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Kam JKT, Castle-Kirszbaum M, Dhaliwal T, Maingard J, Chandra R, Quan G, Gonzalvo CA, Goldschlager T. Preoperative coil localization for spinal surgery is accurate, safe and effective: a single-centre initial experience. ANZ J Surg 2024; 94:840-845. [PMID: 38553888 DOI: 10.1111/ans.18991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE AND STUDY DESIGN This is a retrospective, descriptive study of consecutive patients undergoing novel preoperative pushable coil localization for spinal surgery, in order to evaluate its feasibility, safety and accuracy. METHODS Consecutive patients who underwent pre-operative coil marking for spinal surgery at our institution from May 2018 to July 2021 were included. Data were collected for coil placement, accuracy, complications and fluoroscopy usage. Patient demographic and relevant perioperative and procedural data were also collected. RESULTS A total of 34 patients were identified of which 32 (94%) had complete data and imaging at last clinical follow up, with a mean duration of 13.9 months. There were no incorrect level surgeries performed. There were no coil-related complications found in our cohort. CONCLUSIONS Preoperative coil placement is an accurate, safe and well-tolerated method for level localization in spinal surgeries.
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Affiliation(s)
- Jeremy K T Kam
- Department of Neurosurgery, Monash Health, Melbourne, Australia
| | | | | | - Julian Maingard
- Department of Radiology, Monash Health, Melbourne, Australia
| | - Ronil Chandra
- Department of Radiology, Monash Health, Melbourne, Australia
| | - Gerald Quan
- Department of Orthopaedics and Neurosurgery, Austin Health, Melbourne, Australia
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Ravindra VM, Schmidt MH. Spinal Meningiomas: Diagnosis, Surgical Management, and Adjuvant Therapies. Neurosurg Clin N Am 2023; 34:425-435. [PMID: 37210131 DOI: 10.1016/j.nec.2023.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Meningiomas of the spinal canal are the most common intradural spinal canal tumors encountered in adults and account for 8% of all meningiomas. Patient presentation can vary considerably. Once diagnosed, these lesions are primarily treated surgically, but depending on location and pathological features, chemotherapy and radiosurgery may be required. Emerging modalities may represent adjuvant therapies. In this article, we review the current management of meningiomas of the spinal column.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA; Department of Neurosurgery, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA; Department of Neurosurgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico, 1155 University Bldvd. Southeast, Albuquerque, NM 87131, USA.
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Siminski CP, Carr CM, Kallmes DF, Oien MP, Atkinson JLD, Benson JC, Diehn FE, Kim DK, Liebo GB, Lehman VT, Madhavan AA, Mark IT, Morris PP, Shlapak DP, Verdoorn JT, Morris JM. Fluoroscopy- and CT-Guided Gold Fiducial Marker Placement for Intraoperative Localization during Spinal Surgery: Review of 179 Cases at a Single Institution-Technique and Safety Profile. AJNR Am J Neuroradiol 2023; 44:618-622. [PMID: 37080723 PMCID: PMC10171395 DOI: 10.3174/ajnr.a7854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/16/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND AND PURPOSE Wrong-level spinal surgery, especially in the thoracic spine, remains a challenge for a variety of reasons related to visualization, such as osteopenia, large body habitus, severe kyphosis, radiographic misinterpretation, or anatomic variation. Preoperative fiducial marker placement performed in a dedicated imaging suite has been proposed to facilitate identification of thoracic spine vertebral levels. In this current study, we report our experience using image-guided percutaneous gold fiducial marker placement to enhance the accuracy and safety of thoracic spinal surgical procedures. MATERIALS AND METHODS A retrospective review was performed of all fluoroscopy- or CT-guided gold fiducial markers placed at our institution between January 3, 2019, and March 16, 2022. A chart review of 179 patients was performed detailing the procedural approach and clinical information. In addition, the method of gold fiducial marker placement (fluoroscopy/CT), procedure duration, spinal level of the gold fiducial marker, radiation dose, fluoroscopy time, surgery date, and complications (including whether wrong-level surgery occurred) were recorded. RESULTS A total of 179 patients (104 female) underwent gold fiducial marker placement. The mean age was 57 years (range, 12-96 years). Fiducial marker placement was performed by 13 different neuroradiologists. All placements were technically successful without complications. All 179 (100%) operations were performed at the correct level. Most fiducial markers (143) were placed with fluoroscopy with the most common location at T6-T8. The most common location for placement in CT was at T3 and T4. CONCLUSIONS All operations guided with gold fiducial markers were performed at the correct level. There were no complications of fiducial marker placement.
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Affiliation(s)
- C P Siminski
- From the Mayo Clinic Alix School of Medicine (C.P.S.)
| | - C M Carr
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - D F Kallmes
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - M P Oien
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | | | - J C Benson
- Department of Neuroradiology (J.L.D.A., J.C.B.)
| | - F E Diehn
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - D K Kim
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - G B Liebo
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - V T Lehman
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - A A Madhavan
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - I T Mark
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - P P Morris
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - D P Shlapak
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - J T Verdoorn
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - J M Morris
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
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Tan D, Castle-Kirszbaum M, Mariajoseph FP, Kow CY, Ho B, Danks A, Goldschlager T, Kam J. The utility of internal spinal marking for intraoperative localisation: A systematic review. J Clin Neurosci 2023; 111:78-85. [PMID: 36989767 DOI: 10.1016/j.jocn.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/07/2022] [Accepted: 09/03/2022] [Indexed: 03/29/2023]
Abstract
BACKGROUND Incorrect level spinal surgery is an avoidable complication, with significant ramifications. Several pre-operative spinal marking techniques have been described to aid intraoperative localisation. METHODS A systematic search of Ovid MEDLINE, and EMBASE was performed from inception to July 2022. All publications describing cases of internal spinal marking were included for further analysis. 22 articles describing 503 patients satisfied our eligibility criteria. RESULTS A number of localisation techniques, including endovascular coiling (n = 16), fiducials (n = 177), dye (n = 109), needle/fixed wire (n = 199), cement (n = 4), and gadolinium tubes (n = 1) were described. The highest rates of technical success were observed with endovascular coiling, fiducials, cement and dye (100 %), and complication rates were lowest with endovascular coiling, fiducials and cement (0 %). CONCLUSIONS Overall, internal spinal marking was effective and safe. When considering practicality and efficacy, fiducial marking appears the optimal technique, as it can be performed in the outpatient setting under local anaesthesia. This review demonstrates the need for more targeted investigation into localisation methods in spinal surgery.
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Strong MJ, Santarosa J, Sullivan TP, Kazemi N, Joseph JR, Kashlan ON, Oppenlander ME, Szerlip NJ, Park P, Elswick CM. Pre- and intraoperative thoracic spine localization techniques: a systematic review. J Neurosurg Spine 2022; 36:792-799. [PMID: 34798613 PMCID: PMC10193475 DOI: 10.3171/2021.8.spine21480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In the era of modern medicine with an armamentarium full of state-of-the art technologies at our disposal, the incidence of wrong-level spinal surgery remains problematic. In particular, the thoracic spine presents a challenge for accurate localization due partly to body habitus, anatomical variations, and radiographic artifact from the ribs and scapula. The present review aims to assess and describe thoracic spine localization techniques. METHODS The authors performed a literature search using the PubMed database from 1990 to 2020, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 27 articles were included in this qualitative review. RESULTS A number of pre- and intraoperative strategies have been devised and employed to facilitate correct-level localization. Some of the more well-described approaches include fiducial metallic markers (screw or gold), metallic coils, polymethylmethacrylate, methylene blue, marking wire, use of intraoperative neuronavigation, intraoperative localization techniques (including using a needle, temperature probe, fluoroscopy, MRI, and ultrasonography), and skin marking. CONCLUSIONS While a number of techniques exist to accurately localize lesions in the thoracic spine, each has its advantages and disadvantages. Ultimately, the localization technique deployed by the spine surgeon will be patient-specific but often based on surgeon preference.
