Vertebral artery dissection as the underlying cause of ventral spinal epidural haematoma

Spontaneous spine epidural haematoma is a rare occurrence, with an incidence of 0.1/100 000 inhabitants/year. The anterior location of the haematoma is very uncommon since the dural sac is firmly attached to the posterior longitudinal ligament. Vertebral artery dissection as its underlying cause is an exceptionally rare event, with only two documented cases.This article presents the case of young woman who arrived at the emergency room with a spinal ventral epidural haematoma extending from C2 to T10, caused by a non-traumatic dissecting aneurysm of the right vertebral artery at V2-V3 segment. Since the patient was tetraparetic, she underwent emergent laminectomy, and the vertebral artery dissection was subsequently treated endovascularly with stenting.Vertebral artery dissection with subsequent perivascular haemorrhage is a possible cause of spontaneous spine epidural haematoma, particularly when located ventrally in the cervical and/or high thoracic column. Hence the importance of a thorough investigation of the vertebral artery integrity.

Comparison the effect of bupivacaine plus magnesium sulfate with ropivacaine plus magnesium sulfate infiltration on postoperative pain in patients undergoing lumbar laminectomy with general anesthesia

PURPOSE

In this study, we investigated the effect of local injection of ropivacaine and bupivacaine with magnesium sulfate on postoperative pain in vertebral laminectomy surgery.

DESIGN

This randomized double-blind prospective study was conducted among 60 patients aged 18-65 years old with ASA class I and II.

METHODS

Group RM: (30 people) received 70 mg ropivacaine (14 ml) plus 1 ml magnesium sulfate (500 mg) volume up to 20 ml with normal saline. Group BM: (30 people) received 70 mg bupivacaine (14 ml) plus 1 ml magnesium sulfate (500 mg) volume up to 20 ml with normal saline. The results were analyzed by SPSS 23 software, and statistical analysis consisted of χ2 test and t-test, and a p value less than .05 was considered significant.

FINDINGS

Mean pain score based on VAS in 6 and 12 h after surgery in the RM group was lower in the BM group (p < 0.05). The analgesic request frequency in the RM group was lower than the BM group (p = 0.01). The mean morphine consumption in the RM group was 185 mg and in the BM group was 220 mg. According to the T-test, there was a significant difference between the two groups (p = 0.03). there was no significant difference between the mean arterial blood pressure and mean heart rate between the two groups at 6, 12, 24 and 24 h after surgery (p > 0.05).

CONCLUSION

This study showed that wound infiltration with ropivacaine and magnesium sulfate compared to bupivacaine and magnesium sulfate provided better postoperative analgesia and significantly reduced postoperative opioid consumption in patients undergoing lumbar laminectomy.

Ultrasound-guided erector spinae plane blocks for pain management after open lumbar laminectomy

PURPOSE

Lumbar spine surgery is associated with significant postoperative pain. The benefits of erector spinae plane blocks (ESPBs) combined with multimodal analgesia has not been adequately studied. We evaluated the analgesic effects of bilateral ESPBs as a component of multimodal analgesia after open lumbar laminectomy.

METHODS

Analgesic effects of preoperative, bilateral, ultrasound-guided ESPBs combined with standardized multimodal analgesia (n = 25) was compared with multimodal analgesia alone (n = 25) in patients undergoing one or two level open lumbar laminectomy. Other aspects of perioperative care were similar. The primary outcome measure was cumulative opioid consumption at 24 h. Secondary outcomes included opioid consumption, pain scores, and nausea and vomiting requiring antiemetics on arrival to the post-anesthesia care unit (PACU), at 24 h, 48 h, and 72 h after surgery, as well as duration of the PACU and hospital stay.

RESULTS

Opioid requirements at 24 h were significantly lower with ESPBs (31.9 ± 12.3 mg vs. 61.2 ± 29.9 mg, oral morphine equivalents). Pain scores were significantly lower with ESPBs in the PACU and through postoperative day two. Patients who received ESPBs required fewer postoperative antiemetic therapy (n = 3, 12%) compared to those without ESPBs (n = 12, 48%). Furthermore, PACU duration was significantly shorter with ESPBs (49.7 ± 9.5 vs. 79.9 ± 24.6 min).

CONCLUSIONS

Ultrasound-guided, bilateral ESPBs, when added to an optimal multimodal analgesia technique, reduce opioid consumption and pain scores, the need for antiemetic therapy, and the duration of stay in the PACU after one or two level open lumbar laminectomy.

Clinical features of early recurrence of type I thoracolumbar intervertebral disk herniation in Miniature Dachshunds

Some reports have been published on clinical features in dogs with early recurrence of type I thoracolumbar intervertebral disk herniation (TL-IVDH), but there is little understanding of the changes involved. This retrospective study describes the clinical features, including radiographic image results at the time of recurrence, of dogs with type I TL-IVDH that had undergone hemilaminectomy but then suffered early recurrence. Our medical records were searched between June 2007 and December 2022. Nine dogs showed deterioration in neurological signs within 4 to 6 weeks after surgery. All nine were Miniature Dachshunds. Radiographic images at initial onset showed calcification at the affected intervertebral disk space in all 9 dogs. Disk herniations at the initial onset were located between T11-12 and L1-2. After the first surgery, neurological function improved in all dogs. Recurrence occurred at the same site as at initial onset in all dogs. No calcification was observed at the affected intervertebral disk space on images at the time of recurrence. The extruded disk materials were surgically removed, and neurological function improved after the second surgery. In conclusion, calcification at the affected disk space at the time of initial onset is indicative of residual nucleus materials not yet fully extruded, and is a risk factor for early recurrence of type I TL-IVDH.

Multiple spinal extradural arachnoid cysts presenting as compressive myelopathy in a teenager: case report and literature review with special emphasis on postoperative spine deformity in the current minimally invasive era

INTRODUCTION

Multiple synchronous spinal extradural arachnoid cysts are extremely rare in children and can lead to cord compression and disability. Multiple spinal extradural arachnoid cysts (SEDACs) in children with immature and growing spine need to be studied separately from multiple SEDACs in adults with mature and fully grown spine because of multiple surgical limitations in children (blood loss, surgery duration, long-term spinal stability after long segment exposure, etc.).

MATERIAL AND METHODS

We planned a non-systematic literature review of similar cases described in literature to analyse the pattern of presentation, management, and outcome of this surgically curable disease.

RESULTS

A total of 28 cases of paediatric multiple SEDACs in the age range of 5 months to 17 years and mean age of 11.54 years were analysed. Exposure was achieved by laminectomy in 9, laminoplastic laminotomy in 13, laminectomy in first surgery followed by laminoplasty in second surgery (re-exploration) in 1, hemilaminectomy in 2, and technique "not reported" in 3 children. Complete/near-complete recovery was seen in 27 (96.42%) children. Postoperative spine deformity was reported in 7 (25%) children and was progressive in 2 children during serial follow-up.

CONCLUSIONS

Symptomatic multiple synchronous SEDACs in children is a rare surgically curable condition. Sincere attempt to find out a dural defect in all cysts is a very important step in multiple SEDAC surgery. Total cyst wall excision with closure of all dural defects is the gold standard treatment for symptomatic cases. Laminoplasty is preferred for excision of multiple SEDACs in children to prevent postoperative spine deformity during long-term follow-up. Long serial follow-up for postoperative spine deformity is necessary.

Plate-only open-door laminoplasty is associated with durable, significantly improved clinical outcomes and a very low reoperation rate for progressive spondylosis or adjacent segment disease: average 8-year follow-up

BACKGROUND CONTEXT

Multilevel cervical myelopathy is a common cause of spinal cord dysfunction in adults. Surgical intervention via laminoplasty can provide satisfactory clinical outcomes by expansive decompression of the spinal cord. Traditional suture or bone graft techniques have been associated with insufficient fixation, leading to premature closure and subsequent neurological deterioration. In contrast, plated laminoplasty has been shown to provide stable fixation to maintain canal enlargement, but longer-term outcomes are lacking.

PURPOSE

To evaluate longer-term clinical outcomes and reoperations associated with plate-only open-door laminoplasty.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

Postoperative patients who underwent plate-only open door laminoplasty with minimum 5-year follow up.

OUTCOME MEASURES

modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI), and 12-item Short Form Health Survey (SF-12).

METHODS

All patients at a single academic institution who underwent plate-only open-door cervical laminoplasty from 9/1/2006 to 9/1/2016 were identified to ensure minimum 5 year follow up. Clinical outcomes included the modified Japanese Orthopaedic Association (mJOA) score, the Neck Disability Index (NDI), and the 12-item Short Form Health Survey (SF-12). The occurrence of any repeat operations on the cervical spine was evaluated, as well as its cause. The study team attempted to contact all eligible patients to achieve at least 5 years postoperative follow-up. Pairwise t tests were performed to compare clinical outcomes at preoperative, 6 months, 1-year, and final postoperative follow-up with an α level of 0.05.

RESULTS

A total of 774 met the initial inclusion criteria, of which 157 were included in the study (20.3%). Most common reasons for exclusion included inability to reach after 3 attempts (49.48%), inactive phone numbers (20.28%), and patient declining (3.49%). Included patients had an average age of 60.66±10.63 and an average follow-up time of 8.37±2.57 years (minimum 5 years). mJOA scores (preoperative 11.59±2.16) improved significantly at 6-months (14.57±2.07, p<.001), 1-year (15.19±1.95, p<.001), and final follow-up (14.59±2.63, p<.001). NDI (preoperative 33.89±18.54) improved significantly at 6 months (27.89±19.72, p=.03), 1-year (25.96±19.79, p=.01) and final follow-up (17.88±17.17, p<.001). SF-12 MCS (preoperative 44.73) improved significantly at 6 months (52.01, p=.001), 1-year (51.62, p=.008), and final follow-up (52.32, p<.001). No patient underwent reoperations for plate failure or canal closure with recurrent stenosis. Reoperations for progressive spondylosis during the follow up period were rare and occurred in only three patients for new onset radiculopathy (1.9%) and two patients for myelopathy (1.3%) at an average of 3.2 years postoperative. There were no reoperations performed for adjacent segment disease.

CONCLUSIONS

At a minimum of 5 years and an average of more than 8 years postoperative, laminoplasty was associated with significant and sustained improvements in mJOA, NDI, and SF-12 MCS. Importantly, no patients underwent revision surgery for plate failure or recurrent canal closure. Reoperations for new onset radiculopathy and myelopathy were also very rare over the 8-year average follow-up period, with no reoperations for adjacent segment disease. Plate-only laminoplasty is a durable means of treating multilevel myelopathy with excellent longer-term outcomes and a very low risk of reoperation, either for premature closure or the inevitable spondylotic changes that occur over time in patients with similar baseline characteristics to the study population.

