients with CLS, difficult intubation was reported, and sedation or slow induction maintaining spontaneous breathing was mainly selected for anesthesia induction. Spontaneous breathing should be maintained during anesthesia induction in case of CLS patients.

Spinal intramedullary tuberculoma following pulmonary tuberculosis: A case report and literature review

RATIONALE

Spinal intramedullary tuberculoma (IMTB) is a rare disease that accounts for 1 to 2/100,000 patients with tuberculosis. We presented a case with pulmonary tuberculosis and concurrent IMTB at C3 to C5 level and reviewed the recent case series and discussed the diagnosis, treatment, and outcome.

PATIENT CONCERNS

A 33-year-old male had concurrent pulmonary TB and IMTB at the C3 to C5 level. He had quadriplegia (muscle power 0 at 4 limbs) and sensory loss below C5 level. He also had incontinence, anal tone loss, and paradoxical respiratory pattern.

DIAGNOSIS

Spinal magnetic resonance imaging (MRI) showed a 25 11mm intramedullary lesion at C3/C4 level. Under the impression of IMTB, he underwent surgery.

INTERVENTION

We performed C3 to C5 laminectomy and en bloc removal of the tumor. The patient kept receiving anti-TB medications after the surgery.

OUTCOME

His 4 limbs muscle power had improved but could not be liberated from the endotracheal tube, so tracheostomy was performed. Muscle power gradually increased to 3 points in his upper limbs and to 2 points in his lower limbs. Sensation in his 4 limbs gradually improved as well.

LESSONS

IMTB is a rare disease that should be treated with a combination of medication and surgery. For patients with prominent spinal cord compression and neurological symptoms, early operation to remove the tumor is necessary.

Five-year follow up results of posterior decompression and fixation surgery for delayed neural disorder associated with osteoporotic vertebral fracture

Usually, after osteoporotic vertebral fracture (OVF), bone healing follows a normal clinical course leading to bone union with conservative treatment using a brace. However, some patients with OVF do not undergo the normal fracture healing process for a few months, possibly leading to delayed union and/or pseudoarthrosis. In these cases, we performed posterior surgery with combined decompression, vertebroplasty, and posterior spinal fusion with spinal instrumentation. This study aimed to determine the clinical results of posterior surgery for delayed neural disorder secondary to OVF over a 5-year follow-up.Forty-one Japanese patients who had posterior surgery for delayed paralysis secondary to OVF were enrolled in this study. All patients were followed for ≥5 years (mean, 67 months; range, 61-86 months). Patients comprised 12 men and 29 women with an average age of 76.3 ± 6.2 years (range 63-87 years) at the time of operation. We performed posterior fixation from 2 levels above to 1 level below the decompression and vertebroplasty as an all in one procedure. Vertebral height index (VHI) and kyphotic angle (KA) were evaluated on radiogram. For clinical symptoms, a visual analog scale of back and leg pain and the Frankel classification and Japanese Orthopaedic Association scores were used.During the operation and perioperative period, no serious complications occurred. In all patients, symptoms improved within 1 month and were maintained for 5 years postoperatively. In all patients, VHI and KA improved after surgery; however, reduction losses of 7.7% of VHI and 23% of KA were recognized. Five of 41 patients required reoperation due to adjacent vertebral fracture (AVF) and recollapse of the vertebral body.Operation time and blood loss were acceptable, even for elderly patients. In all patients, alignment and subjective symptoms improved. However, reoperation owing to AVF and recollapse was necessary within 1 year in 5 of 41 (12%) patients. Careful follow-up is required within 1 year after surgery for OVF.

Extreme proximal junctional kyphosis-a complication of delayed lambdoid suture closure in Hajdu-Cheney syndrome: a case report and literature review

PURPOSE

To describe the manifestations, surgical treatment, and potential complications of Hajdu-Cheney syndrome (HCS), and the management of these complications.

METHODS

The clinical presentation, management and outcome of HCS with severe osteoporosis and open skull sutures is presented, together with a literature review.

RESULTS

A 20-year-old female with HCS underwent posterior occipitocervical fusion for symptoms of progressive basilar invagination. Because of delayed lambdoid suture closure, the stiff fusion construct lead to increased suture distraction, most notably in the upright (suture-open) position, with relief in the supine (suture-closed) position. This was successfully remedied with extension of the fusion construct anteriorly over the skull vertex to the frontal bones.

CONCLUSIONS

In patients with HCS and other conditions with delayed suture closure, the surgeon must be cognizant of the presence of mobility at the suture lines, and consider extending the fusion construct anteriorly over the skull vertex up to the frontal bones. Because of significant osteoporosis in these syndromes, multiple fixation points and augmentation with bone graft are important principles.

Vertebral column decortication for the management of sharp angular spinal deformity in Pott disease: Case report

RATIONALE

Extremely sharp angular spinal deformity of healed tuberculosis can be corrected by vertebral column resection (VCR). However, the VCR techniques have many limitations including spinal column instability, greater blood loss, and greater risk of neurologic deficit.

PATIENT CONCERNS

We described a new spinal osteotomy technique to collect sharp angular spinal deformity in Pott disease. A 52-year-old woman presented with back pain and gait imbalance.

DIAGNOSIS

The kyphosis of healed tuberculosis was diagnosed based on history and imaging examinations.

INTERVENTION

A new posterior VCR was designed to treat this disease.

OUTCOMES

The neurological function improved from Japanese Orthopedic Association scale 3 to 7. The back pain and neurological function were significantly improved. The Oswestry Disability Index decreased from 92 to 34. There was also a significant decrease in back pain visual analog scale from 9 to 2.

LESSONS

For cases with extremely severe Pott kyphotic deformity, the technology of modified VCR offers excellent clinical and radiographic results.

Predictive validity of the ACS-NSQIP surgical risk calculator in geriatric patients undergoing lumbar surgery

The risk calculator of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) has been shown to be useful in predicting postoperative complications. In this study, we aimed to evaluate the predictive value of the ACS-NSQIP calculator in geriatric patients undergoing lumbar surgery.A total of 242 geriatric patients who underwent lumbar surgery between January 2014 and December 2016 were included. Preoperative clinical information was retrospectively reviewed and entered into the ACS-NSQIP calculator. The predictive value of the ACS-NSQIP model was assessed using the Hosmer-Lemeshow test, Brier score (B), and receiver operating characteristics (ROC, also referred C-statistic) curve analysis. Additional risk factors were calculated as surgeon-adjusted risk including previous cardiac event and cerebrovascular disease.Preoperative risk factors including age (P = .004), functional independence (P = 0), American Society of Anesthesiologists class (ASA class, P = 0), dyspnea (P = 0), dialysis (P = .049), previous cardiac event (P = .001), and history of cerebrovascular disease (P = 0) were significantly associated with a greater incidence of postoperative complications. Observed and predicted incidence of postoperative complications was 43.8% and 13.7% (±5.9%) (P < .01), respectively. The Hosmer-Lemeshow test demonstrated adequate predictive accuracy of the ACS-NSQIP model for all complications. However, Brier score showed that the ACS-NSQIP model could not accurately predict risk of all (B = 0.321) or serious (B = 0.241) complications, although it accurately predicted the risk of death (B = 0.0072); this was supported by ROC curve analysis. The ROC curve also showed that the model had high sensitivity and specificity for predicting renal failure and readmission.The ACS-NSQIP surgical risk calculator is not an accurate tool for the prediction of postoperative complications in geriatric Chinese patients undergoing lumbar surgery.

Clinical and radiographic outcomes of bilateral decompression via a unilateral approach with transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis with stenosis

BACKGROUND CONTEXT

Laminectomy with posterior lumbar interbody fusion (PLIF) has been shown to achieve satisfactory clinical outcomes, but it leads to potential adverse consequences associated with extensive disruption of posterior bony and soft tissue structures.

PURPOSE

This study aimed to compare the clinical and radiographic outcomes of bilateral decompression via a unilateral approach (BDUA) with transforaminal lumbar interbody fusion (TLIF) and laminectomy with PLIF in the treatment of degenerative lumbar spondylolisthesis (DLS) with stenosis.

STUDY DESIGN

This is a prospective cohort study.