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Affiliation(s)
- Michael J. Strong
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | | | | | - Noojan Kazemi
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Jacob R. Joseph
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Osama N. Kashlan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | | | | | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Clay M. Elswick
- Brain and Spine Specialists of North Texas, Arlington, Texas
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Grin AA, Kasatkin DS, Karanadze VA, Shtadler VD. [Spinal motor segment labeling with a mixture of n-butyl-2-cyanoacrylate and iohexol in determining the level of thoracic spine surgery]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:62-67. [PMID: 34951761 DOI: 10.17116/neiro20218506162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
UNLABELLED Erroneous determining the level of spine surgery is an urgent problem in modern vertebrology. Incidence of this complication is up to 1 per 3110 patients, among patients undergoing thoracic spine surgery - 1 per 25 patients. Despite widespread use of spine surgery, there is still no standard rational method for prevention of erroneous determining the level of intervention. OBJECTIVE To develop a safe minimally invasive low-traumatic and cost-effective method for preoperative marking the level of thoracic spine surgery. MATERIAL AND METHODS A mixture of biodegradable adhesive based on cyanoacrylate and water-soluble iodine-containing X-ray contrast agent was used for preoperative marking in 8 patients scheduled for thoracic spine and spinal cord surgery. This mixture was injected into paravertebral tissues at the level of further intervention. RESULTS Preoperative marking ensured a fixed and clearly visible landmark during intraoperative fluoroscopy in 7 patients. In 1 patient, mixture spread in paravertebral soft tissues that did not allow us to obtain appropriate landmark during intraoperative radiography. CONCLUSION The described method makes it possible to create an immobile X-ray-positive «mark» in paravertebral soft tissues, which can be used to control the level of intervention at all surgical stages.
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Affiliation(s)
- A A Grin
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - D S Kasatkin
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - V A Karanadze
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - V D Shtadler
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Hanna G, Kim TT, Uddin SA, Ross L, Johnson JP. Video-assisted thoracoscopic image-guided spine surgery: evolution of 19 years of experience, from endoscopy to fully integrated 3D navigation. Neurosurg Focus 2021; 50:E8. [PMID: 33386009 DOI: 10.3171/2020.10.focus20792] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the evolution of thoracoscopic spine surgery from basic endoscopic procedures using fluoroscopy and anatomical localization through developmental iterations to the current technology use in which endoscopy and image-guided surgery are merged with intraoperative CT scanning. METHODS The authors provided detailed explanations of their thoracoscopic spine surgery techniques, beginning with their early-generation endoscopy with fluoroscopic localization, which was followed with point surface matching techniques and early image guidance. The authors supplanted this with the modern era of image guidance, thoracoscopic spine surgery, and seamless integration that has reached its current level of refinement. RESULTS A retrospective review of single-institution thoracoscopic procedures performed by the senior author over the course of 19 years yielded a total of 160 patients, including 73 women and 87 men. The mean patient age was 55 years, and the range included patients 16-94 years of age. There were no patients with worsened neurological function. One hundred sixteen patients underwent surgery for thoracic disc herniation, 18 for underlying neoplasms with spinal cord compression, 14 for osteomyelitis and discitis, 12 for thoracic deformity with neurological changes, and 8 for traumatic etiologies. CONCLUSIONS More than 19 years of experience has revealed the benefits of integrating thoracoscopic spine surgery with intraoperative CT scanning and image-guided surgery, including direct decompression without manipulation of neural elements, superior 3D spatial orientation, and localization of complex spinal anatomy. With the exponential growth of machine learning, robotics, artificial intelligence, and advances in imaging techniques and endoscopic imaging, there may be further refinements of this technique on the horizon.
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Affiliation(s)
| | - Terrence T Kim
- 2Orthopaedics, Cedars-Sinai Medical Center, Los Angeles; and
| | - Syed-Abdullah Uddin
- Departments of1Neurological Surgery and.,3Riverside School of Medicine, University of California, Riverside, California
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8
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Prevention of Wrong-level Surgery in the Thoracic Spine: Preoperative Computer Tomography Fluoroscopy-guided Percutaneous Gold Fiducial Marker Placement in 57 Patients. Spine (Phila Pa 1976) 2020; 45:1720-1724. [PMID: 32925684 DOI: 10.1097/brs.0000000000003691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE The aim of this study was to evaluate the feasibility, safety,s and complications of computer tomography (CT) fluoroscopy-guided percutaneous transpedicular gold fiducial marker insertion to reduce incidence of wrong-level surgery in the thoracic spine. SUMMARY OF BACKGROUND DATA Intraoperative localization of the correct thoracic level can be challenging and time-consuming, especially in obese patients and patients with anatomical variations. In the literature there are very few studies containing low numbers of patients which assessed CT or CT fluoroscopy-guided fiducial marker placement of the thoracic spine. Description of this technique has been similarly scarce. METHODS All patients who underwent percutaneous CT fluoroscopy-guided gold fiducial marker placement of the thoracic spine were retrospectively reviewed. Indications for surgery included degenerative disc disease, infection, spinal metastasis, and intra- and extradural tumors. Gold fiducial markers were placed using a percutaneous CT fluoroscopy-guided transpedicular approach with local anesthesia. In addition, sex, age, body mass index (BMI), thoracic level, related pathology, and procedure-related complications were also recorded. RESULTS A total of 57 patients (24 females, 33 males) were included. Mean age was 58.6 ± 15.5 years. No complications during CT fluoroscopy-guided gold fiducial marker placement were recorded. Intraoperative localization was successful in all patients. Mean BMI was 32.98 kg/m (range, 18.63-56.03 kg/m), and 63% of patients were obese (>30 kg/m). T7 (n = 11) was the most often marked vertebral body, followed by T10 (n = 10) and T6 (n = 7). The most cranial and most caudal levels marked were T2 and T12, respectively. CONCLUSION Preoperative CT fluoroscopy-guided percutaneous gold fiducial marker placement is safe, feasible, and accurate. The resulting facilitated localization of the intended thoracic level of surgery can reduce the length of surgery and prevent wrong-level surgery. Further studies are needed to evaluate in the effect on exposure to radiation and quantify the difference in operating room time. LEVEL OF EVIDENCE 4.
