Long-Term Clinical Course of Patients After Decompression and Posterior Instrumented Fusion Surgery for Thoracic Ossification of the Posterior Longitudinal Ligament: An Average Follow-Up of 18 years

STUDY DESIGN

Retrospective observational study.

OBJECTIVES

To evaluate the long-term recurrence rates and functional status of patients with thoracic ossification of the posterior longitudinal ligament (OPLL) after decompression and posterior fusion surgery.

METHODS

Thirty-seven consecutive patients who underwent posterior thoracic spine surgery at a single institution were retrospectively reviewed. The long-term neurological and functional outcomes of 25 patients who were followed up for ≥10 years after surgery were assessed. Factors associated with the recurrence of myelopathy were also analyzed.

RESULTS

The mean preoperative Japanese Orthopaedic Association score was 3.7, which improved to 6.5 at postoperative year 2 and declined to 6.0 at a mean follow-up of 18 years. No patient experienced a relapse of myelopathy due to OPLL within the instrumented spinal segments. However, 15 (60%) patients experienced late neurological deterioration, 10 of whom had a relapse of myelopathy due to OPLL or ossification of the ligamentum flavum (OLF) in the region outside the primary operative lesion, while 4 developed myelopathy due to traumatic vertebral fracture of the ankylosed spine. Young age, a high body mass index, and lumbar OPLL are likely associated with late neurological deterioration.

CONCLUSIONS

Decompression and posterior instrumented fusion surgery is a reliable surgical procedure with stable long-term clinical outcomes for thoracic OPLL. However, as OPLL may progress through the spine, attention should be paid to the recurrence of paralysis due to OPLL or OLF in regions other than the primary operative lesion and vertebral fractures of the ankylosed spine after surgery for thoracic OPLL.

Phosphaturic mesenchymal tumor-induced bilateral osteomalacia femoral neck fractures: a case report

Phosphaturic mesenchymal tumors (PMT) are rare and distinctive tumors that typically result in paraneoplastic syndrome known as tumor-induced osteomalacia (TIO). We report a case of bilateral osteoporotic femoral neck fracture caused by PMT. PMT was surgically resected, followed by sequential treatment of bilateral femoral neck fractures with total hip arthroplasty (THA). A 49-year-old perimenopausal woman experienced consistent bone pain with limb weakness persisting for over 2 years. Initially, she was diagnosed with early osteonecrosis of the femoral head and received nonsurgical treatment. However, from 2020 to 2022, her pain extended to the bilateral shoulders and knees with increased intensity. She had no positive family history or any other genetic diseases, and her menstrual cycles were regular. Physical examination revealed tenderness at the midpoints of the bilateral groin and restricted bilateral hip range of motion, with grade 3/5 muscle strength in both lower extremities. Laboratory findings revealed moderate anemia (hemoglobin 66 g/L), leukopenia (2.70 × 109/L), neutropenia (1.28 × 109/L), hypophosphatemia (0.36 mmol/L), high alkaline phosphatase activity (308.00 U/L), and normal serum calcium (2.22 mmol/L). After surgery, additional examinations were performed to explore the cause of hypophosphatemic osteomalacia. After definitive diagnosis, the patient underwent tumor resection via T11 laminectomy on August 6, 2022. Six months after the second THA, the patient regained normal gait with satisfactory hip movement function without recurrence of PMT-associated osteomalacia or prosthesis loosening. By providing detailed clinical data and a diagnostic and treatment approach, we aimed to improve the clinical understanding of femoral neck fractures caused by TIO.

Combined Effects of Glenohumeral Mobilization, Stretching, and Thoracic Manipulation on Shoulder Internal Rotation Range of Motion

Background/purpose

Interventions including posterior glenohumeral mobilizations (PGM), sleeper stretches, and thoracic manipulation are commonly used to address posterior shoulder tightness. The purpose of this study was to assess the effects of adding thoracic manipulation to PGM and sleeper stretches on passive range of motion (PROM), joint mobility, and infraspinatus electromyographic (EMG) activity in shoulders with decreased internal rotation (IR) PROM.

Design

Randomized Sequential Intervention Laboratory Study.

Methods

Forty individuals with clinically significant IR loss attended two study sessions. Participants were randomized to receive five 30 seconds bouts of either grade III PGM or sleeper stretching. Following a seven-day washout period, all participants attended a second session and received a prescriptive supine HVLA manipulation targeting the T3-4 segment, followed by the previously randomized intervention. Outcome measures included internal rotation PROM, horizontal adduction PROM, posterior glenohumeral joint translation assessed via ultrasound imaging, and EMG activity of the infraspinatus during a PGM. All outcome measures were assessed pre- and immediately post-intervention and compared statistically.

Results

There were significant within-group, but not between-group, differences for IR and horizontal adduction PROM following a single session of PGM or sleeper stretch. When combined with thoracic manipulation, significantly smaller within session changes of IR PROM were observed for both PGM (mean difference 4.4, p=0.017) and sleeper stretches (mean difference 6.4, p=0.0005). There were no significant between group differences for horizontal adduction PROM, humeral head translation, or EMG activity across all time points.

Discussion

Both GH posterior mobilizations and sleeper stretches improved IR and horizontal adduction PROM in a single session. The addition of thoracic manipulation prior to local shoulder interventions resulted in smaller gains of both IR and horizontal adduction ROM.

Level of evidence

Level 2.

Thoracic root-related intradural extramedullary cavernoma presenting with subarachnoid hemorrhage: illustrative case

BACKGROUND

Just 5% of all cavernomas are located in the spine. Thoracic root-related subtypes are the rarest, with a total of 14 cases reported in the literature to date. Among them, only 4 presented with subarachnoid hemorrhage (SAH).

OBSERVATIONS

A 65-year-old female presented after an ictus of headache with no neurological deficits. Computed tomography (CT) demonstrated sulcal SAH, with the remainder of the workup nondiagnostic for etiology. Three weeks later, she re-presented with acute thoracic back pain and thoracic myelopathy. CT and magnetic resonance imaging suggested dubiously a T9-10 disc herniation with spinal cord compression. Surgical decompression and resection were then planned. Intraoperative ultrasound (IUS) demonstrated an intradural extramedullary lesion, confirmed to be cavernoma. Complete resection was achieved, and the patient was discharged a few days postoperatively to inpatient rehabilitation.

LESSONS

Although spine imaging is deemed to be low yield in the evaluation of cryptogenic SAH, algorithms can be revisited even in the absence of spine-related symptoms. Surgeons can be prepared to change the initial surgical plan, especially when preoperative imaging is unclear. IUS is a powerful tool to assess the thecal sac after its exposure and to help guide this decision, as in this rare entity.

Intervertebral fusion sites in patients with ankylosing spondylitis: A computed tomography study

OBJECTIVES

To examine intervertebral fusion sites along the whole spine of patients with ankylosing spondylitis using computed tomography.

METHODS

This retrospective study examined intervertebral fusion of five sites (anterior/posterior vertebrae, left/right zygapophyseal joints, and spinous process) on 23 vertebrae in the cervical, thoracic, and lumbar regions of the spine in 40 patients diagnosed with ankylosing spondylitis at our institute between January 2004 and December 2022.

RESULTS

Mean age [± standard deviation (SD)] was 40.5 (± 17) years, and mean disease duration (± SD) was 11.4 (± 10.5) years at computed tomography evaluation; 55.9% were human leukocyte antigen B-27-positive. Fifteen (37.5%) patients showed intervertebral fusion in the thoracic and/or cervical regions, but not in the lumbar region. Fusion of posterior vertebrae was observed most frequently in the thoracic region, compared to the cervical and lumbar regions. In particular, more than half of the patients showed fusion of posterior vertebrae Th4-Th5 to Th7-Th8.

CONCLUSIONS

In 37.5% of patients, intervertebral fusion was evident in the thoracic and/or cervical regions but not in the lumbar region. The most common site and region of intervertebral fusion were the posterior vertebrae of the middle thoracic region.

Pediatric Prostatic Alveolar Rhabdomyosarcoma Presenting with Metastatic Spinal Cord Compression in the Thoracic Spine: A Case Report and Review of the Literature

Rhabdomyosarcoma (RMS) is a pediatric malignancy with a variable prognosis depending on tumor stage and genotype. There has been a significant improvement in survival rates over the past decades. However, aggressive variants can metastasize to locations that are difficult to treat. We report a case of prostatic alveolar rhabdomyosarcoma with metastases to the bone marrow and thoracic spine in a child. The patient was treated with a multimodal approach that included surgical resection of the epidural mass; the administration of vincristine, dactinomycin, and cyclophosphamide; and radiotherapy. Unfortunately, after six months, the patient showed disease progression and was started on secondary-line treatment. This case illustrates the difficulties in managing end-stage metastatic rhabdomyosarcoma and is the first report of prostatic rhabdomyosarcoma presenting with spinal cord compression in a child.