PATIENT SAMPLE

This study compared 43 patients undergoing BDUA+TLIF and 40 patients undergoing laminectomy+PLIF.

OUTCOME MEASURES

Visual analog scale (VAS) for low back pain and leg pain, Oswestry Disability Index (ODI), and Zurich Claudication Questionnaire (ZCQ) score.

METHODS

The clinical outcomes were assessed, and intraoperative data and complications were collected. Radiographic outcomes included slippage of the vertebra, disc space height, segmental lordosis, and final fusion rate. This study was supported by a grant from The National Natural Science Foundation of China (81572168).

RESULTS

There were significant improvements in clinical and radiographic outcomes from before surgery to 3 months and 2 years after surgery within each group. Analysis of leg pain VAS and ZCQ scores showed no significant differences in improvement between groups at either follow-up. The mean improvements in low back pain VAS and ODI scores were significantly greater in the BDUA+TLIF group than in the laminectomy+PLIF group. No significant difference was found in the final fusion rate at 2-year follow-up. The BDUA+TLIF group had significantly less blood loss, shorter length of postoperative hospital stay, and lower complication rate compared with the laminectomy+PLIF group.

CONCLUSIONS

When compared with the conventional laminectomy+PLIF procedure, the BDUA+TLIF procedure achieves similar and satisfactory effects of decompression and fusion for DLS with stenosis. The BDUA+TLIF procedure appears to be associated with less postoperative low back discomfort and quicker recovery.

Surgical treatment of a paraspinal abscess with osteomyelitis and spinal cord compression in a rabbit

CASE DESCRIPTION A 16-month-old neutered male Continental Giant rabbit (Lepus curpaeums) was referred for evaluation of a 7-day history of acute-onset, progressive, symmetric paraparesis. CLINICAL FINDINGS On initial examination, the rabbit was nonambulatory, and results of neurologic examination were consistent with a lesion affecting the T3-L3 spinal cord segments. Thoracic radiography showed irregular widening of the left T11-12 articular process joint. Marked dorsolateral and lateral extradural spinal cord compression with contrast enhancement of the adjacent epaxial muscles was evident on MRI images of the spine. TREATMENT AND OUTCOME A left-sided T11-T12 hemilaminectomy was performed, which revealed an abnormal and hypertrophic T11-12 articular process joint and an osteolytic lesion communicating with the vertebral canal. Copious purulent material causing marked spinal cord compression was evident, and the surgical site was lavaged extensively with sterile (0.9% NaCl) saline solution. Results of aerobic, anaerobic, and enriched bacteriologic cultures of swab specimens obtained from the surgical site were negative. Histologic analysis of biopsy samples revealed chronic purulent osteomyelitis, myositis, and fasciitis with necrosis, fibrosis, and dystrophic mineralization. The rabbit was discharged 48 hours after surgery. Ten weeks after surgery, the rabbit was ambulatory with mild paraparesis. On telephone follow-up 21 months after surgery, the owners indicated that the rabbit was healthy and expressed satisfaction with the treatment and outcome. CLINICAL RELEVANCE Paraspinal abscess with vertebral canal involvement should be considered as a differential diagnosis for rabbits with clinical signs of progressive T3-L3 myelopathy. Outcome for the patient of the present report suggested that surgical treatment including decompression and debridement can result in a favorable long-term outcome.

C2 Bone Erosion Secondary to Iatrogenic Pseudomeningocele: A Case Report and Description of a Novel Surgical Technique

BACKGROUND

Pseudomeningoceles are a rare cause of bone erosions. Development of such erosions in the C2 vertebral body and the odontoid process can lead to life-threatening instability. Treatment options to regain stability include atlantoaxial and occipitocervical fusion. For patients with a history of Chiari decompression and large C2 lesions, common fusion techniques are not always feasible. In addition, fusion surgery sacrifices physiologic motion and is therefore a disabling procedure, especially for young and active patients.

CASE DESCRIPTION

We report a novel combined open operative and subsequent minimal invasive filling technique of several instable osteolytic/cystic areas within the C2 vertebra of a 28-year-old woman. The underlying cause for the lesions was a pseudomeningocele communicating with the vertebral body. This was an incidental finding 15 years after foramen magnum decompression with C1 and partial C2 laminectomy for Chiari malformation. Novel treatment included open posterior surgery with total laminectomy of the remaining C2 arch and refilling the odontoid with viscous beta tricalcium phosphate and polymethylmethacrylate bone cement. Postoperative 6- and 12-month follow-up computed tomography imaging showed a stable incorporation of the filling.

CONCLUSIONS

Life-threatening fractures at the occipitocervical junction are rare and often are due to high-impact trauma. Osteolytic changes at those bone compartments are a potential cause for pathologic fractures during normal daily activities. In this case, increased pressure on the bone due to a pseudomeningocele resulted in slow bone loss without symptoms. A novel combined technique of bone filling was applied successfully to stabilize the C2 vertebral bone.

Spinal extradural arteriovenous fistula with intradural drainage: three surgical cases with long-term follow-up

Spinal extradural arteriovenous fistulas (SEDAVF) with intradural drainage are uncommon vascular lesions that cause venous congestive myelopathy. We present three SEDAVF with intradural drainage treated with surgical disconnection of the intradural drainage via a single level laminectomy, followed by transarterial embolization (TAE) with Onyx if spontaneous thrombosis of the extradural fistula did not occur spontaneously. All patients improved their neurological condition and no congestive myelopathy recurrence was noted after mean follow-up of 84 months. We believe that SEDAVF with intradural drainage constitute a specific entity that should be included in the classifications of spinal arteriovenous malformations.

Use of a non-invasive surgical skin closure device in dogs following dorsolateral hemilaminectomy

The ZipLine 16 surgical skin closure device (ZipLine 16; Zipline Medical, Campbell, California, USA) provides noninvasive surgical wound closure. This prospective study investigated its use in dogs undergoing a dorsolateral hemilaminectomy. Although the device produced normal appositional healing compared with controls, unacceptable traumatic dermatitis that is likely related to the device adhesive was noted after removal.

Minimally invasive decompression surgery for lumbar spinal stenosis with degenerative scoliosis: Predictive factors of radiographic and clinical outcomes

There is ongoing controversy regarding the most appropriate surgical treatment for lumbar spinal stenosis (LSS) with concurrent degenerative lumbar scoliosis (DLS): decompression alone, decompression with limited spinal fusion, or long spinal fusion for deformity correction. The coexistence of degenerative stenosis and deformity is a common scenario; Nonetheless, selecting the appropriate surgical intervention requires thorough understanding of the patients clinical symptomatology as well as radiographic parameters. Minimally invasive (MIS) decompression surgery was performed for LSS patients with DLS. The aims of this study were (1) to investigate the clinical outcomes of MIS decompression surgery in LSS patients with DLS, and (2) to identify the predictive factors for both radiographic and clinical outcomes after MIS surgery. 438 consecutive patients were enrolled in this study. Inclusion criteria was evidence of LSS and DLS with coronal curvature measuring greater than 10°. The Japanese Orthopaedic Association (JOA) score, JOA recovery rate, low back pain (LBP), and radiographic features were evaluated preoperatively and at over 2 years postoperatively. Of the 438 patients, 122 were included in final analysis, with a mean follow-up of 2.4 years. The JOA recovery rate was 47.6%. LBP was significantly improved at final follow-up. Cobb angle was maintained for 2 years postoperatively (p = 0.159). Clinical outcomes in foraminal stenosis patients were significantly related to sex, preoperative high Cobb angle and progression of scoliosis (p = 0.008). In the severe scoliosis patients, the JOA recovery was 44%, and was significantly depended on progression of scoliosis (Cobb angle: preoperation 29.6°, 2-years follow-up 36.9°) and mismatch between the pelvic incidence (PI) and the lumbar lordosis (LL) (preoperative PI-LL 35.5 ± 21.2°) (p = 0.028). This study investigated clinical outcomes of MIS decompression surgery in LSS patients with DLS. The predictive risk factors of clinical outcomes were severe scoliosis, foramina stenosis, progressive scoliosis and large mismatch of PI-LL.