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Kinon MD, Benton JA, Krystal J, Cezayirli PC, Jansson S, Houten JK. A safe, reliable, inexpensive and novel technique to localize in the mid thoracic spine in the prone position: Proof of concept and technical illustration. J Clin Neurosci 2020; 82:83-86. [PMID: 33317744 DOI: 10.1016/j.jocn.2020.10.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/05/2020] [Accepted: 10/21/2020] [Indexed: 10/23/2022]
Abstract
Intraoperative localization within the thoracic spine in the prone position may be particularly difficult on account of absence of common landmarks such as the sacrum or the C2 vertebra, thus increasing the potential for wrong-level surgery that may lead to patient morbidity and potential litigation. Some current localization methods involve implantation of markers that are invasive and serve to add to procedural expense while yet still failing to entirely eliminate errors. We describe a novel, non-invasive, and inexpensive technique for intraoperative localization of the thoracic spine in the prone position using an esophageal temperature probe. Following patient positioning, anteroposterior fluoroscopy is used to localize the radiopaque tip of the esophageal probe relative to the thoracic spine. After determining the probe tip's location, it becomes the counting reference for all subsequent intraoperative fluoroscopic localizations during surgery. As the probe tip is generally visible in the same fluoroscopic image as the surgical level, error from parallax created when moving the fluoroscopy machine from an anatomic landmark either above or below is avoided and a shorter fluoroscopy time is needed. Use of an esophageal temperature probe as a landmark in localizing spinal level may serve as a reliable and It offers a safe, reliable, and inexpensive technique for proper localization of thoracic spine levels.
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Affiliation(s)
- Merritt D Kinon
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States.
| | - Joshua A Benton
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Jonathan Krystal
- Department of Orthopedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Phillip C Cezayirli
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Samantha Jansson
- Department of Anesthesia, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - John K Houten
- Department of Neurological Surgery, Maimonides Medical Center and Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Brooklyn, NY, United States
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Krishnan A, Degulmadi D, Mayi S, Kulkarni M, Reddy C, Singh M, Rai RR, Dave BR. Transforaminal Thoracic Interbody Fusion for Thoracic Disc Prolapse: Surgicoradiological Analysis of 18 Cases. Global Spine J 2020; 10:706-714. [PMID: 32707016 PMCID: PMC7383794 DOI: 10.1177/2192568219870459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
STUDY DESIGN Retrospective observational study. OBJECTIVES Thoracic disc prolapse (TDP) surgeries have reported complications ranging from paraplegia to approach related complications. This study is to present a series of TDP patients surgically treated with transforaminal thoracic interbody fusion (TTIF). Emphasis on surgical technique and strategies to avoid complications are analyzed. METHODS Eighteen patients with TDP were included. Imagings were analyzed for end-plate changes and calcification. Type of disc prolapse (central/para-central) and percentage of canal occupancy were noted. Objective outcome was quantified with Visual Analogue Scale (VAS), modified Nurick's grade, and ASIA (American Spinal Injury Association) score. All complications were noted. RESULTS Eighteen patients (average age 43.65 years) having total 22 levels operated, that included double level (n = 2) and missed level (n = 2) are reported. All patients had myelopathy. Calcification of disc (n = 13), central disc prolapses (n = 9), para-central (n = 11) and more than 50% canal occupancy (n = 8) were noted. VAS back pain, modified Nurick's grade and ASIA grade improved significantly in all patients. One patient had postoperative transient deficit. The functional score achieved its maximum at 1 year follow-up and remained static at final follow-up of 65.05 months. Union was achieved in all patients. CONCLUSIONS The most important factor for outcome in TDP is the technical aspect of avoiding cord manhandling and avoiding wrong level surgeries. TTIF is not devoid of complications but can give good results to posterior approach trained surgeons.
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Affiliation(s)
- Ajay Krishnan
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
- BIMS Hospital, Bhavnagar, Gujarat, India
- Ajay Krishnan, C302, Orange Avenue, Maple County 1, Thaltej, Ahmedabad, Gujarat 380059, India.
| | | | - Shivanand Mayi
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
| | - Mahesh Kulkarni
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
| | - Chaitanya Reddy
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
| | - Mreetunjay Singh
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
| | - Ravi Ranjan Rai
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
| | - Bharat R. Dave
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
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Choi G, Munoz-Suarez D. Transforaminal Endoscopic Thoracic Discectomy: Technical Review to Prevent Complications. Neurospine 2020; 17:S58-S65. [PMID: 32746518 PMCID: PMC7410381 DOI: 10.14245/ns.2040250.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/08/2020] [Indexed: 11/21/2022] Open
Abstract
For all the spine surgeons, thoracic disc herniations (TDHs) entrust a real challenge in terms of patient diagnosis, proper selection, surgical technique, and potential adverse events. TDHs are relatively uncommon compared to the lumbar and cervical levels. Literature reports a variable prevalence of TDHs around 6% to 40%, but less than 1% of all disk herniations are symptomatic TDHs, evidencing as a relatively unusual condition. Nowadays, transforaminal endoscopic thoracic discectomy (TETD) has been implemented as an alternative to classic open procedures with results that are as good as and, in some situations, better than those in traditional discectomy. However, the surgeon must be familiar with endoscopic lumbar spine surgery before opting to perform a TETD, considering that the learning curve is much harder. We describe all the steps and safety considerations during TETD based on the anatomic differences compared to lumbar endoscopic procedures. TETD is an effective and safe method that yields more benefits, provides a direct route to the lesion with less morbidity, and is performed in a minimally invasive way. Many severe complications related to the thoracic region could be avoided having the proper knowledge, adequate technique, and safety routes and considerations.
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Affiliation(s)
- Gun Choi
- Spine Surgery Department, Pohang Woori Spine Hospital, Pohang, Korea
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12
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He B, Nan G. Use of a radiopaque localizer grid and methylene blue staining as an aid to reduce radiation exposure. MINIM INVASIV THER 2020; 31:84-88. [PMID: 32491922 DOI: 10.1080/13645706.2020.1771374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Localization of small femur lesions for resection can be challenging and may be associated with the need for significant fluoroscopic imaging and tissue dissection. This study was performed to evaluate the use of a radiopaque localizer grid along with methylene blue staining for resection of small femur lesions in children, and to determine the effectiveness of this effectiveness at reducing radiation exposure and tissue injury.Material and methods: A radiopaque localizer grid was used to identify the body surface site of bone lesions, and then 0.02-0.03 mL of methylene blue was injected into the bone lesions. After skin incision, the blue bone tissue was found and complete lesion resection performed.Results: A radiopaque localizer grid was utilized to plan the point of entry for lesion resection. The average operation time was shorter, and the C-arm was used less frequently, and the incision length was shorter in the grid and methylene blue group compared with the control group.Conclusion: A radiopaque localizer grid is a simple and practical device for efficient localization of the skin entry site, and methylene blue accurately pinpoints bone lesions, reducing radiation exposure and tissue injury.
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Affiliation(s)
- Bo He
- Department II of Orthopaedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, the Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Guoxin Nan
- Department II of Orthopaedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, the Children's Hospital of Chongqing Medical University, Chongqing, China
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Castle-Kirszbaum M, Maingard J, Goldschlager T, Chandra RV. Preoperative coil localization for spinal surgery: technical note. J Neurosurg Spine 2020; 32:483-487. [PMID: 31731276 DOI: 10.3171/2019.8.spine19762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/28/2019] [Indexed: 11/06/2022]
Abstract
Intraoperative localization in spinal surgery is essential to facilitate the best surgical outcome and to avoid wrong-site surgery. Intraoperative fluoroscopy is generally adequate, but anatomical variation, body habitus, and the inherent difficulties of fluoroscopy at certain levels may lead the surgeon astray. Here, the authors present their technique for preoperative localization that relies solely on fixed anatomical landmarks using CT-guided, percutaneously placed radiopaque markers. In the outpatient setting, low-dose CT scanning of the neuraxis is performed to identify fixed landmarks and, under local anesthesia and CT guidance, a pushable microcoil is inserted through a Chiba needle into the periosteum of the pedicle at the level of interest. The patient returns home with no precautions while the coil is in situ, and then the patient returns sometime later for surgery. Intraoperatively, typically a single lateral radiograph is required to visualize the coil and the level. Preoperative placement of radiopaque markers at the level of interest is an effective tool for avoiding wrong-site surgery, especially in circumstances in which fluoroscopy may be troublesome. The authors' method is accurate, effective, and expeditious and can be performed easily in the outpatient setting.