Safety and Efficacy Outcomes Following Spinal Endoscopic Procedures for Thoracic Ligamentous Ossification: A Systematic Review and Meta-Analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

This study systematically reviewed and evaluated the safety and efficacy of spinal endoscopic techniques as a treatment for thoracic ligamentum flavum ossification (TOLF).

SUMMARY OF BACKGROUND DATA

The use of spinal endoscopic techniques for the treatment of TOLF has increased in recent years. The present study is the first comprehensive systematic review and meta-analysis focused on the use of spinal endoscopic techniques for TOLF.

MATERIALS AND METHODS

The Cochrane Central, PubMed, Web of Science, and Embase databases were systematically searched for studies focused on patients undergoing spinal endoscopic techniques to treat symptomatic TOLF.

RESULTS

This meta-analysis included 23 studies. We included 323 patients (177 males, 146 females) with a mean age of 58.40±10.06 years, with 304 total recorded lesion locations of which 245 were located in the lower thoracic spine. Complications affected 35/323 patients, and the mean operative duration for 305 patients was 108.15±47.34 minutes. For 187 patients, the mean operative bleeding was 25.13±12.54 mL, while for 87 patients the mean duration of hospitalization was 4.59±1.93 days. At last follow-up, functional assessment was performed for 260 patients, of whom 200 were in excellent condition, visual analog scale (VAS) scores were assessed for 160 patients, with a mean improvement of 4.40 (3.95, 4.86) Japanese Orthopedic Association (JOA) scores were recorded for 115 patients, with a mean improvement of 3.49 (2.79,4.18), and modified Japanese Orthopedic Association (mJOA) scores were recorded for 208 patients, with a mean improvement of 3.62 (2.89,4.35).

CONCLUSIONS

These results support several advantages of spinal endoscopic techniques for the treatment of symptomatic TOLF. These include low complication rates, rapid postoperative recovery, and good functional recovery when used for single-segment, non-nodular ossification and no combined dural ossification.

Relationship between hinge fracture and postoperative axial symptoms after cervical laminoplasty

OBJECTIVE

To identify the clinical characteristics of fractured hinges after open-door cervical laminoplasty for cervical canal stenosis and explore the relationship between hinge fractures and axial symptoms.

METHODS

This was a retrospective study of patients with cervical myelopathy who underwent open-door laminoplasty between November 2014 and November 2016 at the Affiliated Hospital of Qingdao University. Cervical CT scans were performed after surgery and the Takeuchi criteria were applied to evaluate the postoperative axial symptoms.

RESULTS

Of 223 opened laminae in 67 patients, 67 laminae (30.0%) in 30 patients (44.8%) showed fracture. The frequency of hinge fractures was higher at C6 (53.7%). Forty-nine fractured laminae (73.13%) were non-displaced and 18 were displaced. At 3 months, 33 fractured laminae (49.3%) showed bony union on CT, and union rates were 86.6% and 91.0% at 6 and 12 months, respectively, indicating that the union rate was lower for displaced fractures than for non-displaced fractures. Among the 67 patients, 14 had axial symptoms: three of 37 (8.1%) patients without hinge fractures and 11 of 30 (36.7%) patients with hinge fractures. One year later, the hinge fractures were healed in 24/30 patients. Among the six unhealed patients, five still suffered from axial symptoms. The frequency of axial symptoms was higher in the patients with three or more hinge fractures (66.7%) than in the patients with only one (16.7%) or two (46.7%) hinge fractures.

CONCLUSIONS

Patients with hinge fractures may have an increased risk for axial symptoms after open-door cervical laminoplasty. The frequency of axial symptoms decreases with fracture healing.

Treatment of ambulatory patients with metastatic epidural spinal cord compression: a systematic review and meta-analysis

OBJECTIVE

Approximately 10% of patients with spinal metastases develop metastatic epidural spinal cord compression (MESCC), which left undiagnosed and untreated can lead to the loss of ambulation. Timely diagnosis and efficient multidisciplinary treatment are critically important to optimize neurological outcomes. This meta-analysis aimed to determine the most efficient treatment for ambulatory patients with MESCC.

METHODS

The authors conducted a systematic review and meta-analysis of the treatment of mobile patients with MESCC in terms of outcomes described as local control (LC), ambulatory function, quality of life (QOL), morbidity, and overall survival (OS).

RESULTS

Overall, 54 papers (4101 patients) were included. A trend toward improved LC with stereotactic body radiotherapy (SBRT) compared with conventional external beam radiotherapy (cEBRT) was demonstrated: random effects modeling 1-year LC rate 86% (95% CI 84%-88%) versus 81% (95% CI 74%-86%) (p > 0.05), respectively, and common effects modeling 1-year LC rate 85% (95% CI 82%-87%) versus 76% (95% CI 74%-78%) (p < 0.05). Surgery followed by adjuvant radiotherapy, either cEBRT or SBRT, showed no significant benefit in either LC (OR 0.88, 95% CI 0.65-1.19) or ambulatory function (OR 1.51, 95% CI 0.83-2.74) compared with radiotherapy without surgery. There was a significant benefit of surgery compared with cEBRT regarding QOL, and furthermore SBRT alone provided long-term improvement in QOL. The type of treatment was not a significant predictor of OS, but fully ambulatory status was significantly associated with improved OS (HR 0.46-0.52, relative risk 1.79-2.3). Radiation-induced myelopathy is a rare complication of SBRT (2 patients [0.1%] in the included papers). The morbidity rate associated with surgery was relatively high, with a 10% wound complication rate and 1.6% hardware-failure rate.

CONCLUSIONS

SBRT is an extremely promising treatment modality being integrated into treatment algorithms and provides durable LC. In mobile patients with MESCC, surgery does not improve LC, survival, or ambulatory function; nonetheless, there is a significant benefit of surgery in terms of QOL. In patients with MESCC without neurological deficit, the role of surgery is still debatable as studies demonstrate good LC for patients who undergo SBRT without preceding surgery. However, surgery can provide safe margins for the administration of the ablative dose of SBRT to the entire tumor volume within the constraints of spinal cord tolerance. Further randomized controlled trials are needed on the benefit of surgery before SBRT in mobile patients with MESCC. With the excellent results of separation surgery and SBRT, the role of highly invasive vertebrectomy is diminishing given the complication rate and morbidity of these procedures.

Risk factors of instrumentation failure after laminectomy and posterior cervical fusions (PCF)

BACKGROUND

For patients with multilevel degenerative cervical myelopathy, laminectomy and posterior cervical fusions (PCF) with instrumentation are widely accepted techniques for symptom relief. However, hardware failure is not rare and results in neck pain or even permanent neurological lesions. There are no in-depth studies of hardware-related complications following laminectomy and PCF with instrumentation.

METHODS

The present study was a retrospective, single centre, observational study. Patients who underwent laminectomy and PCF with instrumentation in a single institution between January 2019 and January 2021 were included. Patients were divided into hardware failure and no hardware failure group according to whether there was a hardware failure. Data, including sex, age, screw density, end vertebra (C7 or T1), cervical sagittal alignment parameters (C2-C7 cervical lordosis, C2-C7 sagittal vertical axis, T1 slope, Cervical lordosis correction), regional Hounsfield units (HU) of the screw trajectory and osteoporosis status, were collected and compared between the two groups.

RESULTS

We analysed the clinical data of 56 patients in total. The mean overall follow-up duration was 20.6 months (range, 12-30 months). Patients were divided into the hardware failure group (n = 14) and no hardware failure group (n = 42). There were no significant differences in the general information (age, sex, follow-up period) of patients between the two groups. The differences in fusion rate, fixation levels, and screw density between the two groups were not statistically significant (p > 0.05). The failure rate of fixation ending at T1 was lower than that at C7 (9% vs. 36.3%) (p = 0.019). The regional HU values of the pedicle screw (PS) and lateral mass screw (LMS) in the failure group were lower than those in the no failure group (PS: 267 ± 45 vs. 368 ± 43, p = 0.001; LMS: 308 ± 53 vs. 412 ± 41, p = 0.001). The sagittal alignment parameters did not show significant differences between the two groups before surgery or at the final follow-up (p > 0.05). The hardware failure rate in patients without osteoporosis was lower than that in patients with osteoporosis (14.3% vs. 57.1%) (p = 0.001).

CONCLUSIONS

Osteoporosis, fixation ending at C7, and low regional HU value of the screw trajectory were the independent risk factors of hardware failure after laminectomy and PCF. Future studies should illuminate if preventive measures targeting these factors can help reduce hardware failure and identified more risk factors, and perform long-term follow-up.

Pre-emptive infiltration with betamethasone and ropivacaine for postoperative pain in laminoplasty and laminectomy (PRE-EASE): a prospective randomized controlled trial

BACKGROUND

Postoperative pain after laminoplasty and laminectomy occurs partially from local trauma of the paraspinal tissue. Finding a multimodal analgesic cocktail to enhance the duration and effect of local infiltration analgesia is crucial. Because of the rapid onset and long duration of action of betamethasone, the authors hypothesized that, a pre-emptive multimodal infiltration regimen of betamethasone and ropivacaine reduces pain scores and opioid demand, and improves patient satisfaction following laminoplasty and laminectomy.

MATERIALS AND METHODS

This prospective, randomized, open-label, blinded endpoint study was conducted between 1 September 2021 and 3 June 2022, and included patients between the ages of 18 and 64 scheduled for elective laminoplasty or laminectomy under general anesthesia, with American Society of Anesthesiologists classification I/II. One hundred sixteen patients were randomly assigned to either the BR (Betamethasone-Ropivacaine) group or the R (Ropivacaine) group in a 1:1 ratio. Each group received pre-emptive infiltration of a total of 10 ml study solution into each level. Every 30 ml of study solution composed of 0.5 ml of betamethasone plus 14.5 ml of saline and 15 ml of 1% ropivacaine for the BR group, and 15 ml of 1% ropivacaine added to 15 ml of saline for the R group. Infiltration of epidural space and intrathecal space were avoided and the spinous process, transverse process, facet joints, and lamina were injected, along with paravertebral muscles and subcutaneous tissue. Cumulative 48 h postoperative butorphanol consumption via PCA (Patient-controlled analgesia) was the primary outcome. Intention-to-treat (ITT) principle was used for primary analysis.

RESULTS

Baseline characteristics were identical in both groups ( P >0.05). The cumulative 48 h postoperative butorphanol consumption via PCA was 3.0±1.4 mg in the BR group ( n =58), and 7.1±1.2 mg in the R group ( n =58) ( P <0.001). Overall cumulative opioid demand was lower at different time intervals in the BR group ( P <0.001), along with the estimated median time of first analgesia demand via PCA (3.3 h in the BR group and 1.6 h in the R group). The visual analog scale (VAS) score at movement and rest were also significantly lower until 3 months and 6 weeks, respectively. No side effects or adverse events associated with the intervention were observed in this study.