Primary Spinal Cord Glioblastoma Multiforme: A Retrospective Study of Patients at a Single Institution

BACKGROUND AND OBJECTIVE

Primary spinal cord (PSC) glioblastoma multiforme (GBM) is extremely rare and accounts for only 1.5% of all spinal cord tumors. Therefore, its treatment is still ill defined. To elucidate prognostic factors, we performed a single-institutional retrospective review of the largest series to date of patients with PSC GBM who underwent surgical resection in West China Hospital between 2008 and 2014. A total of 14 patients with PSC GBM were reviewed.

METHODS

Demographic, operative, and postoperative factors were recorded. Overall survival (OS) and progression-free survival (PFS) were calculated and compared with the Kaplan-Meier method.

RESULTS

Eight males (57%) and 6 females (43%) were involved in the study. Their median age was 28 years (range, 14-56 years). Median Karnofsky Performance Status score was 60 (range, 20-90). Four patients (28.6%) received gross total resection, 5 (35.7%) partial resection, and the remaining 5 (35.7%) biopsy only. Nine patients (64.3%) received postoperative radiotherapy and chemotherapy, 3 (21.4%) chemotherapy only, and 2 (14.3%) neither. Median follow-up period was 15 months (range, 5-26 months). One-year and 2-year survival was 78.5% (11/14) and 7.1% (1/14), respectively. Median OS was 15 months, and median PFS 8 months. Univariate log-rank analysis showed that OS and PFS were significantly associated with patients' age (P = 0.007 and P = 0.04, respectively) and postoperative radiotherapy (P = 0.001 and P = 0.002, respectively). However, preoperative Karnofsky Performance Status score affected only OS and did not affect PFS (P = 0.033 and P = 0.106, respectively).

CONCLUSIONS

According to our study, the combination of postoperative radiotherapy and temozolomide chemotherapy can improve prognosis and may serve as a feasible postoperative adjuvant treatment of PSC GBM.

Prevalence of complications after surgery in treatment for cervical compressive myelopathy: A meta-analysis for last decade

PURPOSE

We aim to perform a meta-analysis on prevalence of all kinds of operation-related complications following surgery treating cervical compressive myelopathy (CCM) and to provide reference for surgeons making surgical plan.

METHODS

An extensive search of literature was performed in PubMed/MEDLINE, Embase, the Cochrane library, CNKI, and WANFANG databases on incidence of operation-related complications from January 2007 to November 2016. Data was calculated and data analysis was conducted with STATA 12.0 and Revman 5.3.

RESULTS

A total of 107 studies included 1705 of 8612 patients (20.1%, 95% CI 17.3%-22.8%) on overall complications. The incidence of C5 plasy, cerebrospinal fluid (CSF), infection, axial pain, dysphagia, hoarseness, fusion failure, graft subsidence, graft dislodgment, and epidural hematoma is 5.3% (95% CI 4.3%-6.2%), 1.9% (95% CI 1.3%-2.4%), 2.8% (95% CI 1.7%-4.0%), 15.6% (95% CI 11.7%-19.5%), 16.8% (95% CI 13.6%-19.9%), 4.0% (95% CI 2.3%-5.7%), 2.6% (95% CI 0.2%-4.9%), 3.7% (95% CI 2.0%-5.5%), 3.4% (95% CI 2.0%-4.8%), 1.1% (95% CI 0.7%-1.5%), respectively. Patients with ossification of posterior longitudinal ligament (OPLL) (6.3%) had a higher prevalence of C5 plasy than those with cervical spondylotic myelopathy (CSM) (4.1%), and a similar trend in CSF (12.2% vs 0.9%). Individuals after laminectomy and fusion (LF) had highest rate of C5 plasy (15.2%), while those who underwent anterior cervical discectomy and fusion (ACDF) had the lowest prevalence (2.0%). Compared with patients after other surgical options, individuals after anterior cervical corpectomy and fusion (ACCF) have the highest rate of CSF (4.2%), infection (14.2%), and epidural hematoma (3.1%). Patients after ACDF (4.8%) had a higher prevalence of hoarseness than those with ACCF (3.0%), and a similar trend for dysphagia between anterior corpectomy combined with discectomy (ACCDF) and ACCF (16.8% vs 9.9%).

CONCLUSIONS

Based on our meta-analysis, patients with OPLL have a higher incidence of C5 palsy and CSF. Patients after LF have a higher incidence of C5 palsy, ACCDF have a higher incidence of dysphagia, ACCF have a higher incidence of CSF and infection and ACDF have a higher incidence of hoarseness. These figures may be useful in the estimation of the probability of complications following cervical surgery.

A rare thoracic intraspinal schwannoma in twin pregnancy with aggravated clinical presence: A case report following CARE

INTRODUCTION

This is the first case report about a thoracic intraspinal schwannoma in twin pregnancy with aggressive clinical presentation.

CLINICAL PRESENCE AND DIAGNOSES

A 21-year-old woman presented with a 2-month history of back pain and slight lower extremity numbness and weakness, and her symptoms were misdiagnosed as normal reactions to pregnancy until she progressed to complete paralysis and incontinence within 2 weeks. She was then confirmed to have thoracic intraspinal schwannoma through MRI.

INTERVENTIONS AND OUTCOMES

Surgery was performed using a unilateral hemilaminectomy approach with a comfortable lateral position during operation. The patient exhibited significant improvements in sensation and muscle strength after surgery. She delivered 2 healthy baby girls by eutocia in her 38th week of pregnancy.

LESSONS

The diagnosis of this disease and the 4 possible mechanisms of its aggravated clinical presence are discussed. Intraspinal schwannomas during pregnancy are rare but may cause critical consequences for both the mother and the fetus. Timely diagnosis and multidisciplinary treatment by obstetricians, anesthesiologists, surgeons, oncologists, and neonatologists are essential for the clinical management of this disease.

Can tranexamic acid reduce blood loss in cervical laminectomy with lateral mass screw fixation and bone grafting: a retrospective observational study

To assess the safety and efficacy of tranexamic acid (TXA) for decreasing perioperative blood loss in cervical laminectomy with lateral mass screw fixation and bone grafting (CLF), in which all surgical procedures are identical.From November 2014 to April 2016, we performed a retrospective comparative analysis of 119 patients with multilevel cervical spondylotic myelopathy who had undergone a CLF from C3 to C6 in our center. All surgeries were performed on the patients using a consistent, standard procedure. Patients were divided into control (46) and TXA (73) groups according to whether or not they had received TXA treatment before and during surgery. Demographic profiles of patients such as gender, age, body weight, height, and body mass index were collated and differences between the 2 groups compared. Preoperative and postoperative hematological data in addition to intraoperative and postoperative blood loss were compared between the 2 groups. Additionally, any complications of TXA were also evaluated to assess safety.There was no statistically significant difference in demographic traits between the 2 groups. Intraoperative blood loss in the TXA group (179.66 ± 81.45 mL) was significantly lower than that of the control group (269.13 ± 94.68 mL, P < 0.001), as was postoperative blood loss (108.08 ± 44.31 and 132.83 ± 49.39 mL, respectively; P = 0.005). Total blood loss in the TXA group (287.74 ± 115.40 mL) was also significantly lower than that of the control group (401.96 ± 127.88, P < 0.01). No major intraoperative complications occurred in any of the cases.TXA significantly reduced perioperative blood loss in CLF with no major side effects.

High Thoracic Disc Herniation Causing Horner Syndrome with the Intraoperative Finding of Conjoined Nerve Root Compression: A Case Report

CASE

A 29-year-old man presented with right medial arm pain with paresthesia, as well as right-sided ptosis, miosis, and anhidrosis. Magnetic resonance imaging revealed a right paracentral disc herniation at the T1-T2 level. The patient underwent a hemilaminectomy with a medial facetectomy through a posterolateral approach to the T1-T2 disc space, followed by a discectomy. Intraoperative findings were notable for a conjoined nerve root.

CONCLUSION

Although high thoracic disc herniation is rare, its diagnosis should be considered when patients present with radicular arm pain and Horner syndrome. A high index of suspicion should be maintained for nerve root anomalies to limit iatrogenic injury and to ensure successful decompression.