Differences in the Demographics and Clinical Characteristics between the Ossification of the Posterior Longitudinal Ligament and Ossification of the Ligamentum Flavum in Patients Who Underwent Thoracic Spinal Surgery for Compressive Myelopathy

Ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF) are related diseases associated with the ossification of spinal ligaments that can occasionally lead to thoracic myelopathy. We retrospectively analyzed the clinical data of 34 consecutive patients who underwent thoracic spinal surgeries for OPLL and/or OLF at our hospital between July 2010 and June 2022, and statistically compared data between patients with thoracic OPLL (TOPLL; n = 12) and those with thoracic OLF (TOLF; n = 22). The mean age of the TOPLL group was significantly lower than that of the TOLF group (53.7 vs. 68.4 years). The TOPLL group exhibited a greater female predominance than the TOLF group (58.3% vs. 18.2%). The median body mass index of the TOPLL group was significantly higher than that of the TOLF group (33.0 vs. 26.0 kg/m2). Patients with TOPLL significantly required instrumented fusion and repetitive surgical intervention more than those with TOLF (83.3% vs. 9.1%; 50.0% vs. 0.0%). Although neurological deterioration just after the intervention was more common in patients with TOPLL (41.7% vs. 4.6%), no difference was observed in thoracic Japanese Orthopaedic Association score and recovery rate in the chronic phase between TOPLL and TOLF. The TOPLL group had a younger onset, female dominance, and a greater degree of obesity when compared with the TOLF group. The surgery for TOPLL is challenging, considering that it requires long-range decompression and fusion, subsequent operations, careful management, and long-term follow-up, when compared to TOLF, which necessitates only simple decompression.

Assessment of Health-Related Quality of Life in Patients With Traumatic Fractures Following Thoracolumbar Fusion: Short-Term Results

INTRODUCTION

Thoracolumbar vertebral fractures (TVFs) constitute frequent injuries with specific therapeutic challenges and remarkable implications for affected individuals. The aim of this study is to investigate the alteration of overall health-related quality of life (HRQoL) in patients with traumatic TVFs undergoing thoracolumbar fusion surgery.

MATERIALS AND METHODS

A total of 72 patients with single-level traumatic thoracic or lumbar vertebral fractures (AO type A3 or A4) were enrolled in this prospective cohort study. All patients were subjected to thoracolumbar spinal fusion surgery with or without posterior decompression, being followed up for a two-year period. Clinical assessment was conducted via the implementation of the Visual Analog Scale (VAS) and 36-item Short-Form Survey Questionnaire (SF-36) for the evaluation of pain and HRQoL, respectively. Patient assessment was performed in determined postoperative follow-up intervals.

RESULTS

Recorded values of assessed outcome measures demonstrated a statistically significant improvement during the entire two-year follow-up period. This improvement was more pronounced throughout the first three to six postoperative months, subsequently demonstrating a plateau. No statistically significant correlation between age, SF-36, and VAS was found, with the exception of the bodily pain index, the improvement of which was observed to be positively correlated with age. Transient causalgia and cerebrospinal fluid leak were recorded in 5% of evaluated individuals.

CONCLUSIONS

Thoracolumbar fusion constitutes a safe and efficient option for the surgical management of single-level traumatic vertebral fractures. Nevertheless, rehabilitation is a lasting procedure that may last over six months until final amelioration is observed. Clinical improvement may be more pronounced in older patients, potentially due to different expectations.

Patient-Specific Surgical Correction of Adolescent Idiopathic Scoliosis: A Systematic Review

The restoration of sagittal alignment is fundamental to the surgical correction of adolescent idiopathic scoliosis (AIS). Despite established techniques, some patients present with inadequate postoperative thoracic kyphosis (TK), which may increase the risk of proximal junctional kyphosis (PJK) and imbalance. There is a lack of knowledge concerning the effectiveness of patient-specific rods (PSR) with measured sagittal curves in achieving a TK similar to that planned in AIS surgery, the factors influencing this congruence, and the incidence of PJK after PSR use. This is a systematic review of all types of studies reporting on the PSR surgical correction of AIS, including research articles, proceedings, and gray literature between 2013 and December 2023. From the 28,459 titles identified in the literature search, 81 were assessed for full-text reading, and 7 studies were selected. These included six cohort studies and a comparative study versus standard rods, six monocentric and one multicentric, three prospective and four retrospective studies, all with a scientific evidence level of 4 or 3. They reported a combined total of 355 AIS patients treated with PSR. The minimum follow-up was between 4 and 24 months. These studies all reported a good match between predicted and achieved TK, with the main difference ranging from 0 to 5 degrees, p > 0.05, despite the variability in surgical techniques and the rods' properties. There was no proximal junctional kyphosis, whereas the current rate from the literature is between 15 and 46% with standard rods. There are no specific complications related to PSR. The exact role of the type of implants is still unknown. The preliminary results are, therefore, encouraging and support the use of PSR in AIS surgery.

How to Optimize Pedicle Screw Parameters for the Thoracic Spine? A Biomechanical and Finite Element Method Study

STUDY DESIGN

Pedicle screw study.

OBJECTIVE

The selection of pedicle screw parameters usually involves the surgeon's analysis of preoperative CT imaging along with anatomical landmarks and tactile examination. However, there is minimal consensus on a standardized guideline for selection methods on pedicle screws. We aimed to determine the effects of thoracic screw diameter to pedicle width on pullout strength determined by cortical bone purchase.

METHODS

Biomechanical study performed with human cadaveric thoracic vertebrae and experimentally validated three-dimensional finite element model instrumented with pedicle screws of various diameters. We used a variable (SD/PW) ratio to express the screw selection. We hypothesized a positive correlation between the pullout load determined by the bone purchase and the SD/PW. This relationship was first investigated in a validated finite element model considering bone purchase related to the strength of an upper thoracic vertebra. Then, the correlation to the entire spine is evaluated.

RESULTS

The failure load ranged from 371.3 to 1601.0 N, respectively, for 3 and 6 mm screws. The determinant coefficient was increased to R2=.421 when a linear relationship between pullout load and the SD/PW ratio was used. The peak loads of 1216 and 1288N were found for an SD/PW ratio of .83.

CONCLUSION

We have found that the screw pullout load is more correlated to SD/PW than other pedicle measures for a maximized SD/PW ratio of .83. This particular value should be considered the upper limit of the indicated SD/PW ratio and a means to determine the optimal screw diameter to enhance pullout strength.

Non-osseous intradural tuberculoma of the thoracic spine with compressive myelopathy

Key Clinical Message

An uncommon form of CNS tuberculosis called non-osseous IDEM tuberculoma frequently results from paradoxical drug interactions. It should be considered one of the differentials when patients receiving ATT experience acute neurological impairment.

Abstract

Tuberculoma affecting the spinal cord is a rare condition in modern times. The occurrence of non-osseous intradural tuberculosis, specifically in the spine, is even more exceptional. In fact, it is uncommon to encounter an intradural extramedullary tuberculous granuloma that lacks radiological indications of vertebral involvement, especially within the thoracic region. We present a case of a patient with a neurological deficit caused by a non-osseous intradural tuberculoma in the thoracic region, without any associated bone involvement. The patient experienced a gradual deterioration of neurological function. An MRI of the thoracic spine revealed the presence of a tuberculoma located intradurally, extramedullary, and juxtamedullary of the T5 vertebra. The compression of the spinal cord resulted in paraparesis which was worsening to paraplegia. A D4-D6 laminectomy and microsurgical excision were performed under intraoperative neurophysiological monitoring (IONM), and the patient showed clinical recovery. Excellent clinical outcomes were achieved. However, it is crucial to consider the possibility of a non-osseous intradural tuberculoma as a rare condition when encountering a SOL, particularly in patients with a history of tuberculosis and spinal cord compression. In cases where a progressing neurological deficit is present, a combination of surgical intervention and anti-tuberculous treatment should be considered as the optimal approach.

One-stage combined approach en bloc vertebrectomy for primary Ewing's sarcoma of mobile spine in an adult patient: 3 years following aggressive surgery for a rare entity

Key Clinical Message

Currently, there is no consensus on the optimal management of nonmetastatic Ewing's sarcoma of the mobile spine. However, associated to chemotherapy, aggressive surgery with en bloc wide resection seems to improve local control and survival.

Abstract

Primary Ewing's sarcoma (EWS) of non-sacral spine is extremely rare, especially in middle-age. Therapeutic strategy aims: to large tumor resection, to provide spine stability and to avoid recurrence through chemo and radiotherapy. We report a case of thoracic spine EWS in an adult treated by combined approach en bloc vertebrectomy.