CONCLUSIONS

Pre-emptive analgesia with betamethasone and ropivacaine provides better postoperative pain management following laminoplasty and laminectomy, compared to ropivacaine alone. This is an effective technique worthy of further evaluation.

Predictors of clinical and structural outcomes after surgery for spinal nerve sheath tumor resection: a retrospective analysis

OBJECTIVE

Resection of spinal nerve sheath tumors (SNSTs) typically necessitates laminectomy, often with facetectomy, for adequate exposure of tumor. While removal of bone affords a greater operative window and extent of resection, it places the patient at greater risk for spinal instability. Although studies have identified risk factors for fusion at the time of tumor resection, there has yet to be a study assessing long-term stability following SNST resection. In this study, the authors sought to identify preoperative and operative risk factors that predispose to long-term spinal instability and investigate clinical variables associated with greater risk for subsequent fusion in the time following initial SNST resection.

METHODS

An institutional registry of spinal surgeries was queried at a single institution over a 20-year period. Demographic, clinical, and operative variables were recorded retrospectively and investigated for predictive value of several postoperative sequelae.

RESULTS

A total of 122 SNST cases among 112 patients were included. At a mean follow-up time of 27.7 months, patients with a history of neurofibromatosis type 2 (NF2) (p = 0.014) and those who had undergone a laminectomy of ≥ 4 levels at the time of initial SNST resection (p = 0.028) were more likely to present with some degree of structural abnormality or neurological deficit following their initial surgery. The presence of facetectomy, degree of laminectomy, and level of spinal surgery were not found to be predictors of future instability. Ultimately, there was no significant predictor for true spinal instability following index surgery without fusion. A secondary analysis showed that an entirely extradural location (p = 0.044) and facetectomy at index surgery (p = 0.012) were predictive of fusion being performed at the time of tumor resection. Four of the 112 patients required fusion after their index SNST resection, 3 of whom underwent fusion for instability at the level of the index surgery. No variables were identified as predictive for future instrumentation.

CONCLUSIONS

Ultimately, the authors conclude that resection of SNSTs does not always necessitate fusion, and good outcomes can be obtained with motion-preserving techniques and minimizing facetectomy when possible. Patients with a history of NF2 and those with SNSTs that required ≥ 4-level laminectomy were more likely to exhibit some degree of structural abnormality and/or neurological deficit localized to the index level defined as either new or worsening spinal instability and/or new or worsening neurological deficit at last follow-up; however, no variable was found to be predictive of true spinal instability. Furthermore, a complete facetectomy at initial SNST resection and entirely extradural tumor location were noted to be associated with fusion at index surgery. Lastly, the authors were unable to identify a clinical predictor for future instrumentation.

Assessment of Analgesic Efficacy of Bilateral Lumbar Erector Spinae Plane Block for Postoperative Pain following Lumbar Laminectomy: A Single-Blind, Randomized Clinical Trial

Background

The erector spinae plane (ESP) block is a novel approach to minimizing postoperative pain. We investigated the efficacy and side effects of the ultrasonography-guided bilateral ESP block in reducing pain in the first 24 hours after lumbar laminectomy.

Materials and Methods

We conducted a single-blind (statistical analyst and those responsible for recording patient information postoperation were unaware of the study groups) randomized clinical trial on 50 patients aged 18 to 65 with American Society of Anesthesiology (ASA) class I or II physical status scheduled for lumbar laminectomy surgery at Shahid Chamran Hospital, Shiraz, Iran. Patients were randomly allocated to the ESP block (26 participants) or control (24 participants) group. A bilateral ESP block was administered to patients in the first group before general anesthesia, which was provided identically to both groups. The postoperative time to the first request of analgesia, pain score, total opioid use, side effects, and patient satisfaction were compared between the groups.

Results

Compared with the control group, patients in the ESP block group had significantly more postoperative pain relief in the first hour and until 24 hours (P < 0.05). The total opioid consumption was lower in the ESP block group (P < 0.001). However, the ESP block led to a higher rate of urinary retention (P = 0.008).

Conclusion

The bilateral ESP block effectively reduces postoperative pain following lumbar laminectomy, minimizing the need for narcotics. Further research is needed to delineate ways to reduce urinary retention as its main complication. This trial is registered with IRCT20100127003213N6.

Acute disc herniation following surgical decompression of lumbar spinal stenosis: a retrospective comparison of mini-open and minimally invasive techniques

BACKGROUND

Disc herniation following decompression of lumbar spinal stenosis is a less familiar surgical complication. Previous studies suggested that open lumbar decompression techniques, associated with relative segmental instability especially in the presence of degenerated disc in older patients, are more likely to result in disc herniation compared to minimally invasive techniques. The current study compares the incidence of acute disc herniation following mini-open and minimally invasive decompression of lumbar spinal stenosis.

METHODS

This was a retrospective study reviewing 563 patients who underwent spinal decompression for symptomatic lumbar stenosis by mini-open bilateral partial laminectomy technique or minimally invasive laminotomy utilizing a tubular system. Demographic and clinical data were collected and compared between the groups.

RESULTS

Postoperative disc herniation rate was significantly lower in the minimally invasive group with 2 of 237 cases (0.8%) versus 19 of 326 cases (5.8%) in the mini-open group (p = 0.002). This finding was more noticeable following multi-level procedures with no case of postdecompression disc herniation in the minimally invasive group compared to 8 of 39 cases (20.5%) in the mini-open group (p = 0.003).

CONCLUSION

The incidence of postoperative disc herniation following spinal decompression for symptomatic lumbar stenosis was 5.8% following mini-open bilateral partial laminectomy compared to only 0.8% after minimally invasive laminotomy (p = 0.002). These findings highlight the more extensive nature of mini-open surgery associated with relative segmental instability that poses a greater risk for postoperative disc herniation.

Analysis of risk factors for axial symptoms after posterior cervical open-door laminoplasty

BACKGROUND

Laminoplasty (LP), a procedure commonly used to treat cervical spondylotic myelopathy (CSM), often results in the development of axial symptoms (AS) postoperatively. This study aims to analyze the risk factors associated with the occurrence of AS after LP.

METHODS

We collected and evaluated clinical data from 264 patients with CSM who underwent LP treatment at our institution from January 2018 to January 2022 through a single-center retrospective study. Of the patients, 153 were male and 111 were female, with an average age of 58.1 ± 6.7 years. All patients underwent C3-7 posterior laminoplasty. Based on the occurrence of postoperative axial symptoms, the patients were divided into an AS group and a non-AS group. General information, including age, gender, disease duration, Japanese Orthopaedic Association (JOA) score, postoperation early function training, and collar-wearing time, was recorded and compared between the two groups. Surgical-related data, such as operative segments, surgical time, intraoperative blood loss, intraoperative facet joint destruction, and destruction of the C7 spinous process muscle insertion, were also compared. Imaging data, including preoperative cervical curvature, cervical range of motion, preoperative encroachment rate of the anterior spinal canal, and angle of laminar opening, were collected. Univariate and multivariate logistic regression analyses were used to identify risk factors for the development of AS after LP, and receiver operator characteristic (ROC) curves were utilized to explore the optimal preoperative parameters.

RESULTS

All 264 patients successfully underwent surgery and were followed up for an average of 19.5 ± 6.8 months. At the 6-month follow-up, 117 patients were diagnosed with AS, resulting in an incidence rate of 40.2%. The multivariate logistic regression analysis identified that preoperative encroachment rate of anterior spinal canal (Pre-op ERASC), intraoperative facet joints destruction (Intra-op FJD), intraoperative open-door angle (Intra-op OA), destroy the C7 spinous process muscle insertion (Destroy C7 SPMI), postoperative loss of cervical curvature (Post-op LCC), and postoperative loss of cervical range of motion (Post-op LCROM) were independent risk factors for AS. Conversely, preoperative cervical curvature (Pre-op CC) and postoperation early function training (Post-op EFT) were protective factors against AS. According to the ROC curve, the cutoff values for preoperative anterior spinal canal occupation rate and preoperative cervical curvature were 28.5% and 16.5°, respectively. When the preoperative anterior spinal canal occupation rate was greater than 28.5% or the preoperative cervical curvature was less than 16.5°, AS was more likely to occur after surgery.

CONCLUSION

High preoperative anterior spinal canal occupation rate, facet joint damage during surgery, C7 spinous process muscle stop point damage, larger angle of laminar opening, and greater postoperative cervical curvature loss and cervical range of motion loss are associated with an increased risk of developing AS after cervical laminoplasty. Conversely, a larger preoperative cervical curvature and early postoperative functional exercises can help reduce the occurrence of AS.

Predictors for spinal deformity following resection of intramedullary tumor via posterior approach: a systematic review and meta-analysis

PURPOSE

The present study aimed to identify the clinical predictive factors for worsened spinal deformity (SD) following surgical resection via posterior approach for primary intramedullary tumors.

METHODS

A systematic search was performed using PubMed, Web of Science, and Scopus databases to extract potential references. Observational studies reporting predictive factors for worsened SD following surgical resection via posterior approach for primary intramedullary tumors were included. The odds ratio (OR) was calculated for dichotomous parameters.

RESULTS

Four retrospective cohort studies were included in the meta-analysis. They were comprised of two groups of patients; those who developed SD (n = 87) and those who did not (n = 227). For patients with IMSCTs, age under 25 years as well as age under 13 years were the demographic variables associated with postoperative SD (odds ratio [OR] 3.92; p = 0.0002 and OR 4.22; p = 0.003). In both the fusion and the non-fusion subgroups, preoperative spinal deformity strongly predicted postoperative SD (OR 11.94; p < 0.001), with the risk highly elevated among the non-fusion patients (OR 24.64; p < 0.0002). Thoracolumbar junction involvement was also found to be a predictor of postoperative SD for patients with IMSCT (OR 2.89; p = 0.02).

CONCLUSION

This study highlights the importance of considering age, preoperative spinal deformity, and thoracolumbar junction involvement as predictors of postoperative spinal deformity following surgical resection for IMSCT. These findings may provide guidance for the management of these patients, including the development of preoperative planning strategies and the selection of the most appropriate surgical approach for high-risk patients.

The effectiveness of organic vegetable oils with high biocompatibility in preventing epidural fibrosis: An experimental study

Background and purpose

Epidural fibrosis after all spinal surgeries is an important surgical issue. Various biological and non-biological materials have been tried to inhibit epidural fibrosis, which is deemed to be the most important cause of pain after spinal surgery. Olive oil, nigella sativa oil and soybean oil employed in oral nutrition in clinics involving liquid fatty acids, palmatic acid, linoleic acid, stearic acid and palmitoleic acid. The effectiveness of olive oil, nigella sativa oil and soybean oil on epidural fibrosis was researched on for the first time in laminectomy model.