Acute and Rapid Development of Spontaneous Spinal Epidural Hematoma Associated with Combined Aspirin-Dipyridamole Therapy: A Case Report

CASE

Spontaneous spinal epidural hematoma (SSEH) is a known, although rare, clinical entity that may be challenging to diagnose. This case report describes the rapid development of a large SSEH in an elderly patient on aspirin-dipyridamole combination therapy after she shifted her position in bed. Magnetic resonance imaging obtained 4 hours after the onset of symptoms demonstrated a large spinal epidural hematoma that extended from T4 to L1.

CONCLUSION

With early diagnosis, the patient was successfully treated with a laminectomy and evacuation of the hematoma, and there was full neurological recovery.

Preserving Posterior Complex Can Prevent Adjacent Segment Disease following Posterior Lumbar Interbody Fusion Surgeries: A Finite Element Analysis

Objective

To investigate the biomechanical effects of the lumbar posterior complex on the adjacent segments after posterior lumbar interbody fusion (PLIF) surgeries.

Methods

A finite element model of the L1–S1 segment was modified to simulate PLIF with total laminectomy (PLIF-LAM) and PLIF with hemilaminectomy (PLIF-HEMI) procedures. The models were subjected to a 400N follower load with a 7.5-N.m moment of flexion, extension, torsion, and lateral bending. The range of motion (ROM), intradiscal pressure (IDP), and ligament force were compared.

Results

In Flexion, the ROM, IDP and ligament force of posterior longitudinal ligament, intertransverse ligament, and capsular ligament remarkably increased at the proximal adjacent segment in the PLIF-LAM model, and slightly increased in the PLIF-HEMI model. There was almost no difference for the ROM, IDP and ligament force at L5-S1 level between the two PLIF models although the ligament forces of ligamenta flava remarkably increased compared with the intact lumbar spine (INT) model. For the other loading conditions, these two models almost showed no difference in ROM, IDP and ligament force on the adjacent discs.

Conclusions

Preserved posterior complex acts as the posterior tension band during PLIF surgery and results in less ROM, IDP and ligament forces on the proximal adjacent segment in flexion. Preserving the posterior complex during decompression can be effective on preventing adjacent segment degeneration (ASD) following PLIF surgeries.

Anti-adhesive effect of poloxamer-based thermo-sensitive sol-gel in rabbit laminectomy model

Poloxamer-based thermo-sensitive sol-gel has been developed to reduce the incidence of postoperative scar formation at the laminectomy site. The purpose of this study was to evaluate the anti-adhesive effect of poloxamer based thermo-sensitive sol-gel compared to hyaluronate based solution after laminectomy, using a rabbit model. A thermo-sensitive anti-adhesive with a property of sol-gel transition was manufactured by a physical mixture of Poloxamer188/407, Chitosan and Gelatin. The viscosity in different temperatures was assessed. 72 adult New Zealand rabbits underwent lumbar laminectomy and were randomly divided into experimental (treated with the newly developed agent), positive (treated with hyaluronate based solution), and negative control groups. Each group was subdivided into 1 and 4-week subgroups. Gross and histological evaluations were performed to assess the extent of epidural adhesion. The experimental group showed significantly higher viscosity compared to the positive control group and showed a significant increase of viscosity as the temperature increased. Gross evaluation showed no statistically significant differences between the 1- and 4-week subgroups. However, histologic evaluation showed significant differences both in 1- and 4-week subgroups. Although the 4-week histologic results of the experimental and the positive control subgroups showed no significant difference, both subgroups revealed higher value compared to the negative control subgroup with regard to the ratio of adhesion less than 50 %. The new poloxamer based thermo-sensitive agent showed superior efficacy over the hyaluronate based agent at 1 week postoperatively. At 4 weeks postoperatively, there were no statistically significant differences between the two agents, although both showed efficacy over the sham group.

A Prospective Randomized Controlled Trial Comparing Posterolateral Lumbar Fusion With and Without Bone Marrow Concentrate Augmentation in Single-Level Lumbar Spondylolisthesis

BACKGROUND

Bone marrow (BM), which is a good source of stem cells and biological factors, has the potential to enhance bone fusion. Simple centrifugation technique is one of the procedures used to concentrate BM aspirate for increasing number of cells. However, there are limited clinical study for using BM concentrate augmentation in spinal fusion.

OBJECTIVE

This study was designed to examine the spinal fusion enhancement effects of bone marrow (BM) concentrate augmentation on poster lateral lumbar fusion (PLF) with autologous local bone graft in terms of both quality and quantity, as compared with a control procedure without BM concentrate augmentation.

MATERIAL AND METHOD

Twelve patients with L4-L5 spondylolisthesis scheduled for PLF after decompressive laminectomy and pedicle screw instrumentation were included in this study. This prospective randomized controlled trial was conducted at Siriraj Hospital during the 2009 to 2012 study period. Patients were randomly assigned to two groups. One group underwent PLF with local bone graft with BM concentrate augmentation (BM group) and the other group underwent PLF with local bone graft only (non-BM group). Clinical outcomes were evaluated by the Oswestry Disability Index (ODI) preoperatively and at 3 and 6 months after PLF. Bone fusion quality was evaluated by bony bridging on 3D-CT imaging. Fusion mass volumes were measured on quantitative 3D-CT scans at 1 week and 6 months, postoperatively.

RESULTS

Clinical outcome scores did not differ between groups. Six-month postoperative 3D-CT imaging showed complete PLF bridging in 58.3% and 100% of patients in the BM and non-BM groups, respectively. PLF mass volumes were decreased at 6 months by 51.1% in the BM group and by 48.5% in the non-BM group. One patient in the BM group had local inflammation at the BM aspiration site.

CONCLUSION

Bone marrow concentrate augmentation in this small randomized controlled trial failed to demonstrate positive effects on autologous local bone graft in posterolateral lumbar fusion relative to both quality and quantity. The high percentage of incomplete bridging should also be noted and further investigated.

Lumbar Spinous Process-Splitting Laminoplasty: A Novel Technique for Minimally Invasive Lumbar Decompression

Minimally invasive posterior spinous process-splitting laminoplasty preserving the paraspinal musculature has been introduced to treat patients with lumbar spinal stenosis. Despite its theoretical advantage of limiting muscular trauma, additional efforts are required to evaluate patients' clinical and functional results following this procedure. Between 2010 and 2012, 37 patients underwent spinous process-splitting laminoplasty for lumbar stenosis at a mean age of 68 years (range, 36-87 years) and were followed for minimum of 1 year (mean, 1.3 years). There were 22 (59%) men and 15 (41%) women. Mean number of levels treated with a spinous process-splitting laminoplasty was 2.2 (range, 1-6 levels). Patients had statistically significant improvements in their scores for all self-reported outcomes, including visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and Short Form 36 (SF-36) components. Mean VAS significantly decreased by 4.4±3.2 points for back pain and 3.9±3.7 points for leg pain (P<.0001). Mean ODI significantly decreased by 17.5±19.1 points (P<.0001), and mean SF-36 significantly increased by 29±30.4 points (P=.0017) for the physical component and 21.8±25.6 points (P=.0062) for the mental health component. Four (10.8%) patients had a dural tear requiring repair (3 were intraoperative), 3 (8%) had an epidural hematoma requiring evacuation, 1 (2.7%) had an infection requiring irrigation and debridement, and 2 (5%) had additional decompression for symptom recurrence secondary to instability. Lumbar spinous process-splitting laminoplasty is a novel minimally invasive technique that provides adequate decompression for the neuronal elements and may avoid extensive paraspinal muscular damage associated with conventional laminectomy. Patients demonstrated significant improvements in pain and overall heath and function scores at a minimum 1-year follow-up. [Orthopedics.2016; 39(5):e950-e956.].

Efficacy and Safety of One-Stage Selective Discectomy Combined with Expansive Hemilaminectomy in the Treatment of Cervical Spondylotic Myelopathy

OBJECTIVES

We designed a novel surgical strategy named one-stage selective discectomy combined with expansive hemilaminectomy, which might theoretically reduce the postoperative complications of cervical spondylotic myelopathy (CSM). The objective of this study is to evaluate its efficacy and safety.

METHODS

Sixty-two patients with CSM were enrolled in this study. The procedure includes selective discectomy with fusion at 1 or 2 segments of maximal cord compression and expansive hemilaminectomy on the symptomatic or severe side of the body. Neurologic function was evaluated using the Japanese Orthopedics Association Score before and after surgery. Midsagittal dural sac diameter, dural sac transverse area at segments of discetomy on magnetic resonance imaging, and lordosis of the cervical spine on lateral plain film were measured. All patients were followed up for more than 1 year.