Reliability and Validity of a Smartphone Device and Clinical Tools for Thoracic Spine Mobility Assessments

Quantifying thoracic spine mobility with reliable and valid tools is a challenge for clinicians in practice. The aim of this study is to determine the reliability and validity of a smartphone device, bubble inclinometer and universal goniometer to quantify the static kyphotic curve and active range of motion of the thoracic spine. A total of 17 participants (mean age = 23.7 ± 2.3 years) underwent repeated measurements with three raters, on three separate days performing the lumbar-locked trunk rotation, standing full extension, standing full flexion, standing relaxed curve and seated trunk rotation assessments. Mostly "Good" to "Excellent" intra-rater (ICC ranging from 0.624 to 0.981) and inter-reliability (ICC ranging from 0.671 to 0.968) was achieved with the smartphone and clinical tools. "Excellent" validity (ICC ranging from 0.903 to 0.947) with the smartphone was achieved during lumbar-locked trunk rotation and standing relaxed curve assessment. "Good" validity (ICC ranging from 0.836 to 0.867) of the smartphone was achieved during the seated trunk rotation. The Samsung s9+ smartphone with the iSetSquare mobile application is a reliable and valid tool to use for clinical assessments assessing thoracic spine mobility.

In vitro coupled motions of the whole human thoracic and lumbar spine with rib cage

Study design

In vitro biomechanical study investigating the coupled motions of the whole normative human thoracic spine (TS) and lumbar spine (LS) with rib cage.

Objective

To quantify the region-specific coupled motion patterns and magnitudes of the TS, thoracolumbar junction (TLJ), and LS simultaneously.

Background

Studying spinal coupled motions is important in understanding the development of complex spinal deformities and providing data for validating computational models. However, coupled motion patterns reported in vitro are controversial, and no quantitative data on region-specific coupled motions of the whole human TS and LS are available.

Methods

Pure, unconstrained bending moments of 8 Nm were applied to seven fresh-frozen human cadaveric TS and LS specimens (mean age: 70.3 ± 11.3 years) with rib cages to elicit flexion-extension (FE), lateral bending (LB), and axial rotation (AR). During each primary motion, region-specific rotational range of motion (ROM) data were captured.

Results

No statistically significant, consistent coupled motion patterns were observed during primary FE. During primary LB, there was significant (p < 0.05) ipsilateral AR in the TS and a general pattern of contralateral coupled AR in the TLJ and LS. There was also a tendency for the TS to extend and the LS to flex. During primary AR, significant coupled LB was ipsilateral in the TS and contralateral in both the TLJ and LS. Significant coupled flexion in the LS was also observed. Coupled LB and AR ROMs were not significantly different between the TS and LS or from one another.

Conclusions

The findings support evidence of consistent coupled motion patterns of the TS and LS during LB and AR. These novel data may serve as reference for computational model validations and future in vitro studies investigating spinal deformities and implants.

Posterior Decompression and Fixation for Thoracic Spine Ossification: A 10-Year Follow-Up Study

Ossification of the posterior longitudinal ligament of the thoracic spine (T-OPLL) causes symptoms including leg and back pain, and motor and sensory deficits. This study retrospectively reviewed 32 patients who initially underwent posterior decompression with instrumented fusion (PDF) for T-OPLL between 2001 and 2012, with 20 qualifying for the final analysis after applying exclusion criteria. Exclusions included unknown preoperative neurological findings, follow-up less than 10 years, or prior spinal surgeries at other levels. Outcomes were assessed using the Japanese Orthopedic Association (JOA) score, recovery rate, and kyphotic angle. The average preoperative JOA score of 3.6 improved to 7.4 at 1 year post-surgery and remained at 7.4 at 10 years, with a recovery rate of 52%. The kyphotic angle at T4-12 increased from 26 degrees preoperatively to 29 degrees postoperatively and to 37 degrees at 10 years. At the fused levels, the angle remained at 26 degrees immediately post-operation and increased to 32 degrees at 10 years. Forty percent of patients required additional surgery, primarily for conditions related to cervical OPLL, such as myelopathy, or lumbar OPLL, such as radiculopathy, or cauda equina syndrome. In conclusion, PDF effectively reduces T-OPLL symptoms over the long term, but the high rate of additional surgeries calls for careful patient follow-up.

A comparison of intervertebral ligament properties utilized in a thoracic spine functional unit through kinematic evaluation

Ligament properties in the literature are variable, yet scarce, but needed to calibrate computational models for spine clinical research applications. A comparison of ligament stiffness properties and their effect on the kinematic behavior of a thoracic functional spinal unit (FSU) is examined in this paper. Six unique ligament property sets were utilized within a volumetric T7-T8 finite element (FE) model developed using computer-aided design (CAD) spinal geometry. A 7.5 Nm moment was applied along three anatomical planes both with and without costovertebral (CV) joints present. Range of Motion (RoM) was assessed for each property set and compared to published experimental data. Intact and serial ligament removal procedures were implemented in accordance with experimental protocol. The variance in both kinematic behavior and comparability with experimental data among property sets emphasizes the role nonlinear characterization plays in determining proper kinematic behavior in spinal FE models. Additionally, a decrease in RoM variation among property sets was exhibited when the model setup incorporated the CV joint. With proper assessment of the source and size of each ligament, the material properties considered here could be expanded and justified for implementation into thoracic spine clinical studies.

A muscle-preserving, spinous process-splitting approach for ossification of the ligamentum flavum in the thoracic spine in professional athletes: a report of three cases

A muscle-preserving, spinous process-splitting approach may be a less invasive approach to conventional laminectomy in patients with thoracic ossification of the ligamentum flavum. Few reports have discussed the usefulness of this procedure for thoracic lesions in professional athletes who need highly active thoracic spinal function after surgery. The treatment of thoracic ossification of the ligamentum flavum using a spinous process-splitting approach in 3 professional athletes is presented. In all three cases the patients could return to play within 3 months after surgery without complications, and in two of the cases, there was no spinal deformity or local recurrence of ossification of the ligamentum flavum at the final follow-up at least 8 years after surgery. The spinous process-splitting approach could be a safe procedure for multi-level and all other forms of ossification of the ligamentum flavum and is less invasive to the paraspinal muscles, relieves back symptoms, and restores function for athletes.

Navigation-Assisted Micro-Window Excision of Thoracic Ossification of Ligamentum Flavum (Mishima Surgery) in Professional Baseball Pitchers: A Case Report and Technical Note

Background and Objectives: Thoracic ossification of the ligamentum flavum (OLF) often causes myelopathy and/or radiculopathy. The disease is frequently observed in East Asian populations. Although thoracic OLF in young athletes who have underwent decompression surgery has been reported, the removal of posterior spinal bony elements and ligamentous complex may often cause postoperative thoracolumbar instability. We established a novel surgical technique that preserves the posterior spinal elements, including the spinous processes, facet joints, and supraspinous and interspinous ligaments for thoracic OLF. This is the first case report to describe a navigation-assisted micro-window excision of thoracic OLF. Case: A 32-year-old male right-handed professional baseball pitcher with significant weakness and numbness in the left leg was referred to our hospital. The patient was diagnosed with thoracic OLF at T10-11 based on radiographic and magnetic resonance images in August 2022. After exposure of the left T10-11 laminae via a small unilateral incision, the location of T10-11 OLF was detected over the lamina by O-arm navigation. Then, the micro-window was made directly above the OLF using a navigated air drill, and the OLF was removed on the ipsilateral side. The contralateral side of OLF was also resected through the same micro-window, achieving complete spinal cord decompression. Results: The next day of the surgery, his leg weakness and numbness were significantly improved. Six weeks after the surgery, he started pitching. Three months after surgery, his symptoms had gone completely, and he pitched from the mound. Approximately 6 months after surgery, he successfully pitched in a professional baseball game. Conclusions: A navigation-assisted micro-window excision of thoracic OLF effectively preserved the spinal posterior bony elements and ligamentous complex. However, long-term clinical outcomes should be evaluated in future studies.

Low-Intensity Pulsed Ultrasound Neuromodulation of a Rodent's Spinal Cord Suppresses Motor Evoked Potentials

OBJECTIVE

Here we investigate the ability of low-intensity ultrasound (LIUS) applied to the spinal cord to modulate the transmission of motor signals.

METHODS

Male adult Sprague-Dawley rats (n = 10, 250-300 g, 15 weeks old) were used in this study. Anesthesia was initially induced with 2% isoflurane carried by oxygen at 4 L/min via a nose cone. Cranial, upper extremity, and lower extremity electrodes were placed. A thoracic laminectomy was performed to expose the spinal cord at the T11 and T12 vertebral levels. A LIUS transducer was coupled to the exposed spinal cord, and motor evoked potentials (MEPs) were acquired each minute for either 5- or 10-minutes of sonication. Following the sonication period, the ultrasound was turned off and post-sonication MEPs were acquired for an additional 5 minutes.