.

Methods

Fifty adult male Wistar albino rats weighing between 300 and 400 grams were used in the research. A total of 5 groups were formed: sham (Group I) (n = 10), no application was created; Group II (n = 10) 1 cc saline; Group III (n = 10) 1 cc olive oil; Group IV (n = 10) 1 cc nigella sativa oil; Group V (n = 10); 1 cc soybean oil was applied topically to the epidural region after laminectomy. The total spine of the rats was dissected, histopathological and immuno­chemical measurements were conducted. Neuro-histopathological results were scored semi-quantitatively in terms of vascular modification, neuron degeneration, gliosis and bleeding criteria.

.

Results

The lowest level of fibrosis and connective tissue proliferation was observed in the group where nigella sativa oil was used after the operation, followed by the group treated with olive oil and lastly with the group given soybean oil.

.

Conclusion

Nigella sativa oil and olive oil are very efficient for lowering the degree of epidural fibrosis and adhesions following laminectomy and can be employed as a simple, inexpensive and highly biocompatible material in clinical practice.

.

Unilateral laminotomy with bilateral spinal canal decompression: systematic review of outcomes and complications

BACKGROUND

Unilateral laminotomy with bilateral spinal canal decompression has gained popularity recently.

AIM

To systematically review the literature of unilateral laminotomy with bilateral spinal canal decompression for lumbar spinal stenosis (LSS) aiming to assess outcomes and complications of the different techniques described in literature.

METHODS

On August 7, 2022, Pubmed and EMBASE were searched by 2 reviewers independently, and all the relevant studies published up to date were considered based on predetermined inclusion and exclusion criteria. The subject headings "unilateral laminotomy", "bilateral decompression" and their related key terms were used. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles.

RESULTS

A total of seven studies including 371 patients were included. The mean age of the patients was 69.0 years (range: 55-83 years). The follow up duration ranged from 1 to 3 years. Rate of postoperative pain and functional improvement was favorable based on VAS, JOA, JOABPEQ, RMDW, ODI and SF-36, for example improved from a range of 4.2-7.5 preoperatively on the VAS score to a range of 1.4-3.0 postoperatively at the final follow up. Insufficient decompression was noted in 3% of the reported cases. The overall complication rate was reported at 18-20%, with dural tear at 3.6-9% and hematoma at 0-4%.

CONCLUSION

Unilateral laminotomy with bilateral decompression has favorable short- and mid-term pain and functional outcomes with low recurrence and complication rates. This, however, needs to be further confirmed in larger, long-term follow-up, prospective, comparative studies between open, and minimally invasive techniques.

Replantation of lamina spinous process ligament complex and miniature titanium plate shaping internal fixation in the treatment of tumors in the spinal canal

OBJECTIVE

Purpose This study aims to explore the clinical efficacy of laminospinous process ligament complex reimplantation combined with mini-titanium plate fixation in the treatment of thoracolumbar intraspinal tumors.

METHODS

A retrospective analysis was performed on 43 cases of intraspinal tumors treated with thoracolumbar intraspinal tumor resection from August 2018 to March 2021, and 27 cases underwent laminospinous process ligament complex reimplantation combined with micro titanium plate shaping. Fixation (laminar replantation group), and 16 patients underwent laminectomy combined with pedicle screw internal fixation (laminectomy group). The operation time, blood loss, drainage tube removal time, cerebrospinal fluid leakage, spinal instability, and the incidence of secondary spinal stenosis were compared between the two groups. The pain VAS score, ODI score, and modified Macnab at the last follow-up were compared between the two groups. And the laminar fusion rate of the laminoplasty group was measured.

RESULTS

Both groups successfully completed the surgery and obtained complete follow-up. The incidence of cerebrospinal fluid leakage and secondary spinal canal stenosis in the laminectomy group was lower than that in the laminectomy group, and the difference was statistically significant (P < 0.05). There was no statistically significant difference in the incidence of spinal instability between the two groups (P > 0.05). The operation time and intraoperative blood loss in the laminectomy group were less than those in the laminectomy group, and the drainage tube removal time was earlier than that in the laminectomy group. The difference was statistically significant (P < 0.05). At the final follow-up, there was no statistically significant difference in the pain VAS score, ODI score, and modified Macnab between the two groups (P > 0.05), but they were all significantly improved compared with preoperative ones. Fusion evaluation was conducted on the laminoplasty group. Two years after surgery, the fusion rate was 97.56% (40/41).

CONCLUSIONS

The application of laminospinous process ligament complex reimplantation combined with mini titanium plate fixation during thoracolumbar intraspinal tumor resection can effectively reconstruct the spinal canal and posterior column structure, reduce the incidence of cerebrospinal fluid leakage and secondary spinal stenosis. The laminar fusion rate is high.

Association between in situ steroids and spine surgical site infections among instrumented procedures

OBJECTIVE

To estimate the association between in situ steroids and spine surgical-site infections (SSIs), assessing spinal instrumentation as an effect modifier and adjusting for confounders.

DESIGN

Case-control study.

SETTING

Rural academic medical center.

PARTICIPANTS

We identified 1,058 adults undergoing posterior fusion and laminectomy procedures as defined by the National Healthcare Safety Network without a pre-existing SSI between January 2020 and December 2021. We identified 26 SSI as cases and randomly selected 104 controls from the remaining patients without SSI.

METHODS

The primary exposure was the intraoperative administration of methylprednisolone in situ (ie, either in the wound bed or as an epidural injection). The primary outcome was a clinical diagnosis of SSI within 6 months of a patient's first spine surgery at our facility. We quantified the association between the exposure and outcome using logistic regression, using a product term to assess for effect modification by spinal instrumentation and the change-in-estimate approach to select significant confounders.

RESULTS

Adjusting for Charlson comorbidity index and malignancy, in situ steroids were significantly associated with spine SSI relative to no in situ steroids for instrumented procedures (adjusted odds ratio [aOR], 9.93; 95% confidence interval [CI], 1.54-64.0), but they were not associated with spine SSIs among noninstrumented procedures (aOR, 0.86; 95% CI, 0.15-4.93).

CONCLUSIONS

In situ steroids were significantly associated with spine SSI among instrumented procedures. The benefits of in situ steroids for pain management following spine surgery should be weighed against the risk of SSI, especially for instrumented procedures.

Progression to fusion after lumbar laminectomy for degenerative lumbar spondylolisthesis: Rate and risk-factors. A national database study

OBJECTIVE

Lumbar laminectomy is often utilized in the treatment of degenerative lumbar spondylolisthesis. Risk factors that contribute to reoperation rates, in particular to progression to fusion, are poorly understood. We aimed to identify rate and risk factors of lumbar fusion surgery following lumbar laminectomy for the treatment of degenerative lumbar spinal spondylolisthesis.

METHODS

Our sample was obtained from the national MarketScan Commercial Claims and Encounters Database. We reviewed patients undergoing lumbar laminectomy for stable degenerative lumbar spondylolisthesis (Grade-1) at one or two levels between January 2007 and December 2016.

RESULTS

A total of 33,681 patients were included. By 2 years after the index operation, 2.48 % of patients had required lumbar fusion surgery. Female sex was associated with lower odds (OR 0.8, 95 %CI 0.7-0.9) of reoperation for fusion. Diabetes (OR 1.2, 95 %CI 1.1-1.4), rheumatoid arthritis (OR 1.5, 95 %CI 1.2-1.7) and clinical presentation with LBP (OR 2.1, 95 %CI 1.6-2.9), lower extremity weakness (OR 1.4, 95 %CI 1.1-1.5), as well as occurrence of a postoperative neurological complications (OR 2.0, 95 %CI 1.1-3.4) increased the odds ratio for requiring fusion surgery within two years after lumbar laminectomy.

CONCLUSION

In this large cross-sectional sample of a national claims database consisting of lumbar laminectomy patients for the treatment of spondylolisthesis, approximately 2.5 % required subsequent lumbar fusion. Several modifiable risk factors for fusion progression were identified, which may guide clinicians in shared decision-making and to help identify patients with elevated post-operative risk providing potential leverage point for prevention.

Pharmacotherapies to prevent epidural fibrosis after laminectomy: a systematic review of in vitro and in vivo animal models

BACKGROUND CONTEXT

Excessive production of epidural fibrosis in the nerve root can be a pain source after laminectomy. Pharmacotherapy is a minimally invasive treatment option to attenuate epidural fibrosis by suppressing proliferation and activation of fibroblasts, inflammation, and angiogenesis, and inducing apoptosis.

PURPOSE

We reviewed and tabulated pharmaceuticals with their respective signaling axes implicated in reducing epidural fibrosis. Additionally, we summarized current literature for the feasibility of novel biologics and microRNA to lessen epidural fibrosis.

STUDY DESIGN/SETTING

Systematic Review.

METHODS

According to the PRISMA guidelines, we systematically reviewed the literature in October 2022. The exclusion criteria included duplicates, nonrelevant articles, and insufficient detail of drug mechanism.

RESULTS

We obtained a total of 2,499 articles from PubMed and Embase databases. After screening the articles, 74 articles were finally selected for the systematic review and classified based on the functions of drugs and microRNAs which included inhibition of fibroblast proliferation and activation, pro-apoptosis, anti-inflammation, and antiangiogenesis. In addition, we summarized various pathways to prevent epidural fibrosis.

CONCLUSION

This study allows a comprehensive review of pharmacotherapies to prevent epidural fibrosis during laminectomy.

CLINICAL SIGNIFICANCE

We expect that our review would enable researchers and clinicians to better understand the mechanism of anti-fibrosis drugs for the clinical application of epidural fibrosis therapies.

The Role of Prolonged Bed Rest in Postoperative Cerebrospinal Fluid Leakage After Surgery of Intradural Pathology-A Retrospective Cohort Study

BACKGROUND

Postoperative cerebrospinal fluid leakage (CSFL) is a feared complication after surgery on intradural pathologies and may cause postoperative complications and subsequently higher treatment costs.

OBJECTIVE

To assess whether prolonged bed rest may lower the risk of CSFL.

METHODS

We performed a retrospective cohort study including patients with intradural pathologies who underwent surgery at our department between 2013 and 2021. Cohorts included patients who completed 3 days of postoperative bed rest and patients who were mobilized earlier. The primary end point was the occurrence of clinically proven CSFL.