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Affiliation(s)
| | - Julian Maingard
- 2Neurointerventional Radiology Unit, Monash Imaging, Monash Health, Melbourne; and
| | - Tony Goldschlager
- 1Department of Neurosurgery and
- 3Department of Surgery, Monash University, Melbourne, Australia
| | - Ronil V Chandra
- 2Neurointerventional Radiology Unit, Monash Imaging, Monash Health, Melbourne; and
- 3Department of Surgery, Monash University, Melbourne, Australia
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Maduri R, Starnoni D, Duff JM. Letter to the Editor. Bone cylinder plug and coil technique for accurate pedicle localization in thoracic spine surgery. J Neurosurg Spine 2020; 33:124-125. [PMID: 32109869 DOI: 10.3171/2019.12.spine191520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
STUDY DESIGN Basic descriptive analysis was performed for the incident characteristics of wrong level spinal surgery in the Veterans Health Administration (VHA). OBJECTIVE To determine the frequency of reported occurrence of incorrect spine level surgery in the VHA, causal factors for the events, and propose solutions to the issue. SUMMARY OF BACKGROUND DATA Wrong site surgery is one of the most common events reported to The Joint Commission. It has been reported that 50% of spine surgeons experience at least 1 wrong site surgery in their career, with events leading to signficant harm to patients. MATERIALS AND METHODS We examined incorrect level spine surgery adverse events reported to the VHA National Center for Patient Safety (NCPS) from 2000 to 2017. A rate of wrong site spine surgery was determined by dividing the number of wrong site cases by the total number of spine surgeries during the study period. Similarly, a rate of wrong site surgery by orthopedist and neurosurgeons was calculated. RESULTS There were 32 reported cases of wrong site spine surgery between 2000 and 2017. Fourteen cases involved the cervical region, 13 the lumbar region, and 5 the thoracic region. The majority of the root causes (69% or 48 of 69 root causes) fell into 2 broad categories: problems with the radiograph or problems with the intraoperative marker. These were not mutually exclusive and several root cause analyses involved >1 of these issues. CONCLUSIONS Wrong level surgery of the spine is a significant safety issue facing the field that continues to occur despite surgical teams following guidelines. As poor radiograph quality and interpretability were the most common root causes of these events, interventions aimed at optimizing image quality and accurate interpretation would be a logical first action.
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Maduri R, Starnoni D, Barges-Coll J, David Hajdu S, Michael Duff J. Bone cylinder plug and coil technique for accurate pedicle localization in thoracic spine surgery: A technical note. Surg Neurol Int 2019; 10:104. [PMID: 31528442 PMCID: PMC6744771 DOI: 10.25259/sni-258-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 05/04/2019] [Indexed: 11/04/2022] Open
Abstract
Background Intraoperative identification of the correct level during thoracic spine surgery is essential to avoid wrong-level procedures. Despite technological progress, intraoperative imaging modalities for identifying the correct thoracic spine level remain unreliable and often lead to wrong-level surgery. To counter potential wrong-level operations, here, we have proposed a novel pedicle/bone cylinder marking technique for use in the thoracic spine utilizing biplanar fluoroscopy and confirmed with computed tomography (CT). Methods First, under fluoroscopic guidance, a bone cylinder is removed from the correct thoracic pedicle. Next, endovascular coils are packed into the cancellous bone defect followed by reinsertion of the bony plug. The patient then undergoes a CT scan of the entire thoracolumbosacral spine to precisely identify the marked level before surgery. Results We utilized this bone cylinder plug/coil technique to identify the T9-T10 level in a 56-year-old female with a soft thoracic disc herniation. The index thoracic pedicle was successfully localized before performing the unilateral minimally invasive laminectomy followed by the transpedicular thoracic disc excision. Conclusion The bone cylinder plug/coil technique is a safe and effective method for marking the correct level in thoracic spine surgery, while also reducing the operative time.
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Affiliation(s)
- Rodolfo Maduri
- Department of Clinical Neurosciences, Service of Neurosurgery, 46 rue du Bugnon, Lausanne
| | - Daniele Starnoni
- Department of Clinical Neurosciences, Service of Neurosurgery, 46 rue du Bugnon, Lausanne
| | - Juan Barges-Coll
- Department of Clinical Neurosciences, Spine Unit, 46 rue du Bugnon, Lausanne
| | - Steven David Hajdu
- Department of Radiology, Division of Diagnostic and Interventional Neuroradiology, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois), 46 rue du Bugnon, Lausanne
| | - John Michael Duff
- Clinique de Genolier, Spine Center, Route du Muids 5, Genolier, Switzerland
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Sharma SB, Kim JS. A Review of Minimally Invasive Surgical Techniques for the Management of Thoracic Disc Herniations. Neurospine 2019; 16:24-33. [PMID: 30943704 PMCID: PMC6449820 DOI: 10.14245/ns.1938014.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 11/19/2022] Open
Abstract
Thoracic disc herniation (TDH) is a rare, but technically challenging, disorder. Apart from their unfamiliarity with this condition, surgeons are often posed with challenges regarding the diverse methods available to address TDH, the neurological disturbances accompanying the disorder, the prospect of iatrogenic cord damage during surgical procedures, and the complications associated with various surgical approaches. In today's era, when minimally invasive surgery has been incorporated into almost every aspect of managing spine disorders, it is necessary for surgeons to be aware of the various minimally invasive techniques available for the management of these rare and difficult conditions. In this review article, we provide a synopsis of the epidemiology, clinical features, and technical aspects of TDH, starting from level identification to intraoperative neuromonitoring and including important steps and guidance for all the minimally invasive approaches to TDH. We conclude the review by providing insights into the clinical decision-making process and outline the specific aspects of "giant" thoracic discs and indications for fusion in certain conditions. Outcomes of minimally invasive surgery for these conditions are generally favorable. The location of herniation is an important factor for surgical planning.
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Affiliation(s)
- Sagar B. Sharma
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| | - Jin-Sung Kim
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
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Vitale M, Minkara A, Matsumoto H, Albert T, Anderson R, Angevine P, Buckland A, Cho S, Cunningham M, Errico T, Fischer C, Kim HJ, Lehman R, Lonner B, Passias P, Protopsaltis T, Schwab F, Lenke L. Building Consensus: Development of Best Practice Guidelines on Wrong Level Surgery in Spinal Deformity. Spine Deform 2018; 6:121-129. [PMID: 29413733 DOI: 10.1016/j.jspd.2017.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
Abstract
STUDY DESIGN Consensus-building using the Delphi and nominal group technique. OBJECTIVE To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. SUMMARY OF BACKGROUND DATA Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed. METHODS The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting. RESULTS Participants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants. CONCLUSION We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Michael Vitale
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Anas Minkara
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Hiroko Matsumoto
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA.