RESULTS

Hindlimb MEP amplitude significantly decreased during sonication in both the 5- (p < 0.001) and 10-min (p = 0.004) cohorts with a corresponding gradual recovery to baseline. Forelimb MEP amplitude did not demonstrate any statistically significant changes during sonication in either the 5- (p = 0.46) or 10-min (p = 0.80) trials.

CONCLUSION

LIUS applied to the spinal cord suppresses MEP signals caudal to the site of sonication, with recovery of MEPs to baseline after sonication.

SIGNIFICANCE

LIUS can suppress motor signals in the spinal cord and may be useful in treating movement disorders driven by excessive excitation of spinal neurons.

Bilateral Percutaneous Transpedicular Drainage under Local Anesthesia for Thoracic Tuberculous Spondylitis

Tuberculous spondylitis is a common spinal infection. If surgical intervention is necessary, anterior debridement and anterior fixation are typically performed. However, a minimally invasive surgical strategy under local anesthesia seems rarely implemented. A 68-year-old man presented with severe pain in the left flank. Whole spinal magnetic resonance imaging revealed abnormal intensity of vertebral bodies from T6-9. A bilateral paravertebral abscess extending from T4-10 was suspected. The T7/T8 intervertebral disc was destroyed, but severe vertebral deformity or spinal cord compression was not observed. Bilateral percutaneous transpedicular drainage under local anesthesia was planned. The patient was set in the prone position. Under the guide of a biplanar angiographic system, the bilateral drainage tubes were placed paravertebrally in the abscess cavity. The left flank pain improved after the procedure. Laboratory culture of the pus specimen confirmed a diagnosis of tuberculosis. A chemotherapy regimen for tuberculosis was soon initiated. The patient was discharged during postoperative week 2, with continuation of chemotherapy for tuberculosis. Percutaneous transpedicular drainage under local anesthesia can be effective in the management of thoracic tuberculous spondylitis without severe vertebral deformity or compression of the spinal cord by an abscess.

Tips and Complications of Two-step Open Procedure for Ethanol Sclerosis Therapy for a Venous Hemangioma of the Thoracic Spine: A Case Report

Introduction

Venous hemangiomas of the thoracic spine are rare tumors that are diagnose based on radiological findings. Ethanol sclerosis therapy through the percutaneous or open approaches has been reported to be useful treatment options. Therefore, radiological examination and the treatment procedure can be performed together. As pathological diagnosis of the tumor is important, a strategy that comprises biopsy followed by definitive treatment is ideal. The tips and complications of the two-step open procedure for ethanol sclerosis therapy have not been discussed in detail. This is the first report of this kind in the literature, especially about the tips and complications.

Case Report

A 51-year-old woman presented with pain in the upper part of her back. Radiological examination revealed a hypervascular tumor at the second thoracic vertebra. We first performed an open biopsy along with decompression and fixation surgery, because the patient developed a walking disability with motor weakness in her right leg. The tumor was pathologically diagnosed as a venous hemangioma. Therefore, we performed ethanol sclerosis therapy using the open approach as a curative technique for the tumor 17 days after the initial surgery. A total of 10 mL of a mixture of 100% ethanol and a lipid-soluble contrast medium - which improve visibility - was injected intermittently and slowly. This was followed by the injection of 3 mL of a water-soluble contrast medium to confirm sclerosis. Immediately after the last procedure, the amplitudes of motor-evoked potentials in all bilateral lower extremity muscles disappeared simultaneously. The patient incomplete paralysis of the lower extremity and transient dysuria postoperatively; however, she could walk without assistance after 5 months.

Conclusion

This case highlights the following: First, the two-step procedure of open biopsy followed by ethanol injection using the open approach allowed accurate diagnosis and effective treatment. Second, additional injection of a water-soluble contrast medium to confirm sclerosis after ethanol injection can cause paralysis. Third, a mixture of ethanol and a lipid-soluble contrast medium effective improves visibility to identify expansions. These experiences will be useful for following ethanol sclerosis therapy for a venous hemangioma of the thoracic spine.

Remission of Dowager's hump by manipulative correction of spinal alignment: a case report

Dowager's hump is described as excessive kyphotic curvature in the thoracic spine with a Cobb angle of more than 40 degrees. This case report presents a 61 years old female office clerk who experienced headaches and neck pain for 3 years that extended into her right shoulder and upper chest. She consulted her primary care physician two months before seeing the chiropractor when the neck pain worsened. A diagnosis of cervicalgia related to osteoarthritis was made based on cervical and thoracic X-ray findings. The patient received non-steroid anti-inflammatory drugs (celecoxib and etoricoxib) and stretching exercises at home. At the onset of chiropractic care, radiographs showed loss of cervical lordosis, narrowing at the C4-5, C5-C6, and C6-7 intervertebral disc space with marginal osteophytes. Based on these findings, a working diagnosis of cervicogenic headache was established. After treatment for 9 months, the patient showed improvement in symptoms and function from cervical curve radiographic change and dextro-convexity of the thoracic spine. Avoiding forward head flexion and maintaining correct posture in daily activities will be key mechanisms to prevent the reoccurrence of Dowager's hump. The improvement of symptoms following chiropractic therapy has been shown to correlate with radiographic markers of spinal realignment.

Is Thoracic Kyphosis Relevant to Pain, Autonomic Nervous System Function, Disability, and Cervical Sensorimotor Control in Patients with Chronic Nonspecific Neck Pain?

There is great interest in thoracic kyphosis, as it is thought to be a contributor to neck pain, neck disability, and sensorimotor control measures; however, this has not been completely investigated in treatment or case control studies. This case control design investigated participants with non-specific chronic neck pain. Eighty participants with a defined hyper-kyphosis (>55°) were compared to eighty matched participants with normal thoracic kyphosis (<55°). Participants were matched for age and neck pain duration. Hyper-kyphosis was further categorized into two distinct types: postural kyphosis (PK) and Scheuermann's kyphosis (SK). Posture measures included formetric thoracic kyphosis and the craniovertebral angle (CVA) to assess forward head posture. Sensorimotor control was assessed by the following measures: smooth pursuit neck torsion test (SPNT), overall stability index (OSI), and left and right rotation repositioning accuracy. A measure of autonomic nervous system function included the amplitude and latency of skin sympathetic response (SSR). Differences in variable measures were examined using the Student's t-test to compare the means of continuous variables between the two groups. One-way ANOVA was used to compare mean values in the three groups: postural kyphosis, Scheuermann's kyphosis, and normal kyphosis group. Pearson correlation was used to evaluate the relationship between participant's thoracic kyphosis magnitude (in each group separately and as an entire population) and their CVA, SPNT, OSI, head repositioning accuracy, and SSR latency and amplitude. Hyper-kyphosis participants had a significantly greater neck disability index compared to the normal kyphosis group (p < 0.001) with the SK group having greatest disability (p < 0.001). Statistically significant differences between the two kyphosis groups and the normal kyphosis group for all the sensorimotor measured variables were identified with the SK group having the most decreased efficiency of the measures in the hyper-kyphosis group, including: SPNT, OSI, and left and right rotation repositioning accuracy. In addition, there was a significant difference in neurophysiological findings for SSR amplitude (entire sample of kyphosis vs. normal kyphosis, p < 0.001), but there was no significant difference for SSR latency (p = 0.07). The CVA was significantly greater in the hyper-kyphosis group (p < 0.001). The magnitude of the thoracic kyphosis correlated with worsening CVA (with the SK group having the smallest CVA; p < 0.001) and the magnitude of the decreased efficiency of the sensorimotor control measures and the amplitude and latency of the SSR. The PK group, overall, showed the greatest correlations between thoracic kyphosis and measured variables. Participants with hyper-thoracic kyphosis exhibited abnormal sensorimotor control and autonomic nervous system dysfunction compared to those with normal thoracic kyphosis.

Evaluation of the safety, radiographic and resident training results of thoracic pedicle screws placement using resection of the transverse process

OBJECTIVE

This study aimed at the evaluation and assessment of a simple method, the transverse process resection (TPR) technique, for freehand thoracic pedicle screw placement and the learning curve for trainee surgeons.

METHODS

In the TPR technique, the tip of the thoracic transverse process (TP) is removed to create an entry point in the cancellous bone of the TP, and the thoracic pedicle is cannulated from the TP. We retrospectively evaluated the safety and radiographic results of the TPR technique and compared with that of conventional pedicle screws. The training performance of seven neurosurgical residents with TPR techniques were evaluated.