RESULTS

Four hundred and thirty-three patients were included (female [51.7%], male [48.3%]) with a mean age of 48 years (SD ±20). Bed rest was ordered in 315 cases (72.7%). In 7 cases (N = 7/433, 1.6%), we identified a postoperative CSFL. Four of them (N = 4/118) did not preserve bed rest, showing no significant difference to the bed rest cohort (N = 3/315; P = .091). In univariate analysis, laminectomy (N = 4/61; odds ratio [OR] 8.632, 95% CI 1.883-39.573), expansion duraplasty (N = 6/70; OR 33.938, 95% CI 4.019-286.615), and recurrent surgery (N = 5/66; OR 14.959, 95% CI 2.838-78.838) were significant risk factors for developing CSFL. In multivariate analysis, expansion duraplasty was confirmed as independent risk factor (OR 33.937, 95% CI 4.018-286.615, P = .001). In addition, patients with CSFL had significant higher risk for meningitis (N = 3/7; 42.8%, P = .001).

CONCLUSION

Prolonged bed rest did not protect patients from developing CSFL after surgery on intradural pathologies. Avoiding laminectomy, large voids, and minimal invasive approaches may play a role in preventing CSFL. Furthermore, special caution is indicated if expansion duraplasty was done.

Severe Symptomatic Epidural Hematoma Following Percutaneous Endoscopic Unilateral Laminectomy for Bilateral Decompression (Endo-ULBD)-Series Report and Management Strategies

OBJECTIVES

Severe symptomatic epidural hematoma (SSEH) is one of the most severe complications following percutaneous endoscopic unilateral laminectomy for bilateral decompression (Endo-ULBD). Considering that this technique has been performed for a short time, no detailed reports have been recently published. Thus, it is critical to gain a better understanding of SSEH occurring in its postoperative period with regard to its incidence, possible causes, outcome, etc., in order to identify relevant management strategies.

METHODS

Patients with spinal stenosis who had undergone Endo-ULBD in our department from May 2019 to May 2022 were retrospectively analyzed. Of which, patients with postoperative epidural hematoma were followed-up. The preoperative and postoperative physical conditions of each patient were recorded, and the information related to hematoma removal surgery was recorded in detail. Clinical outcomes were assessed using the visual analogue scale (VAS) and Oswestry disability index (ODI), and the results were classified into "excellent," "good," "fair," or "poor" based on the modified MacNab criteria. The incidence of hematoma with different factors was calculated, and a bar graph was used to compare the difference of the indexes related to hematoma removal between cases, and a line graph was used to reflect the trend of the outcome of each patient within 6 months to evaluate the effect of the treatment.

RESULTS

A total of 461 patients with spinal stenosis who underwent Endo-ULBD were enrolled in the study. SSEH occurred in four cases, with an incidence rate of 0.87% (4/461). All these four patients underwent decompression of multiple segments, and three of them had a history of hypertension comorbid with diabetes. Notably, one patient had a past history of hypertension and coronary artery disease and was on postoperative low molecular heparin due to lower extremity venous thrombosis. According to the conditions of the four patients, three types of treatment were used. And with timely treatment, all patients recovered well.

CONCLUSION

Despite being a minimally invasive technique, postoperative epidural hematoma remains a severe complication of Endo-ULBD. Therefore, during percutaneous endoscopic surgery, it is essential to enhance the comprehensive perioperative management of patients with Endo-ULBD. Signs related to postoperative hematoma must be recognized and promptly managed. If necessary, satisfactory results can be achieved by using percutaneous endoscopy along the original surgical channel to remove the hematoma.

Clinical outcomes of modified versus traditional expansive open-door laminoplasty for cervical spondylotic myelopathy: A single-institution experience

PURPOSE

To compare the surgical outcomes of modified expansive open-door laminoplasty (EOL) (C4-C6) and traditional EOL (C3-C7) in patients with cervical spondylotic myelopathy (CSM).

METHODS

One hundred and two CSM patients were retrospectively recruited from Fujian Medical University Union Hospital between March 2012 and December 2019. Seventy-one patients with CSM underwent modified EOL, and 31 patients underwent traditional EOL. The primary endpoint was axial symptoms.

RESULTS

Patients who underwent modified EOL had a significantly lower incidence of axial symptoms (odds ratio: 0.273; 95% confidence interval: 0.184-0.691; p = .002). The length of hospital stay (p = .263), and intraoperative blood loss (p = .402) were not significantly different between the groups. Significantly more postoperative drainage was observed in patients who underwent modified EOL (p < .001), while the cost of hospitalization in patients treated with traditional EOL was higher (p = .011). There were significant differences between modified and traditional EOL for the changes in range of motion (p < .001), modified Japanese Orthopaedic Association score (p = .001), and the Nurick grade (p = .014), while the changes of visual analogue scale (p = .250), and the neck disability index (p = .134) were not significantly different between the groups.

CONCLUSION

This study found modified EOL may decrease the incidence of axial symptoms in patients with CSM compared to traditional EOL.

Comparison of the clinical effects of lamina replantation and screw fixation after laminectomy in the treatment of intraspinal tumours

INTRODUCTION

Intraspinal tumours are common diseases in neurosurgery and spinal surgery. Due to the fact that most of them are benign tumours, surgical resection is usually effective, and it is also the main treatment for these tumours. To maintain the stability of the spine and to reduce the incidence of kyphosis, pedicle screw fixation is required after traditional laminectomy, but there are many complications. In recent years, tumour resection and laminectomy have become increasingly favoured by clinicians. However, the comparison of the clinical effects of lamina complex replantation and pedicle screw fixation after laminectomy in the treatment of intraspinal tumours is still unknown. This paper systematically compared the two methods from many aspects and discussed their advantages and disadvantages to obtain better clinical guidance.

MATERIALS AND METHODS

In this study, a retrospective analysis was conducted to select 58 patients who underwent posterior approach tumour resection in the spinal surgery department of our hospital from January 2017 to January 2020. Among them, 32 patients underwent tumour resection and laminoplasty, and 26 patients underwent tumour resection and screw internal fixation. The age, sex, body mass index (BMI), smoking status, duration of symptoms, operation time, length of hospital stay, postoperative complications, amount of bleeding and other data were summarized, calculated and compared.

RESULTS

1. The age, sex, BMI, smoking status and symptom duration of the two groups were compared. The abovementioned results were not statistically significant. 2. The operation time, hospital stay, postoperative complications, intraoperative bleeding and adjacent segment degeneration (ASD) were counted and compared between the two groups. There was no significant difference in hospital stay or intraoperative bleeding between the two groups; in addition, the operation time, postoperative complications and incidence of ASD were statistically significant. 3. The visual analog scale (VAS) score, Oswestry Disability Index (ODI) score of thoracic and lumbar spines and Neck Disability Index (NDI) score of cervical spine patients in the two groups were counted, and the preoperative and postoperative data, as well as their changes, were counted and compared between groups and within groups. There was no statistical significance between the two groups; moreover, the postoperative scores were all significantly lower than preoperative in the group. 4. According to the spinal cord function ASIA grade, the preoperative, final follow-up and change values of the two groups were counted, and intragroup and intergroup comparisons were made. There was no significant difference between the two groups; in addition, the scores of the final follow-up were significantly higher than preoperative in the group. 5. The spinal mobility was measured and recorded before the operation and at the final follow-up. There was no significant difference between preoperative and postoperative cervical mobility, and there was no statistical significance observed; furthermore, the range of flexion, extension, rotation and lateral bending of the thoracic and lumbar spines in the screw fixation group was significantly lower than that in the lamina replantation group.

CONCLUSIONS

Lamina replantation can be used as splendid methods for the treatment of Intraspinal tumour. Lamina replantation can reduce the operation time, as well as reduce the occurrence of postoperative cerebrospinal fluid leakage, iatrogenic spinal stenosis, posterior soft tissue adhesion and ASD. These complications are reduced in comparison to the other mode of management and better preserve the mobility of the spine.

Could extended laminectomy effectively prevent spinal cord injury due to spinal shortening after 3-column osteotomy?

OBJECTIVE

To explore whether the laminectomy extension can effectively prevent spinal cord injury (SCI) due to spinal shortening after 3-column osteotomy in goat models.

METHODS

A total of twenty healthy goats were included and done with 3-column osteotomy of T13 and L1 under the somatosensory evoked potential (SSEP) monitoring. The samples were divided into two groups. The first group underwent regular laminectomy while the second group underwent an extended laminectomy with an extra 10 mm-lamina cranial to L2. The SSEP measured after 3-column osteotomy was set as the baseline, and the SSEP decreased by 50% from the baseline amplitude and/or delayed by 10% relative to the baseline peak latency was set as positive results, which indicated spinal cord injury. The vertebral column was gradually shortened until the SSEP monitoring just did not show a positive result. The height of the initial osteotomy gap (the distance from the lower endplate of T12 to the upper endplate of L2), the shortened distance (△H), the number of spinal cord angulated and the changed angle of the spinal cord (△α) were measured and recorded in each group. Neurological function was evaluated by the Tarlov scores on day 2 postoperatively.

RESULTS

All the goats except one of the first group due to changes in the SSEP during the osteotomy were included and analyzed. In the first group, the height of the initial osteotomy segment and the safe shortening distances were 61.6 ± 2.6 mm and 35.2 ± 2.6 mm, respectively; the spinal cord of 5 goats was angulated (46.4 ± 6.6°), the other four goats were kinked and not angulated. In the second group, the height of the initial osteotomy segment and the safe shortening distances were 59.8 ± 1.5 mm and 43.3 ± 1.2 mm, respectively, and the spinal cord of ten goats were angulated (97.6 ± 7.2°). There was no significant difference in the height of the initial osteotomy segment between the two groups by using Independent-Samples T-Test, P = 0.095 (P > 0.05); there were significant difference in the safe shortening distance and the changed angle of the spinal cord between the two groups by using Independent-Samples T-Test (both [Formula: see text]H and [Formula: see text]α of P < 0.001), the difference between their mean were 8.1 mm and 51.2°. Significant difference was found in the number of spinal cord angulation between the two groups through Fisher's exact test (5/9 vs. 10/10, P = 0.033).

CONCLUSIONS

An additional resection of 10 mm-lamina cranial to L2 showed the satisfactory effect in alleviating SCI after 3-column osteotomy. Timely and appropriate extend laminectomy could be a promising therapeutic strategy for SCI attributable to facilitating spinal cord angulation rather than spinal cord kinking and increasing the safe shortening distance.

Laminectomy With Fusion is Associated With Greater Functional Improvement Compared With Laminectomy Alone for the Treatment of Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and Meta-analysis.

OBJECTIVE

To compare outcomes and complications profile of laminectomy alone versus laminectomy and fusion for the treatment of degenerative lumbar spondylolisthesis (DLS).

SUMMARY OF BACKGROUND DATA

Degenerative lumbar spondylolisthesis is a common cause of back pain and functional impairment. DLS is associated with high monetary (up to $100 billion annually in the US) and nonmonetary societal and personal costs. While nonoperative management remains the first-line treatment for DLS, decompressive laminectomy with or without fusion is indicated for the treatment-resistant disease.