| | - Todd Albert
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Richard Anderson
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Peter Angevine
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Aaron Buckland
- New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003, USA
| | - Samuel Cho
- Mount Sinai, 5 E 98th St, 4th Floor, New York, NY 10029, USA
| | | | - Thomas Errico
- New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003, USA
| | - Charla Fischer
- New York-Presbyterian The Allen Hospital, 5141 Broadway, New York, NY 10034, USA
| | - Han Jo Kim
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Ronald Lehman
- New York-Presbyterian The Allen Hospital, 5141 Broadway, New York, NY 10034, USA
| | - Baron Lonner
- Scoliosis and Spine Associates, 820 2nd Ave, New York, NY 10017, USA
| | - Peter Passias
- New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003, USA
| | | | - Frank Schwab
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Lawrence Lenke
- New York-Presbyterian The Allen Hospital, 5141 Broadway, New York, NY 10034, USA
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Bouthors C, Benzakour A, Court C. Surgical treatment of thoracic disc herniation: an overview. INTERNATIONAL ORTHOPAEDICS 2018; 43:807-816. [PMID: 30406842 DOI: 10.1007/s00264-018-4224-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord. METHODS Literature review. RESULTS Symptomatic TDH is a rare condition predominantly localized between T8 and L1. Surgical indications include intractable back or radicular pain, neurological deficits, and myelopathy signs. Giant calcified TDH (> 40% spinal canal occupation) are frequently associated with myelopathy, intradural extension, and post-operative complications. Careful pre-operative planning helps reduce the risk of complications. Pre-operative CT and MRI identify the hernia's location and size, calcifications, and intradural extension. The approach must provide adequate dural sac visualization with minimal manipulation of the cord. Non-anterior approaches are favoured if they provide at least equal exposure than anterior approach owing to higher risk of pulmonary morbidity associated with anterior approach. A transthoracic approach is recommended for central calcified herniated discs. A posterolateral approach is often suitable for non-calcified lateralized TDH. Thoracoscopic approaches are less invasive but have a substantial learning curve. Retropleural mini-thoracotomy is an acceptable alternative. Pre-operative identification of the pathological level is confirmed by intra-operative level check. Intra-operative cord monitoring is preferable but warrant further studies. Magnification and adequate lightening of the surgical field are paramount (microscope, thoracoscopy). Intra-operative CT scan with navigation is becoming increasingly popular since it provides real-time control on the decompression. Indications of fusion consist of pre-operative back pain, Scheuermann's disease, multilevel resection, wide vertebral body resection (> 50%), and herniation at thoracolumbar junction. Neurological deterioration, dural tear, and subarachnoid-pleural fistula are the most severe complications. CONCLUSION Further improvements are still warranted in thoracic spine surgery despite the advent of minimally invasive techniques. Intra-operative CT scan will probably enhance the safety of the TDH surgery.
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Affiliation(s)
- Charlie Bouthors
- Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France.
| | - Ahmed Benzakour
- Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France
| | - Charles Court
- Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France
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20
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Fiaschi P, Prior A, Sbaffi PF, Bizzi F, D'Andrea A, Cagetti B, Badaloni F, Allegretti L, Mavilio N, Padolecchia R, Valsania V, Zona G. Spinal Dural Arteriovenous Fistulas: Clinical Results and Quality of Life Assessment with Surgical Treatment as a Crucial Therapy. The Joint Experience of Two Centers. World Neurosurg 2018; 122:e270-e278. [PMID: 30339911 DOI: 10.1016/j.wneu.2018.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Dorsal intradural arteriovenous fistulas (AVFs) consist of a direct connection between a radicular feeding artery and the coronal venous plexus; this direct connection leads to arterialization of the venous plexus, venous congestion, and myelopathy. Controversy still exists regarding the best treatment modality of spinal dural AVFs. Surgical disconnection of spinal dural AVFs is a straightforward procedure with a high success rate and virtually no risk of recurrence or incomplete treatment. To identify factors associated with the clinical progression of dorsal intradural AVFs and quantify the range of surgical outcomes in terms of neurologic improvement as well as patients' perception of quality of life (QOL). METHODS A retrospective observational study of 19 consecutive patients treated with surgery over a 10-year period was carried out. We analyzed surgical results and clinical outcomes. We also evaluated the impact of this disease and its sequelae on the patients' postoperative health-related QOL. RESULTS The surgical procedure showed good results in terms of neurologic improvement as well as patients' perception of QOL. CONCLUSIONS Our series confirmed that surgical obliteration of dorsal intradural AVFs is an effective and safe procedure. The results of this retrospective analysis make us believe that surgery, given its low morbidity and high success rate, represents a safe and effective first therapeutic option for these spinal vascular malformations. It could be considered to avoid unsuccessful endovascular attempts that could delay the definitive treatment of this disease. The surgical procedure showed good results in terms of neurologic improvement as well as patients' perception of QOL.
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Affiliation(s)
- Pietro Fiaschi
- Section of Neurosurgery, Department of Neurosciences (DINOGMI), San Martino University Hospital, University of Genoa, Genoa, Italy.
| | - Alessandro Prior
- Section of Neurosurgery, Department of Neurosciences (DINOGMI), San Martino University Hospital, University of Genoa, Genoa, Italy
| | - Pier Filippo Sbaffi
- Section of Neurosurgery, Department of Neurosciences (DINOGMI), San Martino University Hospital, University of Genoa, Genoa, Italy
| | - Fabiola Bizzi
- Department of Educational Sciences (DISFOR), University of Genoa, Genoa, Italy
| | - Alessandro D'Andrea
- Section of Neurosurgery, Department of Neurosciences (DINOGMI), San Martino University Hospital, University of Genoa, Genoa, Italy
| | - Bernarda Cagetti
- Department of Neurosurgery, S. Corona Hospital, Pietra Ligure, Italy
| | - Filippo Badaloni
- Department of Neurosurgery, S. Corona Hospital, Pietra Ligure, Italy
| | - Luca Allegretti
- Department of Diagnostic and Interventional Neuroradiology, San Martino University Hospital, Genoa, Italy
| | - Nicola Mavilio
- Department of Diagnostic and Interventional Neuroradiology, San Martino University Hospital, Genoa, Italy
| | | | - Valtero Valsania
- Department of Neurosurgery, S. Corona Hospital, Pietra Ligure, Italy
| | - Gianluigi Zona
- Section of Neurosurgery, Department of Neurosciences (DINOGMI), San Martino University Hospital, University of Genoa, Genoa, Italy
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Court C, Mansour E, Bouthors C. Thoracic disc herniation: Surgical treatment. Orthop Traumatol Surg Res 2018; 104:S31-S40. [PMID: 29225115 DOI: 10.1016/j.otsr.2017.04.022] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 02/02/2023]
Abstract
Thoracic disc herniation is rare and mainly occurs between T8 and L1. The herniation is calcified in 40% of cases and is labeled as giant when it occupies more than 40% of the spinal canal. A surgical procedure is indicated when the patient has severe back pain, stubborn intercostal neuralgia or neurological deficits. Selection of the surgical approach is essential. Mid-line calcified hernias are approached from a transthoracic incision, while lateralized soft hernias can be approached from a posterolateral incision. The complication rate for transthoracic approaches is higher than that of posterolateral approaches; however, the former are performed in more complex herniation cases. The thoracoscopic approach is less invasive but has a lengthy learning curve. Retropleural mini-thoracotomy is a potential compromise solution. Fusion is recommended in cases of multilevel herniation, herniation in the context of Scheuermann's disease, when more than 50% bone is resected from the vertebral body, in patients with preoperative back pain or herniation at the thoracolumbar junction. Along with complications specific to the surgical approach, the surgical risks are neurological worsening, dural breach and subarachnoid-pleural fistulas. Giant calcified herniated discs are the largest contributor to myelopathy, intradural extension and postoperative complications. Some of the technical means that can be used to prevent complications are explored, along with how to address these complications.