RESULTS

Among 46 patients, a total of 322 thoracic screws were analyzed, including 178 screws placed using the TPR technique and 144 screws using the conventional straight-forward (SF) technique. TPR screws had greater medial angulations in all levels from T2 to T12 compared to SF screws (p < 0.001). The incidence of pedicle breach was lower in the TPR screws compared to SF screws (6.2% vs. 21.5%, p < 0.001), especially for screws placed by residents (6.7% vs. 29.6%, p < 0.001). Residents had improved performance following a cadaveric training course on the TPR technique (p = 0.001).

CONCLUSION

This study demonstrated the safety of the TPR technique for thoracic pedicle screw placement and its short learning curve for trainee surgeons.

Mid- to Long-Term Outcomes After Resection of Thoracic Dumbbell Tumors Managed by Laminectomy and Unilateral Total Facetectomy Without Instrumented Fusion

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

To evaluate mid- to long-term surgical outcomes of thoracic dumbbell tumors managed by laminectomy and unilateral total facetectomy without instrumented fusion.

METHODS

A total of 15 patients with thoracic dumbbell tumors who underwent primary resection by laminectomy and unilateral total facetectomy without spinal instrumented fusion between 2000 and 2015 were reviewed. Patient characteristics, surgical outcomes (including spinal alignment and stability), disc degeneration, pain, disability, and health-related quality of life were evaluated. Additionally, to analyze the impact of the affected levels on these outcomes, we divided the patients into 2 groups: a middle thoracic group and a thoracolumbar group.

RESULTS

The mean duration of follow-up was 100.5 months (range, 36-190 months). The affected level was T3-T4 or below in all patients. Although the local kyphosis angle (8.1° to 12.7°), thoracic kyphosis angle (25.6° to 33.9°), and coronal Cobb angle (6.6° to 9.5°) significantly increased from preoperative to the final visit (P ≤ .02), no patient demonstrated spinal instability. From magnetic resonance imaging, no patient had a worse grade of disc degeneration in the affected level than those in the adjacent levels. The percentage of patients who presented with an Oswestry disability index ≤ 22% was 80%. Moreover, the surgical region did not adversely affect the outcomes. No patient required additional surgery due to spinal instability or deformity.

CONCLUSIONS

Unilateral total facetectomy without fusion to resect thoracic dumbbell tumors caused neither spinal deformity nor instability requiring additional surgery at the mid- to long-term follow-up.

Anterior Thoracic Discectomy and Fusion for Symptomatic Ventral Bone Spur Associated Type I Cerebrospinal Fluid Leak: A Technical Report and Operative Video

STUDY DESIGN

Technical Report.

OBJECTIVE

Cerebrospinal fluid (CSF) leak secondary to anterior osteophytes at the cervico-thoracic junction is a rare cause of intracranial hypotension. In this article we describe a technique for anterior repair of spontaneous ventral cerebrospinal fluid leaks in the upper thoracic spine.

METHODS

In this technical report and operative video, we describe a 23-year-old male who presented with positional headaches and bilateral subdural hematoma. Dynamic CT myelography demonstrated a high flow ventral cerebrospinal fluid leak associated with a ventral osteophyte at the level of the T1-T2 disc space. Targeted blood patch provided only temporary improvement in symptoms. An anterior approach was chosen to remove the offending spur and micro-surgically repair the dural defect.

RESULTS

The patient had complete resolution of his preoperative symptoms after primary repair.

CONCLUSIONS

In select cases, an anterior approach to the upper thoracic spine is effective to repair Type 1 cerebrospinal fluid leaks.

Schmorl's nodes are associated with prevalent osteoporotic vertebral fracture and low bone mineral density: a population-based thoracic spine MRI study in older men and women

Background

Schmorl's node (SN) corresponds to nucleus pulposus herniation into the vertebral spongy bone with thickened trabeculae around the formed node. We hypothesize that a pathway may exist that: osteoporosis → weakened endplate → SN development ↔ endplate fracture of an osteoporotic vertebra.

Methods

For osteoporotic fractures in men (MrOS) and in women (MsOS) Hong Kong studies, at 14-year follow-up, thoracic spine magnetic resonance imaging (MRI) was sampled in 270 males (mean: 82.9±3.7 years) and 150 females (mean: 81.5±4.3 years). SN and Modic change were assessed as existed or not existed. For posterior disc protrusion, ligamentum flavum ossification, and spinal canal stenosis, semi-quantitative gradings were applied. For each vertebra in women, a score of 0, 0.5, 1, 1.5, 2, 2.5, 3 was assigned for no osteoporotic vertebral fracture (OVF) or OVF of <1/5, ≥1/5-1/4, ≥1/4-1/3, ≥1/3-2/5, ≥2/5-2/3, and ≥2/3 vertebral height loss, respectively, and a summed score was calculated by summing up the scores of vertebrae T1 to T12. For men, those of minimal grade were not considered as OVF and assigned a '0' score.

Results

SN prevalence in women (55.5%) almost doubled that in men (25.9%). SN was statistically significantly correlated with lower bone mineral density (BMD) derived femoral neck T-score, while the other four spine degeneration changes were not statistically significantly correlated with the T-score. SN were statistically significantly correlated with OVF score. Subjects with SN were more likely to have OVF, with odds ratio for men of 4.32 [95% confidence interval (CI): 1.70-11.00, P=0.002] and odds ratio for women of 3.28 (95% CI: 1.23-8.74, P=0.018).

Conclusions

Among older population, many features of SN parallel those of OVF.

Accuracy of Patient-Specific, 3D-Printed Laminofacetal Based Trajectory-Guide for Pedicle Screw Placement in Subaxial Cervical and Thoracic Spine

Background

Conventional methods of pedicle-screw placement have higher breach rates due to variations in pedicle trajectories.

Objective

We studied the accuracy of patient-specific, three-dimensional (3D)-printed laminofacetal-based trajectory guide for pedicle-screw placement in the subaxial-cervical and thoracic spine.

Materials and Methods

We enrolled 23 consecutive patients who underwent subaxial cervical and thoracic pedicle-screw instrumentation. They were divided into two groups: group A (cases without spinal deformity) and group B (cases with pre-existing spinal deformity). Patient-specific, 3D-printed laminofacetal-based trajectory guide for each instrumented level was designed. The accuracy of screw placement was assessed on postoperative computed tomography (CT) using the Gertzbein-Robbins grading.

Results

A total of 194 pedicle screws (114 cervical and 80 thoracics) were placed using trajectory guides, of which 102 belonged to group B (34 cervical and 68 thoracics). Out of a total of 194 pedicle screws, 193 had clinically acceptable placement (grade A: 187; grade B: 6; and grade C: 1). In the cervical spine, 110 pedicle screws out of a total of 114 had grade A placement (grade B: 4). In the thoracic spine, 77 pedicle screws out of a total of 80 had grade A placement (grade B: 2; grade C: 1). Out of a total of 92 pedicle screws in group A, 90 had grade A placement, and the rest 2 had grade B breach. Similarly, 97 out of a total of 102 pedicle screws in group B were placed accurately, 4 had grade B and another had a grade C breach.

Conclusions

Patient-specific, 3D-printed laminofacetal-based trajectory guide may help in accurate placement of subaxial cervical and thoracic pedicle screws. It may help reduce surgical time, blood loss, and radiation exposure.

Spinal arachnoid webs in adults: Clinical and imaging features in a multicenter study

BACKGROUND AND PURPOSE

Spinal arachnoid webs (SAWs) are rare and can present with myelopathic symptoms. This study aims to add 85 more cases of SAWs to the literature so we can continue to analyze clinical and imaging trends of SAWs to better understand this entity and its natural history.

METHODS

An institutional review board-approved retrospective review of SAW cases between 2016 and 2022 within a metropolitan, multihospital network was performed, searching for MR and CT reports that included "arachnoid web." Of 108 identified reports, 85 patients had imaging and/or pathologically proven arachnoid webs. Demographic and clinical data were collected. Images were analyzed for SAW level, point of maximum kyphosis, presence of cord expansion, and signal intensity. The electronic medical record (EMR) was reviewed for age, sex, symptom presentation and duration, management, and outcomes.

RESULTS

Of 85 cases, the most common presenting chief complaint was back pain and weakness. All (100%) SAWs were in the dorsal thoracic subarachnoid space, with 87% (74/85) located from thoracic (T) 2 to T6. Spinal cord expansion and signal abnormality were present in 54.1% and 23.5%, respectively. Twenty-six underwent surgical resection with 20 showing improvement of at least one symptom.

CONCLUSION

We present 85 additional cases of SAWs to the existing literature. Our cases all occurred in the dorsal thoracic subarachnoid space, predominantly from T2 to T6. Patients present with symptoms like other causes of cord compression, and spinal MR studies should be evaluated routinely for the findings of SAWs. Further research could focus on understanding SAW prevalence, risk factors, and pathophysiology.