METHODS

We systematically searched PubMed and EMBASE for RCTs and cohort studies from inception through April 14, 2022. Data were pooled using random-effects meta-analysis. The risk of bias was assessed using the Joanna Briggs Institute risk of bias tool. We generated odds ratio and standard mean difference estimates for select parameters.

RESULTS

A total of 23 manuscripts were included (n=90,996 patients). Complication rates were higher in patients undergoing laminectomy and fusion compared with laminectomy alone (OR: 1.55, P <0.001). Rates of reoperation were similar between both groups (OR: 0.67, P =0.10). Laminectomy with fusion was associated with a longer duration of surgery (Standard Mean Difference: 2.60, P =0.04) and a longer hospital stay (2.16, P =0.01). Compared with laminectomy alone, the extent of functional improvement in pain and disability was superior in the laminectomy and fusion cohort. Laminectomy with fusion had a greater mean change in ODI (-0.38, P <0.01) compared with laminectomy alone. Laminectomy with fusion was associated with a greater mean change in NRS leg score (-0.11, P =0.04) and NRS back score (-0.45, P <0.01).

CONCLUSION

Compared with laminectomy alone, laminectomy with fusion is associated with greater postoperative improvement in pain and disability, albeit with a longer duration of surgery and hospital stay.

Pirfenidone-loaded hyaluronic acid methacryloyl hydrogel for preventing epidural adhesions after laminectomy

It is inevitable that scar formation occurs between the spinal dura and surrounding tissues after laminectomy. While extensive epidural fibrosis, which results in limited nerve root activity and severe pain, is the main cause of postoperative failed-back surgery syndrome. Novel biomaterial loading effective drugs based on reasonable design are eagerly needed for the safe and effective prevention of epidural adhesions. We filtrated a suitable dose of pirfenidone (PFD) to load hyaluronic acid methacryloyl (HAMA) hydrogel in vitro. And then, we compare PFD-loaded HAMA hydrogel with only using PFD or HAMA hydrogels after laminectomy by in vivo studies in rats. We describe a safe and efficient anti-adhesive PFD-loaded HAMA hydrogel that prevents epidural fibrosis through the stable and sustained release of PFD. It was shown that the PFD-loaded HAMA hydrogel effectively inhibited cell penetration and suppressed collagen I/III expression. Thus, it effectively prevented the formation of adhesions through pharmacological and physical processes. The PFD-loaded HAMA hydrogel can effectively prevent adhesion formation in both pharmacological and physical barrier effects.

Predictive risk factors for mechanical complications after multilevel posterior cervical instrumented fusion

OBJECTIVE

Mechanical complications should be considered following the correction of multilevel posterior cervical instrumented fusion. This study aimed to investigate clinical data on the patients' pre- and postoperative cervical alignment in terms of the incidence of mechanical complications after multilevel posterior cervical instrumented fusion.

METHODS

Between January 2008 and December 2018, 156 consecutive patients who underwent posterior cervical laminectomy and instrumented fusion surgery of 4 or more levels and were followed up for more than 2 years were included in this study. Age, sex, bone mineral density (BMD), BMI, mechanical complications, and pre- and postoperative radiographic factors were analyzed using multivariate logistic regression analysis to investigate the factors related to mechanical complications.

RESULTS

Of the 156 patients, 114 were men and 42 were women; the mean age was 60.38 years (range 25-83 years), and the mean follow-up duration of follow-up was 37.56 months (range 24-128 months). Thirty-seven patients (23.7%) experienced mechanical complications, and 6 of them underwent revision surgery. The significant risk factors for mechanical complications were low BMD T-score (-1.36 vs -0.58, p = 0.001), a large number of fused vertebrae (5.08 vs 4.54, p = 0.003), a large preoperative C2-7 sagittal vertical axis (SVA; 32.28 vs 23.24 mm, p = 0.002), and low preoperative C2-7 lordosis (1.85° vs 8.83°, p = 0.001). The clinical outcomes demonstrated overall improvement in both groups; however, the neck visual analog scale, Neck Disability Index, and Japanese Orthopaedic Association scores after surgery were significantly worse in the mechanical complication group compared with the group without mechanical complications.

CONCLUSIONS

Low BMD, a large number of fused vertebrae, a large preoperative C2-7 SVA, and low C2-7 lordosis were significant risk factors for mechanical complications after posterior cervical fusion surgery. The results of this study could be valuable for preoperative counseling, medical treatment, or surgical planning when multilevel posterior cervical instrumented fusion surgery is performed.

A Risk Calculator for the Prediction of C5 Nerve Root Palsy After Instrumented Cervical Fusion

BACKGROUND

C5 palsy is a common postoperative complication after cervical fusion and is associated with increased health care costs and diminished quality of life. Accurate prediction of C5 palsy may allow for appropriate preoperative counseling and risk stratification. We primarily aim to develop an algorithm for the prediction of C5 palsy after instrumented cervical fusion and identify novel features for risk prediction. Additionally, we aim to build a risk calculator to provide the risk of C5 palsy.

METHODS

We identified adult patients who underwent instrumented cervical fusion at a tertiary care medical center between 2013 and 2020. The primary outcome was postoperative C5 palsy. We developed ensemble machine learning, standard machine learning, and logistic regression models predicting the risk of C5 palsy-assessing discrimination and calibration. Additionally, a web-based risk calculator was built with the best-performing model.

RESULTS

A total of 1024 patients were included, with 52 cases of C5 palsy. The ensemble model was well-calibrated and demonstrated excellent discrimination with an area under the receiver-operating characteristic curve of 0.773. The following features were the most important for ensemble model performance: diabetes mellitus, bipolar disorder, C5 or C4 level, surgical approach, preoperative non-motor neurologic symptoms, degenerative disease, number of fused levels, and age.

CONCLUSIONS

We report a risk calculator that generates patient-specific C5 palsy risk after instrumented cervical fusion. Individualized risk prediction for patients may facilitate improved preoperative patient counseling and risk stratification as well as potential intraoperative mitigating measures. This tool may also aid in addressing potentially modifiable risk factors such as diabetes and obesity.

Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery

OBJECTIVE

To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy.

MATERIAL AND METHODS

We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients' positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as>50% attenuation in amplitude or>10% increase in latency of SEP, or abolishment or 50-80% attenuation of MEP.

RESULTS

Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n=6) or partial (n=4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives.

CONCLUSION

Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.

Does Cigarette Smoking Affect Cervical Laminoplasty Clinical and Radiologic Outcomes?

STUDY DESIGN

Retrospective review.

OBJECTIVE

This study aimed to investigate if smokers have both poorer early clinical and radiologic outcomes in cervical laminoplasty when compared with nonsmokers.

SUMMARY OF BACKGROUND DATA

Cigarette smoking had been reported to increase rates of pseudoarthrosis following spinal instrumentation with fusion.

METHODOLOGY

A retrospective review of all patients who underwent open-door cervical laminoplasty was performed. Nurick, neck pain visual analog scale, and neck disability index scores were reviewed. Cervical lordosis, range of motion (ROM), and intervertebral disc height were measured. The rates and reasons for revision surgery were recorded and classified according to the etiology of laminoplasty revision surgery.

RESULTS

Sixty patients were recruited, of which 20 patients (18 males, 2 females) were smokers and 40 patients (27 males, 13 females) were nonsmokers. There was no statistically significant difference between smokers and nonsmokers in preoperative and postoperative visual analog scale, neck disability index, and Nurick scores. A trend was noted toward a greater postoperative reduction in cervical lordosis (13±8 vs. 11±11 degrees). Furthermore, 41% of smokers versus 30% in nonsmokers had >10% loss of postoperative ROM, and 59% smokers versus 50% nonsmokers had >5% loss of postoperative ROM.Postoperative complications and intervertebral disc deterioration were similar in both groups. A higher reoperation rate was noted in smokers with 6 smokers (30%) as compared with 4 nonsmokers (10%), although this did not reach statistical significance. Among the smokers, 4 (20%) were because of cervical disease progression while 2 were technique related. In nonsmokers, all 4 (10%) were because of cervical disease progression.

CONCLUSION

This study showed that while there was a nonstatistically significant trend noted toward higher rates of revision surgery in smokers, the laminoplasty outcomes were not significantly poorer in smokers. In heavy smokers with multilevel cervical myelopathy, laminoplasty may be the treatment of choice over anterior spinal decompression and fusion where a high risk of pseudoarthrosis is anticipated.

Postoperative C5 Palsy Following Cervical Laminectomy With Instrumented Fusion Versus Cervical Laminoplasty With Reconstruction: Single Surgeon and National Inpatient Cohort Analyses

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to investigate whether cervical laminectomy with instrumented fusion (LF) and cervical laminoplasty with reconstruction (LP) are associated with different rates C5 palsy (C5P) at 1-month follow-up in a single surgeon and nationally representative cohort.

SUMMARY OF BACKGROUND DATA

LF and LP both carry a well-known risk of nerve root injury that most commonly presents as C5P which can reduce patient satisfaction, patient function, and impede patient recovery. The procedure type that is more frequently associated with C5P remains largely unclear.

METHODS

We identified patients undergoing primary LF or LP procedures for the treatment of cervical myelopathy in both a single-surgeon series cohort (2004-2018; Mount Sinai Hospital) and a nationally representative cohort drawn from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2006-2017). For the single-surgeon cohort, C5P within 1 month of surgery was recorded. For the NSQIP cohort, peripheral nerve injury (PNI) within 1 month of surgery was recorded and used as a proxy for C5P. Postoperative complications including C5P were compared between cohorts. Multivariable logistic regression was used to evaluate the association between procedure type and postoperative C5P or PNI.

RESULTS

Without adjusting for covariates, LF patients had a higher rate of 1-month C5P in the single-surgeon cohort (8% vs. 0%, P=0.01). An adjusted odds ratio could not be obtained due to the absence of C5P in the LP group. In the national cohort, LP patients had a significantly higher rate of 1-month PNI on unadjusted analysis (11% vs. 16%, P<0.001). After adjusting for covariates, we found no significant difference in odds of 1-month PNI between LF and LP (adjusted odds ratio=0.84, P=0.07).

CONCLUSIONS

Overall, the single-surgeon series suggest that cervical LF is associated with significantly higher rates of postoperative C5P as compared with LP. These findings are not corroborated by nationally representative data, which showed no difference in PNI rates between LF and LP. A surgeon's training and experience likely contribute to which procedure has a higher propensity for a C5P as a complication. Regardless, both LF and LP patients should be closely monitored for new-onset C5P during follow-up visits.

LEVEL OF EVIDENCE

Level III.