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Affiliation(s)
- C Court
- Centre hospitalier universitaire de Bicêtre, Assistance publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France.
| | - E Mansour
- Centre hospitalier universitaire de Bicêtre, Assistance publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - C Bouthors
- Centre hospitalier universitaire de Bicêtre, Assistance publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
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Abstract
STUDY DESIGN A retrospective review. OBJECTIVE The aim of this study was to demonstrate proof-of-concept of preoperative percutaneous intraosseous fiducial marker placement before thoracic spine surgery. SUMMARY OF BACKGROUND DATA Wrong-level spine surgery is defined as a never event by Center for Medicare Services, yet the strength of data supporting the implementation of Universal Protocol to limit wrong level surgery is weak. The thoracic spine is especially prone to intraoperative mislocalization, particularly in cases of morbid obesity and anatomic variations. METHODS We retrospectively reviewed all cases of preoperative percutaneous image-guided intraosseous placement of a metallic marker in the thoracic spine. Indications for surgery included degenerative disc disease (16/19), osteochondroma resection, spinal metastasis, and ligation of dural arteriovenous malformation. All metallic markers were placed from a percutaneous transpedicular approach under imaging guidance [fluoroscopy and computed tomography (CT) or CT alone]. Patient body mass index (BMI) was recorded. Overweight and obese BMI was defined greater than 25 and 30 kg/m, respectively. RESULTS All 19 patients underwent fiducial marker placement and intraoperative localization successfully without complication. Twenty-two thoracic spine levels were localized. The T7, T9, T10, and T11 levels were the most often localized at rate of 18.1% for each level (4/22). The most cranial and caudal levels localized were T4 and T11. About 84.2% (16/19) of the cohort was overweight (57.9%; 11/19) or obese (26.3%; 5/19). The median BMI was 30.2 kg/m (range, 23.9-54.3 kg/m). CONCLUSION Preoperative percutaneous thoracic fiducial marker placement under imaging guidance is a safe method for facilitating intraoperative localization of the target spinal level, especially in obese patients. Further studies are needed to quantify changes in operative time and radiation exposure. LEVEL OF EVIDENCE 4.
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Abstract
STUDY DESIGN A technical report. OBJECTIVE The aim of the present study was to present an improvement on localization techniques employed for use in the thoracic spine using sterile spinal needles docked on the transverse process of each vertebra, which can be performed in both percutaneous and open spinal procedures. SUMMARY OF BACKGROUND DATA Wrong-level surgery may have momentous clinical and emotional implications for a patient and surgeon. It is reported that one in every 2 spine surgeons will operate on the wrong level during his or her career. Correctly localizing the specific thoracic level remains a significant challenge during spine surgery. METHODS Fluoroscopic anteroposterior and lateral views were obtained starting in the lower lumbar spine, and an 18-G spinal needle was placed in the transverse process of L3 counting up from the sacrum and also at T12. The fluoroscopy was then moved cephalad and counting from the spinal needle at T12, the other spinal needles were placed at the targeted operating thoracic vertebrae. Once this was done, we were able to accurately determine the thoracic levels for surgical intervention. RESULTS Using this technique, the markers were kept in place even after the incisions were made. This prevented us from losing our location in the thoracic spine. Correctly placed instrumentation was made evident with postoperative imaging. CONCLUSIONS We have described the successful use of a new technique using spinal needles docked against transverse processes to correctly and reliably identify thoracic levels before instrumentation. The technique was reproducible in both open surgeries and for a percutaneous procedure. This technique maintains the correct spinal level during an open procedure. We posit that wrong-level thoracic spine surgery may be preventable.
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Reitman CA. Pearls: Wrong-level Surgery Prevention. Clin Orthop Relat Res 2016; 474:636-9. [PMID: 26566979 PMCID: PMC4746148 DOI: 10.1007/s11999-015-4627-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 11/02/2015] [Indexed: 01/31/2023]
Affiliation(s)
- Charles A. Reitman
- grid.259828.c0000000121893475Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street, 708 CSB, Charleston, SC 29425 USA
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25
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Ravindra VM, Mazur MD, Driscoll M, McEvoy S, Schmidt MH. BRCA2-positive spinal intramedullary ovarian metastatic disease: case report. Spine J 2016; 16:e201-7. [PMID: 26552643 DOI: 10.1016/j.spinee.2015.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/09/2015] [Accepted: 10/29/2015] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Meghan Driscoll
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Sara McEvoy
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Meic H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
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Takami M, Elwany A, Destandau J. Accuracy and evaluation of irradiation of novel localization devices with unique three-dimensional structures in microendoscopic spine surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:253-8. [PMID: 26911298 DOI: 10.1007/s00590-016-1747-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/16/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although many reports are available on using a variety of instruments and techniques to prevent wrong-level spine surgery, the accurate localization of the correct spinal level remains problematic. At the same time, surgeons are also required to reduce radiation exposure to patients and operating room personnel. To solve these problems, we developed and used specially designed marking devices with a unique three-dimensional structure. PURPOSE To evaluate the accuracy of our novel devices for localization of the spinal level to prevent wrong-level surgery and reduce the amount and time of radiation exposure during surgery. STUDY DESIGN This was a retrospective cohort study. METHODS In 8240 consecutive patients who underwent microendoscopic spine surgery between 1993 and 2012, the incidence of wrong-level surgery was studied. In addition, the amount of radiation exposure and total fluoroscopy time were measured in recent 100 consecutive patients using a digital dosimeter attached to the fluoroscope. RESULTS Eight (0.097 %) patients had undergone wrong-level surgery. The average radiation exposure was 0.26 mGy (range 0.10-1.15 mGy), and the average total fluoroscopy time was 3.1 s (range 1-7 s). CONCLUSIONS Our novel localization devices and technique for their use in spine surgery are reliable and accurate for identifying the target level and contributed to reductions in preoperative localization error and radiation exposure to patients and operating room personnel.
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Affiliation(s)
- Masanari Takami
- Department of Micro-Endoscopic Spine Surgery, 145 Rue de la Pelouse-de-Douet, 33000, Bordeaux, France.
| | - Amr Elwany
- Department of Micro-Endoscopic Spine Surgery, 145 Rue de la Pelouse-de-Douet, 33000, Bordeaux, France
| | - Jean Destandau
- Department of Micro-Endoscopic Spine Surgery, 145 Rue de la Pelouse-de-Douet, 33000, Bordeaux, France
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Abstract
Spinal meningiomas are the most common spinal tumors encountered in adults, and account for 6.5% of all craniospinal tumors. The treatment for these lesions is primarily surgical, but emerging modalities may include chemotherapy and radiosurgery. In this article, the current management of spinal meningiomas and the body of literature surrounding conventional treatment is reviewed and discussed.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132, USA
| | - Meic H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132, USA.