Vertebral Aneurysmal Bone Cyst Mimicking Osteosarcoma: Case Report and Review of the Literature

Aneurysmal bone cysts are benign osseous lesions containing blood-filled cavities separated by walls of connective tissue. They can be difficult to identify clinically due to similarities in presentation, imaging, and histology with other pathologies. Specifically, it is important to distinguish these benign lesions from malignant processes, as both surgical and medical management differ. We present the case of a 21-year-old patient who presented with impaired motor and sensory function in his lower extremities. Radiologic findings were concerning for an invasive neoplasm, and the intraoperative frozen section supported this conclusion. However, an additional histological investigation was confirmatory for a diagnosis of an aneurysmal bone cyst. The patient underwent corpectomy, laminectomy, and a posterior spinal fusion, and regained motor and sensory function shortly thereafter. This report details the importance of considering aneurysmal bone cysts in the differential of infiltrative bone lesions, despite their benign nature, as medical and surgical management can vary greatly.

Biomechanical and functional analysis of the shoulder complex and thoracic spine in patients with subacromial impingement syndrome: A case control study

The motions of the shoulder are mainly carried out through the glenohumeral joint, but are also assisted by the scapulothoracic joint. Therefore, changes in the biomechanics of the thoracic spine and scapula affect the function of the shoulder. However, there is limited information on the biomechanical and functional characteristics of the shoulder complex and thoracic spine in patients with subacromial impingement syndrome (SIS). In this study, the biomechanical and functional characteristics of the shoulder complex and thoracic spine were analyzed in patients with SIS compared to healthy individuals. A total of 108 participants were included in this study. Participants were classified into 2 groups, the SIS (n = 55) and healthy (n = 53) groups. The shoulder and thoracic range of motion (ROM), scapular position, and isokinetic shoulder strength were measured in all participants. The shoulder ROM was significantly decreased in the SIS group compared to the healthy group (P < .001). The thoracic spine ROM showed significantly limited extension in the SIS group (P < .001). The scapular position showed significantly increased anterior tilting (P = .005), internal rotation (P = .032), protraction (P < .001), and decreased upward rotation (P = .002) in the SIS group. The isokinetic shoulder external rotation (P < .001) and abduction (P < .001) strength were significantly lower in the SIS group. Patients with SIS showed reduced shoulder ROM and end-range extension of the thoracic spine compared to healthy individuals, and the scapula was in a more anterior-tilted, protracted, and downward rotated position. In addition, it showed lower external rotation and abduction strength. These results suggest the need for interventions to improve the limited thoracic extension and altered scapular position, which may affect shoulder ROM and muscle strength in the rehabilitation of patients with SIS.

A case of synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome with isolated lesions of the thoracic spine

We report a case of isolated lesions of the thoracic spine attributed to synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. A 55-year-old woman who suffered from 6 months of back pain had vertebral osteomyelitis on magnetic resonance imaging (MRI). There were no laboratory findings suggestive of infection, malignancy, or autoimmune disease. Radiography, computed tomography (CT), and MRI of the thoracic spine showed mixed lesions of sclerosis and erosion, whereas bone scintigraphy did not show accumulation at any site except the thoracic spine. No lesions in the anterior chest wall or sacroiliac joints were apparent from CT and MRI. No lesions other than at the thoracic spine were observed. As the isolated lesions of the thoracic spine were considered not to have resulted from infection, malignancy, or autoimmune disease, the patient was referred to our department for differential diagnosis. Given that isolated sterile hyperostosis/osteitis among adults is included in the modified diagnostic criteria for SAPHO syndrome, we suspected that the mixed lesions of sclerosis and erosion of the thoracic spine in this case may reflect SAPHO syndrome with chronic non-bacterial osteitis (CNO) of the thoracic spine. Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) was initiated and led to alleviation of her back pain, although the thoracic spine lesions remained on the 6-month MRI. Based on the CNO of the thoracic spine and the rapid response to NSAIDs, the final diagnosis was SAPHO syndrome with isolated lesions of the thoracic spine.

Three-level thoracic disc herniation: transthoracic decompression without fixation

Thoracic disc herniation is a rare pathology compared to the rest of the herniated discs. Due to their difficult access to the area of compromise and proximity to the spinal cord they represent a real challenge for the spine surgeon. The objective is to report an atypical case with three symptomatic dorsal disc herniations which required surgical treatment. Surgery was performed in two times with a lapse of 12 months between interventions. It was done a minimally invasive transthoracic decompression and intersomatic arthrodesis without instrumentation. The patient presented good neurological recovery without any serious sequelae.

Atypical Presentation of Hirayama Disease Involving the Cervico-Thoracic Segment Causing Diagnostic Dilemma: A Case Report

Hirayama disease, also known as monomelic amyotrophy, usually affects young males who initially experience increasing muscle weakness and atrophy of the distal upper limb before experiencing a sudden plateauing of symptom progression a few years later. It is a form of cervical myelopathy characterized by self-limiting, asymmetrical lower motor weakness of the upper limbs affecting the hands and forearms. This condition is brought on by the cervical dural sac and spinal cord being abnormally displaced forward during neck flexion, which causes the anterior horn cells to atrophy. However, research into the precise process is ongoing. Patients presenting with such features with additional atypical symptoms, like back pain, weakness, atrophy and paresthesia of lower extremities cause a diagnostic dilemma. We describe a case of a male patient, age 21, who complained of weakness in both upper limbs mostly on the hand and forearm muscles along with weakness and deformity in both lower limbs. He was diagnosed with atypical Cervico-thoracic Hirayama disease and treated.

Surgical approach to single-level symptomatic thoracic disc herniations through costotransversectomy: A report of ten case series

Study Design

This was an observational study.

Objectives

The treatment of symptomatic thoracic disc herniation (TDH) remains a matter of debate. We report our experience with ten patients affected by symptomatic TDH, surgically treated through costotransversectomy.

Methods

A total of ten patients (four men and six women) with single-level symptomatic TDH were surgically treated by two senior spine surgeons at our institution between 2009 and 2021. The most common type was a soft hernia. TDHs were classified as lateral (5) or paracentral (5). Preoperative clinical symptoms were varied. The diagnosis was confirmed by computed tomography (CT) and magnetic resonance imaging of the thoracic spine. The mean follow-up period was 38 months (range: 12-67 months). The Oswestry Disability Index (ODI), the Frankel grading system, and the modified Japanese Orthopedic Association (mJOA) scoring system were used as outcome scores.

Results

Postoperative CT study documented satisfactory decompression either on the nerve root or the spinal cord. All patients experienced a reduction of disability with an improved mean ODI score by 60%. Six patients reported total recovery of neurological function (Frankel Grade E) and four patients improved by 1 Grade (40%). The overall recovery rate estimated with the mJOA score was 43.5%. We reported the absence of significant difference in outcome compared to either calcified and noncalcified discs or paramedian and lateral location. Four patients had minor complications. No revision surgery was required.

Conclusion

Costotransversectomy represents a valuable tool for spine surgeons. The major limit of this technique is the possibility to approach the anterior spinal cord.

Anterior shift of the ventral dura mater: A novel concept of the posterior surgery for ossification of the posterior longitudinal ligament in thoracic spine

Background

Thoracic myelopathy caused by ossification of the posterior longitudinal ligament (OPLL) remains one of the most difficult disorders to treat. The Ohtsuka procedure, extirpation, or anterior floating of the OPLL through a posterior approach, has shown great surgical outcomes after several modifications. However, these procedures are technically demanding and pose a significant risk of neurological deterioration. We have developed a novel modified Ohtsuka procedure in which removal or minimization of the OPLL mass is unnecessary; instead, the ventral dura mater is shifted anteriorly with the posterior part of the vertebral bodies and targeted OPLL.

Surgical Procedure

First, pedicle screws were inserted at more than three spinal levels above and below the spinal level where pediculectomies were performed. After laminectomies and total pediculectomies, partial osteotomy of the posterior vertebra adjacent to the targeted OPLL was performed by using a curved air drill. Then, the PLL is completely resected at the cranial and caudal sites of the OPLL using special rongeurs or a threadwire saw with a diameter of 0.36 mm. The nerve roots were not resected during surgery.

Methods

Eighteen patients (follow-up ≥1 year) treated with our modified Ohtsuka procedure were assessed clinically, including the Japanese Orthopaedic Association (JOA) score for thoracic myelopathy and radiographically.

Results

The average follow-up period was 3.2 years (range, 1.3-6.1 years). The preoperative JOA score was 2.7 ± 1.7, which improved to 8.2 ± 1.8 at 1 year postoperatively; therefore, the recovery rate was 65.8 ± 19.8%. The CT scan at 1 year after surgery revealed the anterior shift of the OPLL averaged 3.1 ± 1.7 mm and the ossification-kyphosis angle of the anterior decompression site decreased at an average of 7.2 ± 6.8 degrees. Three patients demonstrated temporary neurological deterioration, all of whom completely recovered within 4 weeks postoperatively.

