Long-Term Outcome After Midline Lumbar Fusion for the Treatment of Lumbar Spine Instability Due to Degenerative Disease

BACKGROUND

Midline lumbar fusion (MIDLF) is one promising new surgical technique that has been developed to minimize perioperative damage to the paravertebral stabilizing musculotendinous system. The aim of this study was to assess long-term clinical and radiological effects of MIDLF.

METHODS

This prospective cohort study evaluated patients who underwent MIDLF for degenerative spinal instability. Clinical and radiological examinations were performed before and after surgery. Perioperative and postoperative complications were recorded. Follow-up was 2 years. P ≤ 0.05 was considered statistically significant.

RESULTS

The study included 64 patients (mean age 58.9 ± 10.7 years; 41 women [64.1%]). The most frequent indication for MIDLF was degenerative spondylolisthesis grade I (28 cases [43.8%]); the prevalent spinal segment to be fused was L4-L5 (35 cases [54.7%]). Mean duration of surgery was 148.2 ± 28.9 minutes. Relief of low back pain and leg pain was significant and stable in the postoperative period as assessed by visual analog scale (P < 0.001). Of patients, 86.9% reported fair, good, or excellent outcomes in terms of pain relief based on MacNab score 2 years after surgery. Patients' level of function in activities of daily living improved significantly based on Oswestry Disability Index score: from 66.8 ± 9.8 before surgery to 33.9 ± 16.5 2 years after surgery (P < 0.001). X-rays and computed tomography at 12 months showed interbody fusion in 46 cases (73.4%), inconclusive results in 13 cases (20.3%), and no fusion in 4 cases (6.3%). No damage to neural or vascular structures and no failure of hardware or screw loosening were recorded.

CONCLUSIONS

MIDLF is a safe, efficient method for surgical treatment of lumbar spine instability. Its limited invasiveness contributes to better preservation of paravertebral muscles and enhanced postoperative spinal stability.

[Minimally Invasive Posterior Lumbar Interbody Fusion and Instrumentation - Outcomes at 24-Month Follow-up]

PURPOSE OF THE STUDY Minimally invasive posterior lumbar interbody fusion and percutaneous instrumentation were introduced in the clinical practice with the aim to reduce the damage to musculoligamentous structures associated with open surgeries. The purpose of the study is to evaluate the clinical outcomes, radiological results and complications of the group of patients operated with the use of the minimally invasive posterior lumbar interbody fusion technique. MATERIAL AND METHODS The group of 31 patients operated for lumbar degenerative disc disease was followed-up prospectively. The surgical technique included a unilateral microsurgical decompression of the spinal canal with the insertion of interbody cages supplemented by percutaneous transpedicular fixation. The clinical outcomes were evaluated by means of the Oswestry Disability Index (ODI), Macnab classification, VAS score for low back pain (VAS LBP) and lower extremity pain (VAS LE) at 2, 6, 12 and 24 months postoperatively. The success rate of interbody fusion and complications was also assessed. RESULTS The inclusion criteria were met by 29 patients. The mean preoperative ODI score of 68.4 decreased to 25.1 at two-year follow-up (p 0.001). Based on the modified Macnab scale excellent and good outcomes were achieved at two-year-followup by 82.4% patients. The mean value of VAS LBP score decreased from 6.2 to 2.1 and in case of VAS LE from 5.38 to 1.34 (p ˂ 0.001). The mean time of operation was 157 minutes. Solid interbody fusion was achieved in 80% of patients. In one case, revision surgery for dislocation of the interbody cage was performed one year after the operation. A total of five misplaced transpedicular screws (5.2%) were recorded. DISCUSSION Dorsal minimally invasive spinal operational techniques, when compared with the open surgery, result in less iatrogenic injury to paravertebral muscles. From a short-term perspective, there is also less blood loss and lower frequency of infectious complications. Together with the reduction of postoperative pain and shorter hospital stay, they enable faster recovery and rehabilitation with comparable clinical effectiveness of the procedure. Apart from the above-mentioned benefits, also some shortcomings are discussed such as higher frequency of complications, longer time of operation, higher occurrence of implant malposition and higher exposure of the patient and the surgeon to radiation. CONCLUSIONS The minimally invasive posterior lumbar interbody fusion technique resulted in a statistically significant clinical improvement in the ODI, Macnab scale, VAS LBP and VAS LE scores. The percutaneous instrumentation technique shows an acceptable rate of incorrectly inserted screws. Key words: degenerative disc disease, minimally invasive spinal surgery, posterior lumbar interbody fusion, spine stabilization, lumbar interbody fusion complications.

Successful surgical excision of cerebral abscess caused by Fonsecaea monophora in an immunocompetent patient and review of literature

Cerebral abscesses caused by dark-pigmented Fonsecaea fungi are rare, especially in otherwise healthy individuals. In this case report, we present a 61-year-old man from Moldova, living in the Czech Republic, who had worked as a locksmith on oil platforms in Turkmenistan, Kazakhstan, Sudan, and Iraq since 1999, and was admitted to a neurology ward for a sudden motion disorder of the right leg, dysarthria, and hypomimia. Imaging revealed presence of expansive focus around the left lateral ventricle of the brain and a pronounced peripheral edema. The intracranial infectious focus was excised under intraoperative SonoWand guidance. Tissue samples were histologically positive for dark-pigmented hyphae, suggesting dematiaceous fungi. Therefore, liposomal amphotericin B therapy was initiated immediately. Fonsecaea monophora was provisionally identified using ITS rDNA region sequencing directly from brain tissue. The identification was subsequently confirmed by cultivation and DNA sequencing from culture. The strain exhibited in vitro sensitive to voriconazole (MIC = 0.016 μg/mL) and resistance to amphotericin B (MIC = 4 μg/mL); therefore, the amphotericin B was replaced with voriconazole. Postoperatively, a significant clinical improvement was observed and no additional surgery was required. Based on the literature review, this is the third documented case of cerebral infection due to this pathogen in patients without underlying conditions and the first such case in Europe.

Bioactive titan cage Implaspin in treatment of degenerative disease of the cervcal spine--the results from 2007 till 2008

The authors present results of surgical treatment of cervical spine degenerative disease via Implaspin biotitanium replacement. Surgery was indicated for a group of 24 patients with symptoms of cervical spondylogenic myelopathy or the irritation decay root syndrome non-reacting to conservative treatment. Pre-surgery X-ray and MRI examinations showed spinal canal stenosis caused by the intervertebral disk osteochondrosis combined with prolapse or dorsal osteophytes. Clinical problems of the group of patients were evaluated through the JOA classification before surgery and during the 2nd, the 6th and month 12th after surgery. The surgery rate of success was evaluated in percentages during post-surgery examinations that took place in the 12th month. Based on the JOA classification, that rate of success falls into the good surgery results zone. The post-surgery X-ray examinations showed two sank replacements by 1/3 of its height into the surrounding vertebral bodies. In these cases we performed the control MRI. No signs of the new spinal compression were found and the spinal canal was free in the operated site. Based on our short-term experiences, the Implaspin bioactive replacement seems to be a suitable alternative to the other types of replacements designed for intervertebral fusion in the lower cervical spine area.