RESULTS

A total of 88 discs and 272 hemilaminas were resected from 62 patients. The Japanese Orthopedics Association Score improved from 8.7 ± 1.76 preoperatively to 13.4 ± 1.61 at 1 year follow-up (P < 0.001). The mean midsagittal dural sac diameter, dural sac area, and lordotic angle also increased from 0.45 ± 0.10 cm, 0.83 ± 0.14 cm², and 7.9 ± 2.60° to 0.81 ± 0.08 cm, 0.96 ± 0.14 cm², and 11.7 ± 3.06°, respectively (P < 0.05). No case of postoperative axial pain, C5 palsy, nonunion, or kyphosis was reported.

CONCLUSIONS

One-stage selective discectomy combined with expansive hemilaminectomy is an effective surgical approach for the treatment of CSM in patients whose neurologic function, midsagittal dura sac diameter, and dura transverse area can be improved and has few postoperative complications.

Laminoplasty versus laminectomy and fusion for multilevel cervical compressive myelopathy: A meta-analysis

This is a meta-analysis to compare the results between laminoplasty and laminectomy followed by fusion for the patients with multilevel cervical compressive myelopathy. An extensive search of literature was performed in MEDLINE, Embase, the Cochrane library, CNKI, and WANFANG. The following outcome measures were extracted: the Japanese Orthopaedic Association (JOA) scores, cervical curvature index (CCI), visual analog scale (VAS), cervical lordosis (C2-7), complications, blood loss, and operation time. Data analysis was conducted with RevMan 5.3 and STATA 12.0. A total of 23 studies comprising 774 and 743 patients treated with laminoplasty and laminectomy followed by fusion, respectively, were included in the final analysis. The pooled analysis showed that there was no significant difference in preoperative JOA scores [P = 0.89], postoperative JOA scores [P = 0.13], JOA scores improvement rate [P = 0.27], preoperative CCI [P = 0.15], postoperative CCI [P = 0.14], preoperative VAS [P = 0.41], postoperative VAS [P = 0.52], preoperative cervical lordosis (C2-7) [P = 0.46], postoperative cervical lordosis (C2-7) [P = 0.67], total complications [P = 0.07], axial pain [P = 0.94], and blood loss [P = 0.51]. However, there were significant difference in operation time (WMD = -19.57 [-32.11, -7.02], P = 0.002) and C5 palsy (OR = 0.26 [0.15, 0.44], P < 0.001). As compared with laminectomy followed by fusion, expansive laminoplasty showed no significant differences in JOA scores, CCI, ROM, VAS, cervical lordosis (C2-7), axial pain, total complications, and blood loss, but shorter operation time and fewer C5 palsy.

Central Spinal Canal Decompression for Lumbar Spondylosis with Uniportal Full-Endoscopic Interlaminar Approach: Technical Note and Preliminary Results in Thailand

OBJECTIVE

To describe surgical techniques for central spinal canal decompression with uniportal full-endoscopic interlaminar approach and report preliminary results of the first three cases.

MATERIAL AND METHOD

Surgical technique for uniportal full-endoscopic interlaminar approach for central spinal canal decompression was described step by step. Three consecutive cases that were operated by this new technique were illustrated by retrospective chart review. Results: All three illustrative cases achieved excellent clinical outcomes in terms of leg pain and claudication without postoperative complications. A follow-up period was two to eight months. Intra-operative blood loss varied from 20 to 50 milliliter. All cases were discharged from the hospital within two days after surgery.

CONCLUSION

Uniportal full-endoscopic interlaminar approach is a viable alternative procedure for central spinal canal decompression with the advantages of smaller skin incision and less tissue trauma. However, studies with larger number of cases and longer follow-up periods are needed in order to make a clear conclusion of the superiority of this new technique comparing to conventional microsurgical laminectomy.

Clinical outcomes following sublaminar decompression and instrumented fusion for lumbar degenerative spinal pathology

Traditional treatment for lumbar stenosis with instability is laminectomy and posterolateral arthrodesis, with or without interbody fusion. However, laminectomies remove the posterior elements and decrease the available surface area for fusion. Therefore, a sublaminar decompression may be a preferred approach for adequate decompression while preserving bone surface area for fusion. A retrospective review of 71 patients who underwent sublaminar decompression in conjunction with instrumented fusion for degenerative spinal disorders at a single institution was performed. Data collected included demographics, preoperative symptoms, operative data, and radiographical measurements of the central canal, lateral recesses, and neural foramina, and fusion outcomes. Paired t-tests were used to test significance of the outcomes. Thirty-one males and 40 females with a median age 60years underwent sublaminar decompression and fusion. A median of two levels were fused. The mean Visual Analog Scale pain score improved from 6.7 preoperatively to 2.9 at last follow-up. The fusion rate was 88%, and the median time to fusion was 11months. Preoperative and postoperative mean thecal sac cross-sectional area, right lateral recess height, left lateral recess height, right foraminal diameter, and left foraminal diameter were 153 and 209mm(2) (p<0.001), 5.9 and 5.9mm (p=0.43), 5.8 and 6.3mm (p=0.027), 4.6 and 5.2mm (p=0.008), and 4.2 and 5.2mm (p<0.001), respectively. Sublaminar decompression provided adequate decompression, with significant increases in thecal sac cross-sectional area and bilateral foraminal diameter. It may be an effective alternative to laminectomy in treating central and foraminal stenosis in conjunction with instrumented fusion.

COMPARISON TACHOCOMB WITH SURGIWRAP, SURGICEL AND LYODURA IN EPIDURAL FIBROSIS: AN EXPERIMENTAL RAT MODEL

OBJECTIVES

We designed this study to evaluate the effect of TachoComb and to compare it with SurgiWrap, Surgicel, and Lyodura in an experimental rat model for epidural fibrosis (EF).

METHODS

This prospective and experimental rat model study was performed at Dicle University, School of Medicine, Department of Neurosurgery, in Diyarbakir, Turkey, between January 2005 and June 2005, using 50 Sprague Dawley rats (30 female and 20 male) with a mean weight of 290 g. The rats were divided into five groups: TachoComb, Surgicel, SurgiWrap, Lyodura, and control.

RESULTS

Eight weeks after laminectomy, the rats were killed and EF was evaluated. EF was statistically different between the groups. The lowest EF score was in the TachoComb group (F = 6.915, p < 0.001).

CONCLUSIONS

According to this study, TachoComb was found to be a more effective agent in decreasing EF than Surgicel, SurgiWrap, or Lyodura.

BRCA2-positive spinal intramedullary ovarian metastatic disease: case report

BACKGROUND CONTEXT

Ovarian cancer is the fourth leading cause of cancer death in women, but advances in treatment have led to longer survival among these patients. Tied to these advances and increased survival, however, have been new patterns of metastatic spread.

PURPOSE

The authors discuss the management and surgical decision making in patients with intramedullary ovarian metastatic disease using a case illustration and relevant literature.

STUDY DESIGN/SETTING

A case report was used.

METHODS

The authors describe a case of a 59-year-old woman with Breast Cancer gene (BRCA) 2-positive ovarian cancer who developed progressive myelopathy from a T10 to T11 intramedullary metastatic lesion.

RESULTS

The patient underwent a standard open T10-T11 laminectomy for intramedullary tumor resection. Intraoperative ultrasound was used to direct the dural opening over the lesion. After a posterior midline myelotomy, microsurgical dissection revealed the intramedullary tumor with a discolored fibrous capsule, which was carefully dissected off of the spinal tracts, and a gross total resection was achieved. Postoperative magnetic resonance imaging at 6 months demonstrated no evidence of residual or recurrent intramedullary tumor. The patient underwent adjuvant external beam radiation to the thoracic spine but succumbed to her primary disease 1 year after surgery.

CONCLUSION

Although central nervous system involvement of ovarian cancer confers a poor prognosis, patients presenting with a solitary lesion and neurologic deficit may benefit from surgical resection followed by steroids and radiation therapy, especially when tissue diagnosis is necessary.