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Technical modifications and decision-making to reduce morbidity in thoracic disc surgery: An institutional experience and treatment algorithm. Clin Neurol Neurosurg 2015; 133:75-82. [DOI: 10.1016/j.clineuro.2015.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/08/2015] [Accepted: 03/21/2015] [Indexed: 11/24/2022]
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Bogner R, Resch H, Mayer M, Lederer S, Ortmaier R. Rupture of the spleen following thoracoscopic spine surgery in a patient with chronic pancreatitis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24 Suppl 4:S569-72. [PMID: 25501876 DOI: 10.1007/s00586-014-3724-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 12/07/2014] [Accepted: 12/08/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE To highlight the perioperative risk of intracapsular haematoma of the spleen or splenic ruptures during thoracoscopic spine surgery in patients with chronic pancreatitis. METHODS A 38-year-old patient with an L1 burst fracture (AO A3.3) underwent a standard thoracoscopic corpectomy and replacement of the vertebral body with an extendable vertebral body replacement 10 days after posterior instrumentation of T12-L2. In patients history chronic abusive alcoholism with related diseases such as pancreatitis, followed by hemipancreatectomy was found. Six hours after the surgery, the patient became hemodynamically unstable. An emergency CT scan revealed a splenic rupture. Emergent splenectomy was performed. RESULTS After surgical treatment of the L1 burst fracture, a rupture of the spleen was detected. An immediate splenectomy was performed. At the 18-month follow-up, an unchanged stable position of the cage was observed on CT. CONCLUSIONS Due to its proximity to the thoracolumbar junction, the spleen is vulnerable to injury during spine surgery. If the patient has undergone previous intra-abdominal operations or chronic inflammation of the pancreas is found, special care of the spleen during the operation is necessary.
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Affiliation(s)
- Robert Bogner
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Muellner Hauptstrasse 48, 5020, Salzburg, Austria,
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Macki M, Bydon M, McGovern K, Abt N, de la Garza-Ramos R, Naff N, Bydon A. Gold fiducials are a unique marker for localization in the thoracic spine: a cost comparison with percutaneous vertebroplasty. Neurol Res 2014; 36:925-7. [PMID: 24963696 DOI: 10.1179/1743132814y.0000000413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
We present a unique application of the gold fiducial as a preoperative, radiographic marker placed in the thoracic spine and used for intraoperative localization. In comparison to percutaneous vertebroplasty marking of thoracic spinal levels with polymethyl methacrylate (PMMA) cement, implantation of the gold fiducial is technically facile with a minimal learning curve. The fiducial markers are also associated with significantly less financial resources. Following 2013 Current Procedural Terminology (CPT) coding, the cost of vertebroplasty under fluoroscopic guidance, $3195·43, or under computed tomography (CT) guidance, $3232·54, is more than double the cost of the gold fiducial implantation - $1237·55 and $1267·03, under similar imaging techniques, respectively. In the first description of gold fiducials in the thoracic spine, we conclude that the marker is a safe and cost-effective method for preoperative localization of the thoracic levels.
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Abstract
STUDY DESIGN Retrospective review of the literature. OBJECTIVE To update recent trends in the surgical treatment for thoracic disc herniation (TDH). SUMMARY OF BACKGROUND DATA TDH is rare; however, it is usually accompanied by myelopathy and is indicated for surgical treatment. A variety of surgical approaches have been described to reach these anatomically challenging lesions. METHODS Review of the literature. RESULTS Recently, minimally invasive techniques for TDH have gained popularity. These include thoracoscopic and mini-open anterolateral retropleural approaches, as well as microscopic and endoscopic surgery. In addition, this article updates important aspects of surgical treatment for TDH such as definition of surgical level, treatment of calcified and/or giant disc, multilevel lesions, and fusion requirements. CONCLUSION Definition of surgical level is imperative in the surgical treatment for TDH. Outcomes of minimum invasive surgery are satisfactory. Type of disc herniation and biomechanical stability are the important factors for surgical planning.
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Grimm BD, Laxer EB, Blessinger BJ, Rhyne AL, Darden BV. Wrong-Level Spine Surgery. JBJS Rev 2014; 2:01874474-201402030-00002. [DOI: 10.2106/jbjs.rvw.m.00052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
Imaging of the postoperative spine is common, although it remains a difficult task for radiologists. This article presents an overview of common surgical approaches and spinal hardware, and specific complications that may be associated with each procedure. In addition, expected postoperative changes and complications that are common among procedures, with their differential diagnosis and imaging features, are discussed.
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Affiliation(s)
- Morgan C Willson
- Department of Radiology, Foothills Medical Center, 1403 29th Street Northwest, Calgary, Alberta T2N 2T9, Canada.
| | - Jeffrey S Ross
- Neuroradiology Department, Barrow Neurologic Institute, St Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ 85013, USA
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Young RM, Prasad V, Wind JJ, Olan W, Caputy AJ. Novel technique for preoperative pedicle localization in spinal surgery with challenging anatomy. J Neurosurg Spine 2014; 20:400-3. [PMID: 24506100 DOI: 10.3171/2013.12.spine13477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Accurately localizing a spine level in the thoracic spine is often not easily achieved with the existing imaging modalities available in the operating room. The coordination of the preoperative imaging pathology with intraoperative imaging is even more difficult in patients with challenging anatomy. Using standard percutaneous techniques, the authors placed a radiopaque embolization coil into the pedicle of interest under biplanar fluoroscopy in 1 patient. Thoracic spine MRI along with scout MRI was then performed to confirm coil marker placement in relation to the actual spine pathology prior to surgical intervention. No complications were observed during placement of the radiopaque marker. Intraoperatively, the marker was immediately and easily visualized, leading to a confident identification of the correct thoracic spinal level. The preoperative placement of a radiopaque marker into the vertebral pedicle of the identified pathological level combined with postplacement MRI verification provides an advantage over previously proposed techniques in the literature.
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Affiliation(s)
- Richard M Young
- Department of Neurological Surgery, George Washington University Medical Center, Washington, DC
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Ahmadi SA, Slotty PJ, Schröter C, Kröpil P, Steiger HJ, Eicker SO. Marking wire placement for improved accuracy in thoracic spinal surgery. Clin Neurol Neurosurg 2014; 119:100-5. [PMID: 24635936 DOI: 10.1016/j.clineuro.2014.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 12/18/2013] [Accepted: 01/19/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To present an innovative approach that does not rely on intraoperative X-ray imaging for identifying thoracic target levels and critically appraise its value in reducing the risk of wrong-level surgery and radiation exposure. METHODS 96 patients admitted for surgery of the thoracic spine were prospectively enrolled, undergoing a total of 99 marking wire placements. Preoperatively a flexible marking wire derived from breast cancer surgery was inserted with computed tomography (CT) guidance at the site of interest--the wire was then used as an intraoperative guidance tool. RESULTS Wire placement was considered successful in 96 cases (97%). Most common pathologies were tumors (62.5%) and degenerative disorders (16.7%). Effective doses from CT imaging were significantly higher for wire placements in the upper third of the thoracic spine compared to the lower two thirds (p = 0.015). Radiation exposure to operating room personnel could be reduced by more than 90% in all non-instrumented cases. No adverse reactions were observed, one patient (1.04%) underwent surgical revision due to an epifascial empyema. No wires had to be removed due to lack of patient compliance or infection. CONCLUSIONS This is a safe and practical approach to identify the level of interest in thoracic spinal surgery employing a marking wire. Its application merits consideration in any spinal case where X-ray localization could prove unsafe, particularly in cases lacking bony pathologies such as intradural tumors.