Discussion

The concept of our modified Ohtsuka procedure is 1) not OPLL extirpation or minimization but only the creation of space between the OPLL and spinal cord by an anterior shift of the ventral dura mater, which is achieved by complete resection of the PLL at the cranial and caudal sites of the OPLL; and 2) no nerve roots are sacrificed to prevent ischemic spinal cord injury. This procedure is not technically demanding and safe and provides secure decompression for thoracic OPLL. The anterior shift of the OPLL was smaller than expected, but it resulted in a relatively good surgical outcome with a recovery rate ≥65%.

Conclusion

Our modified Ohtsuka procedure is quite secure and is not technically demanding, with a recovery rate of 65.8%.

Osteophytes' position in subjects with DISH and right-sided aorta: verification of the 'aortic pulsation protective effect' theory

OBJECTIVES

To validate in a large cohort with right-sided aorta the theory that thoracic right-sided flowing osteophytes in DISH results from a 'protective' effect of the pulsating descending left-sided thoracic aorta.

METHODS

Chest CTs of patients with DISH and right-sided aorta and controls with DISH and left-sided aorta were evaluated and compared on each intervertebral space (IS) for the location of the aorta (right, left, centre) and the location of the osteophyte relative to the aorta (contralateral, ipsilateral, bilateral).

RESULTS

The study and control cohorts included 31 and 35 subjects, respectively (male 22/9 and female 27/8; median age 64.8/65.3 years; P = 0.86). Osteophytes contralateral to the aorta's location were recorded in the majority of ISs in both the study and control groups (47% and 60%, respectively; P > 0.05), while ipsilateral osteophytes were recorded in 6.9% and 7.7%, respectively (P = 0.002). Bilateral osteophytes located to the right and the left of the aorta were significantly more prevalent in the study group compared with the controls (17.2% and 5.4%, respectively; P = 0.04).

CONCLUSIONS

Aortic pulsation plays an important role in inhibiting the development of osteophytes and results in the majority of contralateral osteophytes on both right-sided and left-sided aortas. However, since both ipsilateral and bilateral osteophytes were not at all rare in both groups, other parameters, which are yet to be established, probably contribute to the location of osteophytes.

Illustrative case

BACKGROUND

Spinal cysts in the interdural space are extremely rare and are not included in the standard classification of spinal meningeal cysts.

OBSERVATIONS

A 60-year-old female presented to our hospital with a spastic gait and numbness in both palms. Magnetic resonance imaging (MRI) revealed a spinal cyst from C4 to T4 compressing the spinal cord. Computed tomography myelography revealed a fistula at C4-5 and C5-6 that connected the cyst along the right C5 and C6 root sleeves. The cyst was located within the dura mater, and communication with the arachnoid space was achieved using a shunt tube. There was partial spastic gait amelioration after the procedure, but the patient experienced a relapse 2 months postoperation. A repeat procedure was performed without a shunt tube to allow greater communication between the cyst and the subarachnoid space. After this, marked improvement in gait function was observed, and MRI showed a significant reduction in cyst volume.

LESSONS

Interdural spinal meningeal cysts are rare. When the interdural cyst cannot be removed entirely, surgery may be appropriate for providing a shunt tube or establishing communication between the cyst and arachnoid space to maintain the circulation of cerebrospinal fluid collected in the cyst cavity.

A unique case of isolated thoracic spinal Rosai-Dorfman disease related to IgG4

Rosai-Dorfman disease (RDD) is a rare benign histiocytosis usually characterized by massive cervical lymphadenopathy and systemic manifestations. Extranodal, especially spinal involvement, is extremely rare. Our case was deemed worthy of presentation because it was the first reported isolated case of spinal RDD related to IgG4 and mimicked meningioma clinically and radiologically. A case with an intradural extramedullary mass causing neurological compression findings in the thoracic spinal region and radiologically mimicking meningioma is presented. In the histomorphological examination of the resection material, polymorphonuclear leukocytes in the dura, histiocytes showing emperipolesis, an increase in collagenized fibrous connective tissue, and intense lymphoplasmacytic cell infiltration accompanied by obliterative phlebitis were observed. Immunohistochemically, the histiocytic cells were found to be S-100 protein, CD68, and CD163 positive and CD1a and langerin negative, and more than half of the plasma cells were immunoglobulin-G4 (IgG4) positive. Although rare, RDD or IgG4-related meningeal disease should be considered in the differential diagnosis of dural-based spinal masses that radiologically suggest meningioma. The pathologist should be aware that these two histopathological entities may coexist. To our knowledge, this is the first case of "isolated spinal RDD related to IgG4" reported in the literature.

Factors Predicting Poor Surgical Outcome in Patients with Thoracic Ossified Ligamentum Flavum - Analysis Of 106 Patients in a Tertiary Care Hospital in South India

Background

Ossified ligamentum flavum (OLF) is the major cause of thoracic myelopathy in our locality. Surgical outcomes and their related factors for patients with thoracic OLF (T-OLF) remain unclear because of the few studies on this condition.

Objectives

The present study aimed to examine the factors predicting poor surgical outcomes and the effectiveness of decompressive laminectomy and OLF resection in patients with T-OLF.

Material and Methods

A total of 106 patients with T-OLF operated at our institute from 2007 to 2018 were included. The mJOA score was used in neurological assessment preoperatively and during the follow-up. Multiple regression analysis was conducted to know the best correlation between factors and surgical outcomes.

Results

The mean mJOA score was 5.67 ± 2.13 preoperatively and 7.50 ± 2.60 postoperatively at the end of follow-up. The recovery rate was 43.29 ± 30.55%. After decompressive laminectomy, the mean mJOA score, modified Nurick score, and Ashworth's grade showed significant improvement (P < 0.001). Multiple regression analysis showed that the age of the patient, associated trauma, OLF level, tuberous type OLF, intramedullary signal change on T2WI, preoperative severity of myelopathy, pre-op mJOA score, and pre-op Nurick grade were significantly correlated with the surgical outcome (P < 0.001). No correlation was identified with the duration of symptoms, dural ossification, dural tear, and CSF leak (P > 0.05).

Conclusion

It is important to identify preventable risk factors for poor surgical outcomes for T-OLF. Age of the patient, associated trauma, OLF level, tuberous type OLF, intramedullary signal change on T2WI, preoperative severity of myelopathy, preoperative mJOA score, and Nurick grade were important predictors of surgical outcome in our study series.

Simple sutureless closure of a thoracic ventral dural defect in a patient with superficial siderosis: technical report

BACKGROUND

Closure of the ventral dura mater of the thoracic spinal cord is challenging because it requires both avoiding spinal cord damage and obtaining sufficient working space in an anatomically narrow area. We report a case of superficial siderosis (SS) due to chronic bleeding from a thoracic ventral dural defect in which we preformed dural repair using as a simple sutureless method and obtained good results.

CASE DESCRIPTION

A 75-year-old man complained of slowly progressive gait, speech, and hearing disturbances over 5 years. Magnetic resonance imaging (MRI) showed SS in the brain and the spinal cord and a dural defect ventral to the spinal cord at the T2 level. Neurological examination revealed bilateral cerebellar ataxia and mild motor weakness in left iliopsoas muscle. T2 and T3 hemi-laminectomy was performed in the prone position. Transdurally, a dural defect on the ventral side of the spinal cord and a fluid-filled space beyond it could be observed. With endoscopic assistance, a blood clot in the space was confirmed. For dural closure, we performed a simple manipulation using a collagen-based dural graft. The graft was cut into pieces, softened with saline, and simply packed into the space with minimal strain on the spinal cord despite the narrow space. The postoperative clinical course was uneventful. Postoperative MRI at 1 year showed the space had disappeared.

CONCLUSION

In patients with SS, sutureless dural closure using a collagen-based dural graft allows for effective, minimally invasive dural closure, even for thoracic ventral lesions.

Thoracic ossification of the ligamentum flavum causing Brown-Séquard syndrome: a case report and literature review

Brown-Séquard syndrome (BSS) has many etiologies, including penetrating trauma, extramedullary tumors, and disc herniation. However, thoracic ossification of the ligamentum flavum (OLF) is an extremely rare cause of this syndrome. A 46-year-old woman with motor weakness in her right lower extremity and urinary retention was admitted to our department. Based on the results of physical examination, computed tomography, and magnetic resonance imaging, a diagnosis of BSS with OLF was considered. The patient underwent urgent conservative treatment. BSS is a rare condition characterized by hemisection or hemicompression of the spinal marrow. The herein-described case of incomplete BSS due to OLF responded to conservative treatment. However, the successful nonoperative management of this case is insufficient evidence to consider it as the standard of care. Therefore, emergency laminectomy decompression remains the standard of care for BSS.