A Rare Case Report of C1 Posterior Arch and C2 Laminae Hypertrophy Causing Cervical Myelopathy

Cervical canal stenosis, localized to upper cervical spine, is very rare which can be developmental or acquired. Hypertrophic osteoarthritis accompanied by dens hypertrophy, hypertrophy of the osodontoideum, ossification of the transverse atlantal ligament, aplasia or developmental defect of the posterior arches of Atlas, and unilateral lateral mass hypertrophy are some of the rare reported conditions causing cervical myelopathy. Localized upper cervical canal stenosis due to hypertrophied C1 posterior arch and C2 laminae hypertrophy as an isolated cause of cervical myelopathy has not been reported earlier to our knowledge. We report a case of cervical myelopathy in a 52-year-old gentleman due to the hypertrophied posterior arch of atlas and laminae of axis. C2 laminectomy along with removal of the posterior arch of Atlas and decompression is the treatment. No adjuvant radiotherapy or chemotherapy is needed. The knowledge of such an entity will avoid surprises in the diagnosis and facilitates the management.

Evaluation of the effects of berberine in the prevention of epidural fibrosis in rats: An experimental research

OBJECTIVES

To evaluate the effect of berberine (BBR) in preventing the development of epidural fibrosis (EF) after lumbar surgery in rats.

METHODS

This experimental study was carried out at the animal laboratory of Zonguldak Bülent Ecevit University, Zonguldak, Trurkey, between April 2020 and June 2020. A total of 32 Wistar albino female rats underwent laminectomy and were divided into 4 equal groups. Group 1 did not receive any treatment (control group). In group 2, absorbable gelatin sponge was placed at the surgical site. Groups 3 was administered BBR 10 mg/kg and group 4 was administered BBR 60 mg/kg per oral per day for one week after laminectomy. All rats were sacrificed 6 weeks after the operation. Concentration of hydroxyproline (HP) in tissues and histopathological evaluations were carried out to evaluate the level of fibrosis.

RESULTS

Epidural fibrosis results in group 4 were significantly lower than those in groups 1 and 2 (p≤0.001). However, there was no significant difference between the mean EF degree between group 2 and group 3. Arachnoidal invasion in both group 3 and group 4 were significantly lower compared to group 1 (p<0.05). In terms of HP results, the difference between group 4 and group 1 was statistically significant (p<0.001).

CONCLUSION

This study provides preliminary evidence of the potential use of BBR for preventing the development of EF.

Clinical and Radiological Outcomes of Two Modified Open-door Laminoplasties Based on a Novel Paraspinal Approach for Treatment of Multilevel Cervical Spondylotic Myelopathy

STUDY DESIGN

A case-control study.

OBJECTIVES

The aim of this study was to evaluate the outcomes of two modified laminoplasties (LPs) based on a novel paraspinal approach for treating multilevel cervical spondylotic myelopathy.

SUMMARY OF BACKGROUND DATA

No laminoplasty through a natural intermuscular plane mimicking Wiltse approach to minimize intraoperative injury to extensor muscles has ever been developed and studied.

METHODS

Ninety-two patients were enrolled, including patients treated with either modified LP and patients treated with concurrent conventional LP. Operation time, blood loss, and complications were recorded. Clinical outcomes were evaluated by VAS, JOA scores, and recovery rate. Cervical sagittal alignment was measured on cervical radiographs. Spinal canal expansion was assessed on CT scans. Cross-sectional area (CSA) and atrophy rate (AR) of cervical deep extensors were evaluated on MRI.

RESULTS

The average follow-up duration was 33.05, 31.55, 33.02, and 32.52 months, respectively in each group. Compared to concurrent conventional procedure, unilateral muscle-preserving procedure displayed similar, whereas bilateral muscle-preserving procedure showed significantly increased operation time and blood loss; each modified procedure resulted in comparable and satisfied perioperative clinical scores, spinal canal expansion while achieving significantly lower axial pain incidence, better cervical lordosis maintenance, and better deep extensor preservation. AR of deep extensors on the open side was significantly lower than that on the hinge side. Bilateral paraspinal approach demonstrated significantly better muscle-preservation on the open side and increased operation duration, with similar clinical scores, axial pain incidence, cervical lordosis maintenance, and spinal canal expansion compared to unilateral paraspinal approach. Loss of cervical lordosis was strongly correlated with AR of deep extensors.

CONCLUSION

Paraspinal approach is a good manner to protect deep extensor muscles; the two modified LPs have similar effects on clinical outcomes.Level of Evidence: 3.

An Experimental Rat Model of C5 Palsy Following Posterior Decompression Surgery of the Cervical Spine

STUDY DESIGN

Basic in vivo research.

OBJECTIVES

The aim of this study was to establish an animal model that is appropriate for analyzing the mechanisms of C5 palsy (C5P) and to clarify the structural and functional alterations of cervical roots following posterior decompression.

SUMMARY OF BACKGROUND DATA

Although C5P is one of the major complications of cervical surgery, the exact pathogenesis of C5P remains unclear partly because of the lack of an appropriate animal model. Tethering of the cervical roots due to posterior cord shift following posterior decompression is thought to be one of the possible factors that cause C5P.

METHODS

Twenty-eight Sprague-Dawley rats were divided into Group L (cervical laminectomy, N = 18) or Group S (sham surgery, N = 10) and examined up to postoperative day 14 (PO14). Posterior cord shift and the length of the anterior rootlets were quantified by computed tomography-myelogram images. Motor evoked potential (MEP) of the deltoid (C5, 6 innervated) and triceps brachii (C7-T1 innervated), mechanical allodynia, and grip strength of the forepaw (C7-T1 regulated) were measured.

RESULTS

All anterior rootlets were elongated as the cord gradually shifted posteriorly postoperatively. The elongation rate of the C6 anterior rootlets was the highest (142% at PO14). The MEP latency of the deltoid was significantly delayed throughout all postoperative time points. However, significant delay in the latency of the triceps brachii was observed only on postoperative day 10. The withdrawal threshold of the forepaw did not change; grip strength of the forelimb decreased at PO14.

CONCLUSION

This model was thought to be appropriate for analyzing the pathogenesis of C5P since our findings were comparable to the clinical course of C5P subsequent to posterior cervical decompression. Although a future study for clarifying histological and molecular alterations will be needed, tethering of the anterior rootlets due to posterior cord shift was suggested to be a probable mechanism causing C5P.Level of Evidence: 5.

Association of Spinal Cord Stimulator Implantation With Persistent Opioid Use in Patients With Postlaminectomy Syndrome

IMPORTANCE

The results of studies evaluating spinal cord stimulation (SCS) for postlaminectomy syndrome (PLS) have yielded mixed results. This has led to an increased emphasis on objective outcome measures such as opioid prescribing.

OBJECTIVE

To determine the association between SCS and long-term opioid therapy (LOT) for PLS.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, adults with PLS were identified using the TriNetx Diamond Network and separated based on whether they underwent SCS. Patients were stratified according to baseline opioid use (opioid-naive or receiving LOT) and subsequent opioid therapy over the 12-month period ranging from 3 to 15 months post-SCS implantation or post-PLS index date. Statistical analysis was performed from June to December 2021.

EXPOSURE

SCS.

MAIN OUTCOMES AND MEASURES

The main outcome was cessation of opioid use among patients receiving LOT or abstinence from opioids among opioid-naive patients. Opioid-naive patients were defined as those receiving at most 2 opioid prescriptions per year, and patients on LOT were those receiving at least 6 opioid prescriptions per year.

RESULTS

Among 552 937 eligible patients treated between December 2015 and May 2021, 26 179 with PLS received an SCS implant. The median (IQR) patient age was 60 (51-69) years; 305 802 patients (55.3%) were female. Among those reporting racial identify (37.0% [204 758 patients]), 9.3% (18 971 patients) were African American, 0.3% (648 patients) were Asian, and 90.4% (185 139 patients) were White. Compared with those who did not receive an SCS, individuals who received an SCS were more likely to be using opioids preimplantation (mean [SD] prescriptions: 4.3 [8.5] vs 4.1 [9.3]; P < .001) but less likely to be using opioids after SCS implantation (mean [SD] prescriptions: 3.8 [8.2] vs 4.0 [9.4]; P = .006). In the 12-month study period, similar proportions in the SCS and no-SCS groups receiving baseline LOT remained on LOT (70.3% [n = 74 585] vs 69.2% [n = 3882], respectively; P = .10). In opioid-naive patients, SCS was associated with a small decreased likelihood of patients subsequently receiving LOT (7.6% vs 7.0%; difference, -0.6% [95% CI, -1.0% to -0.2%]; P = .003). In multivariable analysis, SCS was associated with an increased likelihood of not being on opioids in both opioid-naive (adjusted odds ratio [OR], 0.90 [95% CI, 0.85-0.96]; P < .001) and LOT patients (adjusted OR, 0.93 [95% CI, 0.88-0.99]; P = .02). White patients were significantly more likely to be diagnosed with PLS (ie, underwent surgery) (90.4% vs 85.2%; difference, 5.2% [95% CI, 5.1%-5.4%]; P < .001) and receive an SCS (93.7% vs 90.3%; difference, 3.4% [95% CI, 2.9% to 4.0%]; P < .001) than patients of other racial identities.

CONCLUSIONS AND RELEVANCE

These findings suggest that under real-life conditions, SCS was associated with small, clinically questionable associations with opioid discontinuation and not starting opioids in the context of PLS.

[Adolescent radiculopathy associated with extradural intraspinal tumor]

INTRODUCTION

Expansive intra-spinal processes usually have an insidious course that makes their early diagnosis difficult. Intra-spinal tumors are classified according to their location in the spinal canal: extradural and intradural, and these are classified as extramedullary and intramedullary. At the beginning, they can cause non-specific pain conditions and, sometimes, root-type pain. The patient may have symptoms such as: loss of strength, loss of balance, loss of sensation, sphincter disorders. Intra-spinal neoplasms, when diagnosed, have an indication for surgical treatment.

MATERIAL AND METHODS

The clinical case of a 14-year-old male adolescent is described, pain in the lumbar region for four years, of insidious onset, intermittent, progressive, exacerbated six months ago, with radiation to the lower extremities, which is accompanied by progressive paresthesia and paresis predominantly in the lower right limb.

RESULTS

Bilateral L4 and L5 laminotomy is performed, exploration and resection of the tumor and release of nerve roots. Tumor with characteristics similar to adipose tissue is obtained, where a wide vascular network is observed inside, with an approximate size of 14 × 10 × 4 mm, ovoid in shape, flattened with a smooth and shiny surface.

CONCLUSION

Spinal tumors are relatively rare tumors, however, of these tumors, the extradural intraspinal location accounts for half of the cases. In our patient, the diagnosis of lipoma of the filum terminale was integrated, which corresponds to less than 1% of all tumors of the spine.