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Affiliation(s)
- Sebastian A Ahmadi
- Department of Neurosurgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany.
| | - Philipp J Slotty
- Department of Neurosurgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | - Patric Kröpil
- Institute of Diagnostic and Interventional Radiology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Sven O Eicker
- Department of Neurosurgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany; Department of Neurosurgery, University of Hamburg-Eppendorf, Hamburg, Germany
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Verdú-López F, Beisse R. [Current status of thoracoscopic surgery for thoracic and lumbar spine. Part 2: treatment of the thoracic disc hernia, spinal deformities, spinal tumors, infections and miscellaneous]. Neurocirugia (Astur) 2014; 25:62-72. [PMID: 24456908 DOI: 10.1016/j.neucir.2013.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/12/2013] [Accepted: 02/13/2013] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Thoracoscopic surgery or video-assisted thoracic surgery (VATS) of the thoracic and lumbar spine has evolved greatly since it appeared less than 20 years ago. It is currently used in a large number of processes and injuries. The aim of this article, in its two parts, is to review the current status of VATS of the thoracic and lumbar spine in its entire spectrum. DEVELOPMENT After reviewing the current literature, we developed each of the large groups of indications where VATS takes place, one by one. This second part reviews and discusses the management, treatment and specific thoracoscopic technique in thoracic disc herniation, spinal deformities, tumour pathology, infections of the spine and other possible indications for VATS. CONCLUSIONS Thoracoscopic surgery is in many cases an alternative to conventional open surgery. The transdiaphragmatic approach has made endoscopic treatment of many thoracolumbar junction processes possible, thus widening the spectrum of therapeutic indications. These include the treatment of spinal deformities, spinal tumours, infections and other pathological processes, as well as the reconstruction of injured spinal segments and decompression of the spinal canal if lesion placement is favourable to antero-lateral approach. Good clinical results of thoracoscopic surgery are supported by growing experience reflected in a large number of articles. The degree of complications in thoracoscopic surgery is comparable to open surgery, with benefits in regard to morbidity of the approach and subsequent patient recovery.
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Affiliation(s)
| | - Rudolf Beisse
- Wirbelsäulenzentrum Starnberger See Benedictus Krankenhaus, Tutzing, Alemania
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Thambiraj S, Quraishi NA. Intra-operative localisation of thoracic spine level: a simple "'K'-wire in pedicle" technique. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 21 Suppl 2:S221-4. [PMID: 22349971 DOI: 10.1007/s00586-012-2193-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Revised: 01/29/2012] [Accepted: 02/03/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE OF STUDY To describe a simple and reliable method of intra-operative localisation of thoracic spine in a single surgical setting. Intra-operative localisation of thoracic spine levels can be difficult due to anatomical constraints, such as scapular shadow, patient's size and poor bone quality. This is particularly true in cases of thoracic discectomies in which the vertebral bodies appear normal. There are several methods described in recent literature to address this. Many of them require a separate procedure which was performed often the previous day. We report a technique which addresses the issue of localising thoracic level intra-operatively. MATERIALS AND METHODS After induction of general anaesthesia, the patient was placed prone and the pedicle of interest was identified using fluoroscopy. A K-wire was then inserted percutaneously into this pedicle under image guidance [confirmed in the antero-posterior (AP) and lateral views]. The wire was then cut close to the skin after bending it. The patient was now positioned laterally and the intended procedure performed through an anterior trans-thoracic approach. The 'K' wire was removed at the end of the procedure. RESULTS AND CONCLUSION We routinely used this technique in all our thoracic discectomies (four cases in 2 years). There were no intra-operative complications. This method is simple, avoids the patient undergoing two procedures and requires no more ability than placing an implant in the pedicle under fluoroscopy. Placing the 'K' wire into a fixed point like the pedicle facilitates rapid intra-operative viewing of the level of interest and is removed easily at the conclusion of surgery.
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Affiliation(s)
- Sathya Thambiraj
- Centre for Spine Studies and Surgery, Queen's Medical Centre, Nottingham, UK.
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Hsu W, Kretzer RM, Dorsi MJ, Gokaslan ZL. Strategies to avoid wrong-site surgery during spinal procedures. Neurosurg Focus 2011; 31:E5. [DOI: 10.3171/2011.7.focus1166] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Wrong-site surgery (WSS) is a rare occurrence that can have devastating consequences for patient care. There are several factors inherent to spine surgery that increase the risk of WSS compared with other types of surgery. Not only can a surgeon potentially operate on the wrong side of the spine or the wrong level, but there are unique issues related to spinal localization that can be challenging for even the most experienced clinicians. The following review discusses important issues that can help prevent WSS during spinal procedures.
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Affiliation(s)
- Wesley Hsu
- 1Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; and
| | - Ryan M. Kretzer
- 2Department of Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Michael J. Dorsi
- 2Department of Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ziya L. Gokaslan
- 2Department of Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Kim KD, Li W, Galloway CL. Use of a radiopaque localizer grid to reduce radiation exposure. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2011; 5:6. [PMID: 21827694 PMCID: PMC3177900 DOI: 10.1186/1750-1164-5-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 08/09/2011] [Indexed: 11/12/2022]
Abstract
Background Minimally invasive spine surgery requires placement of the skin incision at an ideal location in the patient's back by the surgeon. However, numerous fluoroscopic x-ray images are sometimes required to find the site of entry, thereby exposing patients and Operating Room personnel to additional radiation. To minimize this exposure, a radiopaque localizer grid was devised to increase planning efficiency and reduce radiation exposure. Results The radiopaque localizer grid was utilized to plan the point of entry for minimally invasive spine surgery. Use of the grid allowed the surgeon to accurately pinpoint the ideal entry point for the procedure with just one or two fluoroscopic X-ray images. Conclusions The reusable localizer grid is a simple and practical device that may be utilized to more efficiently plan an entry site on the skin, thus reducing radiation exposure. This device or a modified version may be utilized for any procedure involving the spine.
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Affiliation(s)
- Kee D Kim
- Department of Neurological Surgery, University of California, Davis, 4860 Y Street Suite 3740, Sacramento, CA 95816, USA.
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Bisson EF, Jost GF, Apfelbaum RI, Schmidt MH. Thoracoscopic discectomy and instrumented fusion using a minimally invasive plate system: surgical technique and early clinical outcome. Neurosurg Focus 2011; 30:E15. [PMID: 21456926 DOI: 10.3171/2011.1.focus10309] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The use of minimally invasive noninstrumented fusions has increased as thoracoscopic approaches to the spine have evolved. The addition of instrumentation is infrequent, in part because of the lack of a minimally invasive implant system. The authors describe a technique for thoracoscopic plating after discectomy and report early clinical outcomes. METHODS After a standard endoscopic discectomy and partial corpectomy and before exposure of the ventral thecal sac, the authors implanted a polyaxial screw and clamping element under fluoroscopic guidance. Reconstruction involves placement of autograft in the defect and subsequent placement of the remainder of the screw/plate construct with 2 screws per vertebral level. RESULTS Twenty-five patients underwent thoracoscopic and thoracoscopy-assisted discectomies and fusion in which the aforementioned plate system was used. Of 19 patients presenting with pain, 10 had 6-month clinical follow-up with a greater than 50% reduction in visual analog scale score, which continued to improve up to 2 years postoperatively. There were 3 cases of pneumonia, 3 CSF leaks, 1 chyle leak, and 1 death due to a massive pulmonary embolus on the 1st postoperative day. CONCLUSIONS The authors conclude that thoracoscopic discectomy and plate-instrumented fusion can be achieved with acceptable results and morbidity. Further studies should evaluate the role of instrumented fusions after thoracoscopic discectomy in larger groups of patients and during a longer follow-up period.
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Affiliation(s)
- Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah 84132, USA
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