Outcomes of Instrumented and Noninstrumented Posterolateral Lumbar Fusion

The purpose of this study was to evaluate the long-term clinical and radiographic outcomes of posterolateral lumbar fusion for lumbar stenosis cases requiring bilateral facetectomy in conjunction with a laminectomy. The authors evaluated 34 consecutive patients who had undergone a lumbar laminectomy, bilateral partial facetectomy, and posterolateral fusion at a single institution between 1981 and 1996. They included 25 men and 9 women with a mean age of 42 years (range, 27-57 years). Twenty-three cases were instrumented and 11 were noninstrumented. Mean follow-up was 21 years (range, 15-29 years). Outcomes evaluated included reoperation rate, clinical outcomes evaluated by the Oswestry Disability Index (ODI) score, radiographic evaluations of adjacent segmental degeneration (ASD) and lumbar lordosis, and contributing demographic factors to disease progression. At final follow-up, 17 of the 34 patients had undergone reoperation (43% of the instrumented group and 64% of the noninstrumented group). There were no differences in the reoperation rate or ODI improvement between the instrumented and noninstrumented groups (P>.05). Female patients required more revisions, had less ODI improvement, had greater postoperative ASD, and had less maintenance of their postoperative lumbar lordosis. There was no difference in maintenance of postoperative lumbar lordosis or ASD between the instrumented and noninstrumented groups. Instrumentation did not improve revision rates, clinical outcomes, or radiographic outcomes in laminectomies requiring contemporaneous facetectomies.

Long Segment Spinal Dural Cyst: A Case Report

BACKGROUND

Spinal meningeal cysts are a rare benign disease that can cause myelopathy. In most cases, spinal meningeal cysts consist of an arachnoid membrane. To the best of our knowledge, few articles have report on intradural spinal meningeal cyst consisting of dura mater.

CASE DESCRIPTION

A 58-year-old man presented to our institute with aggravation of clumsy hands and dysesthesia of the feet. Magnetic resonance imaging of the entire spine revealed a cystic lesion compressing the spinal cord posteriorly. Cyst fenestration and placement of the cyst-subarachnoid shunt was performed via an anterior approach. Postoperatively, the histopathologic results revealed that the cyst wall consisted of a dura mater-like membrane. The patient's symptoms resolved without the appearance of any new neurologic deficits.

CONCLUSIONS

The etiology of spinal meningeal cysts remains unclear. Spinal meningeal cysts consisting of dura mater (spinal dural cysts) are extremely rare. Treatment with only decompression with laminectomy causes enlargement of the dural cyst later. Cyst fenestration and placement of a cyst-subarachnoid shunt for the spinal dural cyst resulted in the resolution of myelopathy and cyst shrinkage.

Evaluation of Degenerative Lumbar Scoliosis After Short Segment Decompression and Fusion

The objective of this study was to investigate short segment decompression of degenerative lumbar scoliosis (DLS) and the efficiency of fusion treatment.After DLS surgery, the patients were retrospectively reviewed using the VAS (visual analog scale) and ODI (Oswestry Disability Index) to assess clinical outcomes. All patients underwent posterior lumbar decompressive laminectomy, pedicle screw internal fixation, and posterolateral bone graft fusion surgery. Radiographic measurements included the scoliotic Cobb angle, the fused Cobb angle, the anterior intervertebral angle (AIA), the sagittal intervertebral angle (SIA), and lumbar lordosis angle. The relationships between these parameters were examined by bivariate Pearson analysis and linear regression analysis.Preoperatively, the Cobb angle at the scoliotic segment was 15.4°, which decreased to 10.2° immediately following surgery (P < 0.05). The AIA significantly increased by the last follow-up (4.4 ± 3.4) compared with pre- and postoperative values (2.5 ± 2.8 and 2.2 ± 2.4, respectively; P < 0.05). However, the scoliotic Cobb angle and the AIA did not correlate with the VAS or ODI scores. At the final follow-up, no patients had pseudoarthrosis or internal instrumentation-related complications.Short fusion surgical treatment results in limited DLS correction, with correction loss over time. The AIA between the upper adjacent segment and proximal fused vertebra continues to increase postoperatively, which does not exacerbate clinical symptoms, as reflected by the low reoperation rates for repairing degeneration at adjacent levels.

Bilateral spinal canal decompression via hemilaminectomy in cervical spondylotic myelopathy

BACKGROUND

In cervical spondylotic myelopathy (CSM), laminoplasty (LP) or laminectomy plus fusion (LF) are accepted operative options and alternatives to anterior approaches. Both LP and LF have distinctive disadvantages, which might be avoided by unilateral hemilaminectomy and bilateral decompression of the spinal cord.

METHODS

Description of the surgical technique, indications, and limitations. The potential advantages in comparison to LP and LF are discussed.

CONCLUSIONS

Unilateral hemilaminectomy allows bilateral decompression of the whole dorsal circumference of spinal cord from nerve root to nerve root. The potential major advantages are a reduction of invasiveness by only unilateral muscle detachment, avoidance of implants, and shorter operation times.

Microsurgical resection of an intramedullary glomus arteriovenous malformation in the high cervical spinal cord: retrograde dissection techniques of the nidus located between spinal tracts

BACKGROUND

Spinal intramedullary arteriovenous malformations (AVMs) fed by an anterior spinal artery are surgically challenging vascular lesions.

METHOD

We herein presented microsurgical resection techniques for an intramedullary glomus AVM located in the lateral part of the high cervical spinal cord with an operative video. These techniques included (1) a lateral suboccipital approach via cervical hemilaminectomy in the lateral position; (2) retrograde dissection of the AVM located between the spinal tracts; (3) coagulation and division of multiple narrow sulcal branches of the anterior spinal artery.

CONCLUSION

Patients who underwent these techniques achieved good outcomes with minimal bleeding and morbidity.

Aortic issues in scoliosis and scoliotic operations

The spatial relations between the aorta and vertebrae are changing with posture, surgical techniques, and operative maneuvers. "Risky screws" (within 1-3 mm proximity to the aorta or other adjacent tissues) were found in 5.8-15.2% screws. In order to avoid early and later aortic complications secondary to scoliotic operations, careful preoperative metrology of aorto-vertebrae relations is of crucial importance. Compared with patients with idiopathic scoliosis, Marfan-related scoliosis is characterized by faster progression and it is more bracing-resistant due to the particular developmental anomalies in Marfan syndrome, implying the refractory nature of the latter. The present study aims to highlight the clinical impact of preoperative aorto-vertebra metrology in the scoliotic operations.

A rare and unexpected clinical progress and location on a primary extradural spinal hydatid cyst in a pediatric patient: a case report

BACKGROUND

Involvement of spine in patients with hydatid disease (HD) is less than 1% and primary intra-spinal extradural HD is extremely rare. Although this disease is introduced as benign pathology according to its clinical presentation and biological behavior, intraoperative rupture of the cyst may aggravate the patients' outcome in the long-term especially in pediatric patient population.

CASE PRESENTATION

We report a 9-year-old girl who presented a progressive neurological deterioration due to an enlargement of a ventrally located extradural hydatid cyst within the thoracic spinal canal. Total removal of the cyst was achieved by preserving the capsule integrity for preventing potential seeding. Our preoperative initial diagnosis based on the radiological findings was confirmed as cyst hydatid histopathologically.

CONCLUSION

Cyst hydatid should be considered in the differential diagnosis of the presence of homogenous cystic lesions with regular shape inside the spinal canal especially in patients from endemic region. To our knowledge, this pediatric patient is the first case of cyst hydatid located ventral side of the spinal cord extradurally located inside the spinal canal showing no extension.

WOUND INSTILLATION OF LOCAL ANESTHETIC BUPIVACAINE FOR POSTOPERATIVE ANALGESIA FOLLOWING LUMBAR LAMINECTOMY

PURPOSE

Lumbar laminectomy is a commonly performed procedure in neurosurgical and orthopedic practice. Postoperative pain reliefhelps in early mobilization, initiation of physiotherapy, provides satisfaction to the patients and plays an important role in reducing the morbidity and mortality. This prospective study investigated the simple technique of instillation of wound with bupivacaine and leaving a contact time of 60 seconds on postoperative pain following lumbar laminectomy.