Anteroposterior shear stiffness of the upper thoracic spine at quasi-static and dynamic loading rates-An in vitro biomechanical study

To evaluate the biomechanical properties of the upper thoracic spine in anterior-posterior shear loading at various displacement rates. These data broaden our understanding of thoracic spine biomechanics and inform efforts to model the spine and spinal cord injuries. Seven T1-T2 thoracic functional spinal units were loaded non-destructively by a pure shear force up to 200 N, starting from a neutral posture. Tests were run in both posterior and anterior directions, at displacement rates of 1, 10, and 100 mm/s. The three-dimensional motion of the specimen was recorded at 1000 Hz. Individual and averaged load-displacement curves were generated and specimen stiffnesses were calculated. Due to a nonlinear response of the specimens, stiffness was defined separately for both the lower half and the upper half of the specimen range of motion. Specimens were significantly stiffer in the anterior direction than in the posterior direction, across all rates. At low displacements, the anterior stiffness averaged 230 N/mm, 76% higher than the low displacement posterior stiffness of 131 N/mm. At high displacements, anterior stiffness averaged 258 N/mm, 51% stiffer than the high displacement posterior stiffness of 171 N/mm. Shear displacement rate had a small effect on the load response, with the 100 mm/s rate causing a mildly stiffer response at low displacements in the anterior direction. Overall, the load-displacement response exhibited pseudo-quadratic behavior at 1 and 10 mm/s but became more linear at 100 mm/s. The shear stiffness in the upper thoracic spine is greatest in the anterior loading direction, being 51%-76% greater than posterior, most likely due to facet interactions. The effect of the shear displacement rate is low.

Intracranial Seeding Following Surgery and Chemotherapy in a Child with a Spinal Cord Endodermal Sinus Tumor: A Case Report

We herein report a case of an extremely rare spinal cord endodermal sinus tumor (EST). A nine-year-old boy presented with progressive paraparesis, hypesthesia, and urinary retention. Gadolinium-enhanced magnetic resonance imaging (MRI) revealed multiple intradural enhancing lesions at T1 to T9 without evidence of intracranial tumors. He underwent partial resection of the lesions, and histology revealed an EST. He received chemotherapy, but 12 months after surgery, rapid tumor progression and intracranial metastases with obstructive hydrocephalus were detected. Following external ventricular drainage, the patient's condition rapidly deteriorated, and he ultimately died. EST should be considered when confronting a homogenously enhancing intradural tumor of the spine on post-contrast MRI.

Mechanical Analysis of 3 Posterior Fusion Assemblies Intended to Cross the Cervicothoracic Junction

STUDY DESIGN

This was a biomechanical comparison study.

OBJECTIVE

The objective of this study is to evaluate the mechanical properties of 3 posterior spinal fusion assemblies commonly used to cross the cervicothoracic junction.

SUMMARY OF BACKGROUND

When posterior cervical fusions are extended into the thoracic spine, an instrumentation transition is often utilized. The cervical rod (3.5 mm) can continue using thoracic screws designed to accept the cervical rods. Alternatively, traditional thoracic screws may be used to accept thoracic rods (5.5 mm). This requires the use of a 3.5-5.5 mm transition rod or a separate 5.5 mm rod and a connector to fix the 3.5 and 5.5 mm rod together. Fusion success depends on the immobilization of vertebrae, yet the mechanics provided by these different assemblies are unknown.

MATERIALS AND METHODS

Three titanium alloy posterior fusion assemblies intended to cross the cervicothoracic junction underwent static compressive bending, tensile bending, and torsion as described in ASTM F1717 to a torque of 2.5 Nm. Five samples of each assembly were attached to ultrahigh molecular weight polyethylene blocks via multiaxial screws for testing. Force and displacement were recorded, and the stiffness of each construct was calculated.

RESULTS

The 2 assemblies that included a 5.5 mm rod were found to be stiffer and have less range of motion than the assembly that used only 3.5 mm rods.

CONCLUSIONS

The results of this study indicate that incorporating a 5.5 mm rod in a fusion assembly adds significant stiffness to the construct. When the stability of a fusion is of heightened concern, as demonstrated by the ASTM F1717 vertebrectomy (worst-case scenario) model, including 5.5 mm rods may increase fusion success rates.

LEVEL OF EVIDENCE

Level V.

Anatomical method for rib disconnection during posterior costotransversectomy for paravertebral access to the ventral thoracic spine

Posterior surgical approaches to the thoracic spine are commonly used for degenerative diseases, tumors, trauma, and other operative indications. A posterior approach for access to the paravertebral space is advantageous because it allows for resection of the vertebral body without violating the pleural cavity. Posterior costotransversectomy (PCT) is widely used for this purpose. It involves resection of the rib head after the ligamentous complexes have been disconnected from the transverse process and lateral vertebral body. The current literature provides only vague descriptions of the steps involved in rib disconnection with respect to PCT. A comprehensive knowledge of the anatomical relationships of the ligamentous and soft tissue complexes connecting the rib to the vertebral body is paramount for completing an efficient and safe surgery. This manuscript describes an anatomically directed method for rib disconnection during costotransvrersectomy.

Lower thoracic spine extension mobility is associated with higher intensity of thoracic spine pain

Objectives

To evaluate the association of thoracic spine (TS) posture and mobility with TS pain.

Methods

Participants with TS pain reported maximum, average, and night pain in TS area, and pain summary score was calculated. Upright and sitting TS postures were evaluated by inspection. TS posture and mobility (flexion and extension) were recorded using an inclinometer and a tape measure, respectively. Correlations between posture and mobility assessments were calculated using Spearman rank correlation, the association of TS posture and mobility with TS pain by logistic regression analysis.

Results

The participants’ (n = 73, 52 females, age range 22–56) TS pain duration was 12 weeks on average. The correlations for measurements of TS posture and flexion mobility were higher than correlations of other TS measurements being between 0.53 and 0.82. Decreased extension mobility of the upper (from 1^st to 6^th TS segments; Th1–Th6) TS was associated with higher worst pain (OR 1.04, 95% CI 1.00–1.07) and whole TS with pain sum score (OR 1.05, 95% CI 1.01–1.08). Less kyphotic whole TS was associated with lower pain sum score (OR 0.96, 95% CI 0.92–1.00). Greater flexion mobility of upper and lower (Th6–Th12) TS were associated with lower pain sum score (OR 0.96, 95% CI 0.91–1.00, and OR 0.96, 95% CI 0.91–1.00, respectively).

Conclusions

Reduced thoracic extension mobility was associated with higher pain scores and the greater flexion mobility with lower pain scores. Future research is warranted to evaluate if treatments geared toward TS extension mobility improvements would result in lower TS pain.

[Surgical treatment of thoracic spine fracture in a patient with ankylosing spondylitis: case report and literature review]

OBJECTIVE

To describe the features of diagnosis and surgical treatment of thoracic spine fracture in a patient with ankylosing spondylitis.

MATERIAL AND METHODS

We present a patient with ankylosing spondylitis, blunt thoracic spine trauma and Th10-Th11 fracture, spinal cord compression and contusion and moderate lower extremity paresis. Preoperative and postoperative CT and MRI (after 8 months) were performed for control of decompression.

RESULTS

The authors identified the main factors affecting the quality of life of patients with spine fractures following ankylosing spondylitis and formulated treatment algorithm.

CONCLUSION

Active strategy is advisable for spine fractures following ankylosing spondylitis: spinal cord decompression, creation of anatomical compliance in the damaged vertebral segment and its fixation by transpedicular system. A similar surgical treatment of spine fractures following ankylosing spondylitis makes it possible to achieve early activation of patients and reduce rehabilitation period.

[Physical rehabilitation for osteochondrosis of the cervical and thoracic spine in elderly and senile people (Stage 3).]

The concept of a multidisciplinary approach to the treatment of osteochondrosis in elderly and senile patients by specialists of various profiles using medicinal and non-medicinal methods is especially relevant today, therefore, it is necessary to develop and put into practice various options for the combined use of physical rehabilitation means at different stages of rehabilitation treatment of elderly and senile patients with osteochondrosis of the cervical and thoracic spine. The dynamics of clinical manifestations of osteochondrosis after rehabilitation treatment relative to the age of patients in groups showed that the effectiveness of the technique is much higher in elderly patients, in contrast to senile patients and centenarians. The study revealed no significant complications and side effects when using this technique, which allows us to recommend it as a means of secondary prevention of diseases of the cervical and thoracic osteochondrosis, especially in the presence of contraindications to the use of non-steroidal anti-inflammatory drugs and glucocorticoids. The technique can be recommended for use in fitness clubs, athletic halls and medical and physical education dispensaries.