Oblique corpectomy for treatment of cervical spine epidural abscesses: Report on four cases

Multilevel Corpectomy for Subaxial Cervical Spondylodiscitis: Literature Review and Role of Navigation, Intraoperative Imaging and Augmented Reality

BACKGROUND

Subaxial cervical spine spondylodiscitis represents a real challenge in spine surgery. In later stages multiple spinal metamers can the interested by the pathological infection and the alteration of the spinal stability leading to spinal deformity. There is scant literature on subaxial cervical spondylodiscitis management and especially on ≥three-level cervical corpectomies. The authors conducted a literature search on this specific topic and presented an emblematic case of a patient treated with circumferential cervical fixation and four-level cervicothoracic corpectomy.

MATERIALS AND METHODS

A comprehensive literature review was performed using the combined Medical Subject Headings (MeSH) terms (multilevel) AND (sub axial spine OR cervical spine) AND (spine osteomyelitis OR spinal osteomyelitis), to search in the PubMed and Scopus databases. Our case was also included in this literature review. From our literature search the authors selected 13 papers, eight were excluded because they did not match our inclusion criteria (the involvement of only one or two levels, or did not perform corpectomy, discectomy, or cervical spine localization). The authors also presented a 71-year-old patient, in poor general clinical status who underwent several cage repositioning, with a final four-level corpectomy (C5, C6, C7, and T1), expandable C5-T1 cage positioning and C4-T2 anterior plating performed merging augmented reality, neuronavigation and intraoperative imaging.

RESULTS

This systematic review included 28 patients treated with ≥ three-level corpectomy (11 patients with three-level corpectomy, 15 patients with four-level corpectomy, and 2 patients with six-level corpectomy), 6 women, 5 men, and 17 not reported specifically, with a mean age of 55.9 years (range: 44-72 years). The combined anterior and posterior approach was taken in all but one case, which was treated with the anterior approach only. In one case of six-level cervicothoracic corpectomy, sternotomy was necessary. All reported patients recovered after surgery, except one who died after nosocomial pneumonia. No major intraoperative complications were reported. Usual postoperative complications include wound hematoma, pneumonia, subsidence, epidural hematoma, dural leakage, dysphagia, soft tissue swelling. The mean follow-up time was 31.9 months (range: 8-110 months).

CONCLUSION

According to the literature search performed by the authors, multilevel corpectomies for cervical spinal osteomyelitis is a safe and effective complex surgical procedure, even in extended procedures involving up to six levels or those at the cervicothoracic junction. The use multimodal navigation merging intraoperative imaging acquisition, navigation, and augmented reality may provide useful information during implant positioning in complex and altered anatomy and for assessing the best final result.

Case report: Anterior midline decompression of a cervical epidural abscess: Technical note and case series of seven patients

Background

A spinal epidural abscess (SEA) of the cervical spine is a relatively rare disease and is generally characterized by progressive neurological deterioration due to compression of the spinal cord. Up to 40% of cervical SEAs are located ventrally of the spinal cord. Urgent surgical intervention is warranted to decompress the spinal cord and collect material for cultures to guide antibiotic treatment. However, the optimal timing of the intervention is unclear, and the associated risk of spinal instability in the presence of an extensive infection is a significant clinical dilemma.

Methods

In this paper, we present a novel surgical technique to treat a cervical SEA by anterior decompression through a linear transvertebral midline approach. This technique has the advantage of effectively draining the ventrally located SEA and obtaining material for bacteria culture while maintaining spinal stability without additional instrumentation.

Results

This case study presents seven patients with cervical SEAs who were successfully treated with surgical decompression by this transvertebral linear midline technique and antibiotic treatment.

Conclusion

Anterior decompression through a linear transvertebral midline approach for a ventrally located cervical SEA is a safe and pragmatic surgical procedure to achieve spinal cord decompression and collect bacteria culture without destabilizing the cervical spine.

Cervical Oblique Corpectomy: Revitalizing the Underused Surgical Approach With Step-By-Step Simulation in Cadavers

ABSTRACT

Recently, the World Federation of Neurosurgical Societies Spine committee recommended that additional research on cost-benefit analysis of various surgical approaches for cervical spondylotic myelopathy be carried out and their efficacy with long-term outcomes be compared. Unfortunately, it is highly probable that the oblique corpectomy (OC) will not be included in cost-benefit investigations due to its infrequent application by neurosurgeons dealing with the spine. In this cadaveric study, head and necks of 5 adult human cadavers stained with colored latex and preserved in 70% alcohol solution were dissected under a table-mounted surgical microscope using 3× to 40× magnifications. The OC approach was performed to simulate real surgery, and the neurovascular structures encountered during the procedure and their relations with each other were examined. Oblique corpectomy was performed unilaterally, although neck dissections were performed bilaterally on 10 sides in all 5 cadavers. At each stage of the dissection, multiple three-dimensional photographs were obtained from different angles and distances. For an optimal OC, both the anterior spinal cord must be sufficiently decompressed and sufficient bone must be left in place to prevent instability in the cervical spine. Oblique corpectomy is a valid and potentially low cost alternative to other anterior and posterior approaches in the surgical treatment of cervical spondylotic myelopathy. However, meticulous cadaver studies are essential before starting real surgical practice on patients in order to perform it effectively and to avoid the risks of the technique.

Lateral approach for recurrent unilateral cervical radiculopathy after anterior discectomy with fusion. Report of two cases

Recurrent radiculopathy after anterior cervical discectomy with fusion (ACDF) occurs in approximately 4% of cases. The main obstacles of revision surgery after ACDF via the same approach are scar tissue and arthrodesis. We present two patients with recurrent symptoms after ACDF who underwent revision surgery using an alternative, less invasive lateral approach (LA). These two patients both presented with recurrent unilateral cervical radiculopathy due to progression of intervertebral foraminal stenosis. The second patient also presented with paraparesis of the lower limbs and central stenosis. Anterior foraminotomy in the first case and oblique corpectomy in the second were performed via the LA. The previously implanted interbody cages were left intact and no new fusion procedures were needed. No spinal instability or symptom relapse was observed in follow-up. The lateral approach to the cervical spine enables direct and effective decompression of neural structures without violation of previously achieved interbody fusion.

Oblique corpectomy in the cervical spine

STUDY DESIGN

A narrative review.

OBJECTIVES

A literature review of studies reporting on the application of oblique corpectomy (OC) in various pathologies of the cervical spine.

SETTING

UK.

METHODS

A search was carried out using the PubMed and Google Scholar up to 18 March 2017. Finally, 26 studies met the inclusion criteria.

RESULTS

A multilevel OC shows good clinical outcomes in various pathologies in the cervical spine. The clinical improvement in cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament was found to be over 70%. OC allows wide anterior decompression of the spinal cord and complete unilateral nerve root decompression. The approach carries a risk of Horner's syndrome, vertebral artery and accessory nerve injury. OC does not compromise spine stability and osteoarthrodesis with bone grafting is not necessary. Spinal motions are preserved and appear close to normal. OC can be applied in patients with a low fusion rate such as the elderly, diabetics, and heavy smokers. Furthermore, OC was found to be an optimal approach for exta-intradural tumors of the cervical spine.

CONCLUSIONS

OC seems to be a valid alternative for the management of multisegmental CSM in selected cases. It should not be considered a first-line treatment strategy due to the relatively high morbidity. There are no studies comparing OC without fusion to other treatment options in CSM. Therefore, rigorous prospective studies using validated outcome measures with long-term follow-up are required.