METHODS

32 ASA I and II patients scheduled for laminectomy were randomly allocated to receive either 20 ml of normal saline (group I) or 0.25% of bupivacaine (group II) into the wound after securing hemostasis. After a dwell time of 60sec the wound was closed in layers without mopping or suctioning. After extubation, the pain scores were evaluated by visual analog scale at every 4 hrs. for 24hrs and also the time for first demand of analgesia, number of analgesic demands and the total amount of analgesia consumed were noted by an independent observer..

RESULTS

The median duration of analgesia in group I was 8.8 [5-11] and in group II 13 [8.5-16] hrs. with a p = 0.04. The number of demands and the amount of analgesia consumed was also statistically significant.

CONCLUSION

Wound instillation technique is simple, safe and effective in management of acute pain management after lumbar laminectomy and can be used as one among the multimodal armamentarium in pain management.

Treatment of holocord spinal epidural abscess via alternating side unilateral approach for bilateral laminectomy

To date, this is the first reported case of the surgical management of a holocord epidural abscess done through level-skipping laminectomies. It is also the first reported case of these laminectomies being performed via an alternating side unilateral approach for this condition. A 51-year-old patient presenting with progressive lower extremity weakness secondary to a spinal epidural abscess extending from C4 to S1. A minimally disruptive method of relieving the spinal cord compression via evacuation of the abscess was employed successfully. This report demonstrates the efficacy of level skipping laminectomies via a unilateral approach for holocord epidural abscesses (extending 20 vertebral levels). Performing the laminectomies via a unilateral approach as well as alternating the side of the approach minimized iatrogenic instability risk. Both strategies were designed to minimize incision size, tissue disruption, and the amount of muscular weakness/imbalance postoperatively.

Effectiveness and safety of transforaminal lumbar interbody fusion in patients with previous laminectomy

PURPOSE

To determine the efficacy and safety of transforaminal lumbar interbody fusion (TLIF) for revision lumbar spine surgery in patients with previous laminectomy. The secondary objective was to evaluate the clinical and radiological outcome after such a procedure.

METHODS

Retrospective case series study. Eighty-two patients were included. There were 48 women (58.5 %) and 34 men (41.5 %) with a mean age of 51 years (range 26-84) at the time of index procedure. The outpatient and inpatient charts were reviewed to identify patients' demographic data, preoperative, perioperative, and postoperative data. The outcome measures were assessed by Oswestry Disability Index (ODI) and visual analog scale (VAS) for back and leg pain. An independent spine surgeon and musculoskeletal radiologist reviewed the imaging studies.

RESULTS

The average operative time was 160 min (range 131-250). The average estimated blood loss was 652 cc (100-1,400 cc). Nineteen patients (23.1 %) required blood transfusion. Five patients (6 %) had dural tear. One patient (1.2 %) had a surgical site infection. Two patients (2.4 %) had thromboembolic events. The average hospital stay was 3.8 days (2-5 days). At a mean follow-up of 28 months, there were statically significant improvement in the ODI and VAS for back and leg pain. None of the patients' radiographs showed hardware failure or pedicle screw loosening and no patient returned to the operating room for pseudarthrosis.

CONCLUSIONS

The current study confirmed that TLIF approach in patients with previous laminectomy is effective and safe with good outcomes.

THE INFLUENCE OF POSTERIOR APPROACH CERVICAL INTRASPINAL TUMOR RESECTION ON THE STABILITY OF CERVICAL VERTEBRA

This paper discusses the influence of posterior approach cervical intraspinal tumor resection on the stability of cervical vertebra. A total of 32 patients with cervical intraspinal tumor were included and divided into a group undergoing posterior approach bilateral vertebral lamina resection (group A) (n=16) and a group undergoing posterior approach semi-laminectomy (group B) (n=16). It was found, through follow-up visits, that the incidence rate of cervical instability of the patients was 25% and the incidence rate of cervical curvature deterioration of the patients was 37.5% in group A, whereas the two incidence rates of group B were 6.25% and 12.5% respectively; the incidence rates of cervical curvature deterioration and instability were significantly increased compared to group B (P< 0.05). It is concluded that, both regular posterior approach vertebral lamina resection and semi-laminectomy influence the biomechanical change of cervical vertebra, but the influence of the latter is less. Also, it is found that, applying titanium connectors and titanium nails for rigid internal fixation maintains the completeness and stability of the structure of the cervical vertebra.

Use of lumbar laminoplasty vs. laminotomy for transection of the filum terminale does not affect early complication rates or postoperative course

INTRODUCTION

Various techniques are used for spinal cord untethering. The purpose of this study was to compare patient characteristics, postoperative course, and early complications after laminotomy vs. laminoplasty for transection of the filum terminale for tethered cord release.

METHODS

Retrospective analysis of clinical and magnetic resonance imaging data was undertaken for all patients (<18 years) who underwent tethered cord release by transection of the filum terminale at Oregon Health & Science University, Doernbecher Children's Hospital, from 2000 to 2011.

RESULTS

Data from two hundred and forty-eight patients were analyzed. Mean age was 5.2 years (range 0.3 to 16.8 years). Access to the thecal space during surgery was achieved using laminotomy or laminoplasty in 82 (33.1 %) and 166 (66.9 %) patients, respectively. Laminoplasty patients were significantly younger than laminotomy patients (3.2 vs. 9.3 years, p<0.0001); other clinical and radiographic characteristics were similar between the groups. Nine patients (3.6 %) experienced early complications, including cerebrospinal fluid leak (n=2), suprafascial infection requiring surgical management and intravenous (IV) antibiotics (n=3) or IV antibiotics alone (n=1), a small area of peri-incisional cutaneous necrosis (n=1), perioperative seizures (n=1), and mild, transient malignant hyperthermia (n=1). There was no difference in the number of early complications between the two groups. Univariate and multivariate analyses revealed no significant risk factor for postoperative complication associated with technique. As judged by caregivers, independent of surgical technique, 97 % of patients improved after surgery.

CONCLUSION

There was no difference in complication risk when performing transection of the filum terminale for tethered cord release using laminotomy or laminoplasty.

Effectiveness of posterior decompression techniques compared with conventional laminectomy for lumbar stenosis

BACKGROUND

The gold standard treatment for symptomatic lumbar stenosis refractory to conservative management is a facet-preserving laminectomy. New techniques of posterior decompression have been developed to preserve spinal integrity and to minimise tissue damage by limiting bony decompression and avoiding removal of the midline structures (i.e. spinous process, vertebral arch and interspinous and supraspinous ligaments).

OBJECTIVES

To compare the effectiveness of techniques of posterior decompression that limit the extent of bony decompression or avoid removal of posterior midline structures of the lumbar spine versus conventional facet-preserving laminectomy for the treatment of patients with degenerative lumbar stenosis.

SEARCH METHODS

An experienced librarian conducted a comprehensive electronic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and the clinical trials registries ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) for relevant literature up to June 2014.

SELECTION CRITERIA

We included prospective controlled studies comparing conventional facet-preserving laminectomy versus a posterior decompressive technique that avoids removal of posterior midline structures or a technique involving only partial resection of the vertebral arch. We excluded studies describing techniques of decompression by means of interspinous process devices or concomitant (instrumented) fusion procedures. Participants included individuals with symptomatic degenerative lumbar stenosis only.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias using the Cochrane Back Review Group criteria for randomised controlled trials (RCTs) and the Newcastle-Ottawa Scale for non-randomised studies. We extracted data regarding demographics, intervention details and outcome measures.

MAIN RESULTS

A total of four high-quality RCTs and six low-quality RCTs met the search criteria of this review. These studies included a total of 733 participants. Investigators compared three different posterior decompression techniques versus conventional laminectomy. Three studies (173 participants) compared unilateral laminotomy for bilateral decompression versus conventional laminectomy. Four studies (382 participants) compared bilateral laminotomy versus conventional laminectomy (one study included three treatment groups and compared unilateral and bilateral laminotomy vs conventional laminectomy). Finally, four studies (218 participants) compared a split-spinous process laminotomy versus conventional laminectomy.Evidence of low or very low quality suggests that different techniques of posterior decompression and conventional laminectomy have similar effects on functional disability and leg pain. Only perceived recovery at final follow-up was better in people who underwent bilateral laminotomy compared with conventional laminectomy (two RCTs, 223 participants, odds ratio 5.69, 95% confidence interval (CI) 2.55 to 12.71).Among the secondary outcome measures, unilateral laminotomy for bilateral decompression and bilateral laminotomy resulted in numerically fewer cases of iatrogenic instability, although in both cases, the incidence of instability was low (three RCTs, 166 participants, odds ratio 0.28, 95% CI 0.07 to 1.15; three RCTs, 294 participants, odds ratio 0.10, 95% CI 0.02 to 0.55, respectively). The difference in severity of postoperative low back pain following bilateral laminotomy (two RCTs, 223 participants, mean difference -0.51, 95% CI -0.80 to -0.23) and split-spinous process laminotomy compared with conventional laminectomy (two RCTs, 97 participants, mean difference -1.07, 95% CI -2.15 to -0.00) was significantly less, but was too small to be clinically important. A quantitative comparison between unilateral laminotomy and conventional laminectomy was not possible because of different reporting of outcome measures. We found no evidence to show that the incidence of complications, length of the procedure, length of hospital stay and postoperative walking distance differed between techniques of posterior decompression.

AUTHORS' CONCLUSIONS

The evidence provided by this systematic review for the effects of unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy compared with conventional laminectomy on functional disability, perceived recovery and leg pain is of low or very low quality. Therefore, further research is necessary to establish whether these techniques provide a safe and effective alternative for conventional laminectomy. Proposed advantages of these techniques regarding the incidence of iatrogenic instability and postoperative back pain are plausible, but definitive conclusions are limited by poor methodology and poor reporting of outcome measures among included studies. Future research is necessary to establish the incidence of iatrogenic instability using standardised definitions of radiological and clinical instability at comparable follow-up intervals. Long-term results with these techniques are currently lacking.

Multilevel en bloc spondylectomy for tumors of the thoracic and lumbar spine is challenging but rewarding

BACKGROUND

Over the years, en bloc spondylectomy has proven its efficacy in controlling spinal tumors and improving survival rates. However, there are few reports of large series that critically evaluate the results of multilevel en bloc spondylectomies for spinal neoplasms.

QUESTIONS/PURPOSES

Using data from a large spine tumor center, we answered the following questions: (1) Does multilevel total en bloc spondylectomy result in acceptable function, survival rates, and local control in spinal neoplasms? (2) Is reconstruction after this procedure feasible? (3) What complications are associated with this procedure? (4) is it possible to achieve adequate surgical margins with this procedure?

METHODS

We retrospectively investigated 38 patients undergoing multilevel total en bloc spondylectomy by a single surgeon (AL) from 1994 to 2011. Indications for this procedure were primary spinal sarcomas, solitary metastases, and aggressive primary benign tumors involving multiple segments of the thoracic or lumbar spine. Patients had to be medically fit and have no visceral metastases. Analysis was by chart and radiographic review. Margin quality was classified into intralesional, marginal, and wide. Radiographs, MR images, and CT scans were studied for local recurrence. Graft healing and instrumentation failures at subsequent followup were assessed. Complications were divided into major or minor and further classified as intraoperative and early and late postoperative. We evaluated the oncologic status using cumulative disease-specific and metastases-free survival analysis. Minimum followup was 24 months (mean, 39 months; range, 24-124 months).

RESULTS

Of the 38 patients, 34 (89%) were alive and walking without support at final followup. Thirty-one (81%) had no evidence of disease. Two patients died postoperatively and another two died of systemic disease (without local recurrence). Only three patients (8%) had a local recurrence. There were 14 major complications and 22 minor complications in 25 patients (65%). Only one patient required revision of implants secondary to mechanical failure. Two cases of cage subsidence were noted but had no clinical significance. Wide margins were achieved in nine patients (23%), marginal in 25 (66%), and intralesional in four (11%).

CONCLUSIONS

In patients with multisegmental spinal tumors, oncologic resections were achieved by multilevel en bloc spondylectomy and led to an acceptable survival rate with reasonable local control. Multilevel en bloc surgery was associated with a high complication rate; however, most patients recovered from their complications. Although the surgical procedure is challenging, our encouraging mid-term results clearly favor and validate this technique.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Surgical treatment of the osteoporotic spine with bone cement-injectable cannulated pedicle screw fixation: technical description and preliminary application in 43 patients

OBJECTIVES

To describe a new approach for the application of polymethylmethacrylate augmentation of bone cement-injectable cannulated pedicle screws.

METHODS

Between June 2010 and February 2013, 43 patients with degenerative spinal disease and osteoporosis (T-score <-2.5) underwent lumbar fusion using cement-injectable cannulated pedicle screws. Clinical outcomes were evaluated using a Visual Analog Scale and the Oswestry Disability Index. Patients were given radiographic follow-up examinations after 3, 6, and 12 months and once per year thereafter.

RESULTS

All patients were followed for a mean of 15.7 ± 5.6 months (range, 6 to 35 months). The Visual Analog Scale and Oswestry Disability Index scores showed a significant reduction in back pain (p = 0.018) and an improvement in lower extremity function (p = 0.025) in patients who underwent lumbar fusion using the novel screw. Intraoperative cement leakage occurred in four patients, but no neurological complications were observed. Radiological observation indicated no loosening or pulling out of the novel screw, and bone fusion was excellent.

CONCLUSIONS

The described polymethylmethacrylate augmentation technique using bone cement-injectable cannulated pedicle screws can reduce pain and improve spinal dysfunction in osteoporotic patients undergoing osteoporotic spine surgery.

Finite element analysis for comparison of spinous process osteotomies technique with conventional laminectomy as lumbar decompression procedure

PURPOSE

The purpose of this study was to evaluate and compare the biomechanical behavior of the lumbar spine after posterior decompression with the spinous process osteotomy (SPiO) technique or the conventional laminectomy (CL) technique using a finite element (FE) model.

MATERIALS AND METHODS

Three validated lumbar FE models (L2-5) which represented intact spine and two decompression models using SPiO and CL techniques at the L3-4 segment were developed. In each model, the ranges of motion, the maximal von Mises stress of the annulus fibrosus, and the intradiscal pressures at the index segment (L3-4) and adjacent segments (L2-3 and L4-5) under 7.5 Nm moments were analyzed. Facet contact forces were also compared among three models under the extension and torsion moments.

RESULTS

Compared to the intact model, the CL and SPiO models had increased range of motion and annulus stress at both the index segment (L3-4) and the adjacent segments under flexion and torsion. However, the SPiO model demonstrated a reduced range of motion and annulus stress than the CL model. Both CL and SPiO models had an increase of facet contact force at the L3-4 segment under the torsion moment compared to that of the intact model. Under the extension moment, however, three models demonstrated a similar facet contact force even at the L3-4 model.

CONCLUSION

Both decompression methods lead to postoperative segmental instability compared to the intact model. However, SPiO technique leads to better segmental stability compared to the CL technique.

Reduction of epidural scar adhesion by topical application of simvastatin after laminectomy in rats

OBJECTIVE

Epidural scar adhesion is one of the major causes of the failed back surgery syndrome after laminectomy. Recent studies have shown that simvastatin has potent anti-fibrotic and anti-inflammatory properties. This study evaluates the effect of the topical application of simvastatin on reducing epidural scar adhesion after laminectomy in rats.

MATERIALS AND METHODS

Thirty-six male Sprague-Dawley rats were randomly divided into three groups: control, chitosan and simvastatin group. After laminectomy was performed at L1 level, simvastatin and chitosan were applied to the laminectomy sites. The control group received no additional treatment. Four weeks later, the rats were killed and the epidural adhesion was evaluated by macroscopic assessment, hydroxyproline content analysis and histological analysis. The number of fibroblasts and the optical density of the collagen were also determined.

RESULTS

The results showed that simvastatin could reduce epidural scar adhesion in rats. Little epidural adhesions were seen in the laminectomy sites treated with simvastatin. The hydroxyproline content, the number of fibroblasts and the optical density of the collagen in the simvastatin group were significantly less than those of the chitosan and control group. However, dense epidural adhesion was found in control group.

CONCLUSIONS

Topical application of simvastatin could reduce epidural scar adhesion after laminectomy in rats. Further research is necessary to determine the optimal dosage and the safety of simvastatin.