Acute aortic occlusion after microendoscopic laminectomy in a patient with lumbar spinal stenosis: A case report

RATIONALE

Acute aortic occlusion is an uncommon disease with a high morbidity and high mortality. Clinical symptoms typically include acute lower limb pain, acute paralysis, and absent pulses. We report a very rare case of acute aortic occlusion causing complete paralysis of bilateral lower limbs following microendoscopic laminectomy.

PATIENT CONCERNS

A 64-year-old man with hypertension, hyperlipidemia, diabetes, and atrial fibrillation underwent microendoscopic laminectomy for lumbar spinal stenosis. After the operation, intermittent claudication improved significantly without neurological deficit. However, 7 days later, he developed complete paralysis of the bilateral lower limbs, extreme pain of the bilateral lower limbs, and mottling of the left extremity.

DIAGNOSIS

An emergency magnetic resonance imaging examination revealed no epidural hematoma behind the spinal cord, proscribing spinal cord compression. Computed tomography revealed occlusion of the infrarenal abdominal aorta. Blood tests revealed high values of total plasminogen activator inhibitor-1 before surgery.

INTERVENTIONS

The acute aortic occlusion was verified and underwent thrombectomy and right axillary-bifemoral bypass.

OUTCOMES

Following the revascularization, the neurological deficit of the lower limbs improved. On follow-up after 1 year, the muscle strength of the bilateral lower limbs had returned to normal.

LESSONS

This case presentation highlights the necessity of early diagnosis and early revascularization. Moreover, a preoperative high value of plasminogen activator inhibitor-1 may indicate vascular complications including Acute Aortic Occlusion.

Treatment of Kyphosis Arising Secondary to Laminectomy and Irradiation in the Pediatric Population

The effects of radiation therapy and laminectomy on the growing spine have been well documented. Due to compromised bone quality after irradiation, spinal fusion has a high failure rate. The aim of this study was to evaluate treatment of post-laminectomy and post-irradiation kyphosis in children using a vascularized rib graft (VRG) to augment anterior spinal fusion and posterior spinal fusion. Data were collected retrospectively from electronic medical records for all patients treated at a single institution for post-laminectomy and post-irradiation kyphosis who underwent VRG to augment spinal fusions done between December 2003 and August 2015. Five patients were included in the analysis. Imaging studies were analyzed by 2 senior pediatric orthopedic surgeons and a pediatric orthopedic surgery fellow. The outcome for all 5 patients who underwent VRG were considered successful at most recent clinical follow-up. Success was defined as the following: complete fusion evident through computed tomography scan, no implant failure, and no kyphosis progression. Follow-up ranged from 21 to 63 months. One patient experienced 2 complications: esophageal tear and deep infection. Spinal fusion with a VRG is a viable treatment option for children who have developed kyphosis following laminectomy and irradiation. On long-term follow-up, there has been no evidence of progression of kyphosis for patients who were treated with VRG in either the primary fusion procedure or in subsequent revision procedures. A VRG provides a non-irradiated, vascularized bone graft to bridge the irradiated segments, increasing the stability of the spine. [Orthopedics. 2021;44(4):e563-e569.].

Patient Outcomes After Single-level Coflex Interspinous Implants Versus Single-level Laminectomy

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

The aim of this study was to compare postoperative outcomes of Coflex interspinous device versus laminectomy.

SUMMARY OF BACKGROUND DATA

Coflex Interlaminar Stabilization device (CID) is indicated for one- or two-level lumbar stenosis with grade 1 stable spondylolisthesis in adult patients, as an alternative to laminectomy, or laminectomy and fusion. CID provides stability against progressive spondylolisthesis, retains motion, and prevents further disc space collapse.

METHODS

Patients ≥18 years' old with lumbar stenosis and grade 1 stable spondylolisthesis who underwent either primary single-level decompression and implantation of CID, or single-level laminectomy alone were included with a minimum 90-day follow-up at a single academic institution. Clinical characteristics, perioperative outcomes, and postoperative complications were reviewed until the latest follow-up. χ2 and independent samples t tests were used for analysis.

RESULTS

Eighty-three patients (2007-2019) were included: 37 cases of single-level laminectomy (48.6% female) were compared to 46 single-level CID (50% female). CID cohort was older (CID 69.0 ± 9.4 vs. laminectomy 64.2 ± 11.0, P = 0.042) and had higher American Society of Anesthesiologists (ASA) grade (CID 2.59 ± 0.73 vs. laminectomy 2.17 ± 0.48, P = 0.020). CID patients had higher estimated blood loss (EBL) (97.50 ± 77.76 vs. 52.84 ± 50.63 mL, P = 0.004), longer operative time (141.91 ± 47.88 vs. 106.81 ± 41.30 minutes, P = 0.001), and longer length of stay (2.0 ± 1.5 vs. 1.1 ± 1.0 days, P = 0.001). Total perioperative complications (21.7% vs. 5.4%, P = 0.035) and instrumentation-related complication was higher in CID (10.9% vs. 0% laminectomy group, P = 0.039). There were no other significant differences between the groups in demographics or outcomes.

CONCLUSION

Single-level CID devices had higher perioperative 90-day complications, longer operative time, length of stay, higher EBL compared to laminectomies alone. Similar overall revision and neurologic complication rates were noted compared to laminectomy at last follow-up.Level of Evidence: 3.

Universal approach for full endoscopic decompression and percutaneous transpedicular fixation of the lumbar spine: A medial central approach (ACM)

Cohort study.This study aimed to determine the effectiveness of the universal approach of full endoscopy and percutaneous transpedicular fixation via a medial central approach (ACM) performed to surgically treat patients with lumbar degenerative surgical pathologies.Alternatives to interventionist treatments available to patients with lumbar degenerative surgical pathologies are related to recovery from minimally invasive surgery. Considering this, full endoscopic spinal decompression (full endoscopy) and percutaneous transpedicular fixation via an ACM represent advances in neurosurgical procedures, in particular, spinal surgery. Thus, the introduction of endoscopic and minimally invasive surgeries for the lumbar region has become 1 of the most important advances in modern surgery.A cohort of 79 patients undergoing full endoscopy and percutaneous transpedicular fixation was evaluated 6 times in 1 year. Pain intensity was measured using the visual analog scale (VAS), and lumbar functionality was measured using the Oswestry Disability Index (ODI). Six evaluations were performed: before surgery and on discharge after surgery as well as at 1, 3, 6, and 12 months after surgery.Before the ACM was applied, the VAS pain score was 8.52. At 11 hours post-surgery, the pain score reduced to 2.59 points (a difference of 5.73 points; P = 0.001). Of the 10 ODI domains evaluated, a difference was found between the period prior to surgery and 1 month later (P < 0.01).The universal approach to full endoscopy and lumbar percutaneous transpedicular fixation via an ACM is highly effective for patients with lumbar surgical degenerative pathologies.

Predictors of postoperative complications after selective dorsal rhizotomy

BACKGROUND

Selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy (CP). We analyzed potential preoperative predictors of complications after SDR via single-level laminectomy at the conus medullaris.

METHODS

One hundred and forty SDRs performed in children (2-17 years) with CP were included in this retrospective study (March 2016 to July 2019). Of these children, 69% were ambulatory (Gross Motor Functional Classification System (GMFCS) II and III). Variables associated with wound dehiscence and infections, cerebrospinal fluid (CSF) leaks, and prolonged epidural pain management were analyzed statistically.

RESULTS

Five children (3.6%) showed prolonged wound healing, which was associated with obesity (BMI z-score ≥ 1.64; odds ratio (OR) 24.4; 95% confidence interval (CI) 3-199; p = 0.003). Two cases (1.4%) had superficial surgical site infections (SSIs), which was associated with obesity (p = 0.004) and thrombocytopenia (< 180,000 G/l; p = 0.028). The area under the curve at ≥ 1.55 BMI z-score for SSI was 0.97 (95% CI 0.93-0.99, p = 0.024), with a sensitivity and specificity for SSI of 100 and 94.9%, respectively. CSF leaks occurred in four (2.9%) children, associated with age ≤ 5 years (p = 0.029). Fifteen (10.7%) children required prolonged (4-5 days) epidural pain treatment, which was associated with non-ambulatory GMFCS levels (IV and V) (OR 3.6; 95% CI 1.2-10.8; p = 0.008).

CONCLUSIONS

SDR is safe for all GMFCS levels. Obesity predicts prolonged wound healing and SSI. Prolonged pain management via epidural pain catheter is safe, but care should be taken with non-ambulatory children.

[Successful surgical treatment of patient with cervical myelopathy due to ossification of the posterior longitudinal ligament: a rare clinical observation and literature review]

The authors describe the result of combined surgical treatment of a patient with symptomatic multiple-level cervical spine stenosis following ossification of posterior longitudinal ligament. The first stage included decompressive laminectomy and cervical spine fusion using a screw. At the second stage, C_IV-C_V-C_VI-C_VII corporectomy with total resection of the ossified posterior longitudinal ligament and C_III-Th_I corporodesis with a bone autograft were carried out. This approach was valuable to minimize the risk of iatrogenic damage to the spinal cord, eliminate long spinal stenosis and perform circular fusion of the cervical spine. These measures led to regression of cervical myelopathy symptoms. A brief review is presented.

Use of hypnosis preoperatively for surgery of the spine: Pilot study

INTRODUCTION

Hypnosis is a technique requiring no drugs that acts during the three phases of surgery, reducing stress at the pre-surgical phase and the adminstration of anesthetic drugs during the intraoperative phase, as well as leading to improved management of postoperative pain and quality of life management.

MATERIAL ET METHOD

We carried out a retrospective study of 46 patients operated on for herniated disc or one or two-level laminectomy without arthrodesis. All patients benefited from a preoperative hypnosis session and completed a questionnaire about their possible concerns. The day after surgery, patients completed a second questionnaire on their postoperative experience following hypnosis.

RESULTATS

Our results indicate that this technique had a positive impact on the management of preoperative stress (80% of patients) and on postoperative quality of life (48% of patients). Pain measured by decreased from 4.8/10 preoperatively to 0.9/10 postoperatively.

CONCLUSION

Our results are consistent with previous findings in the literature as to the positive contribution of this technique in the management of preoperative stress and patient quality of life. Further studies are however required involving considerably larger cohorts and more extensive surgeries to confirm the effect of this technique on management of anesthesia and pain in spine surgery.

Posterior cord syndrome associated with postoperative seroma: The case to perform a complete neurologic exam

Context: Posterior cord syndrome (PCS) is the least common incomplete spinal cord injury. Findings of posterior cord syndrome include loss of proprioception and vibration, which are not routinely tested with the American Spinal Cord Injury Association's International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam and can easily be missed. Seromas may develop after spinal instrumentation and can cause cord compression. Findings: This case describes a unique presentation of posterior cord syndrome following a large seroma formation after laminectomy. A patient developed ataxia with functional decline following posterior laminectomy. Examination revealed loss of vibration and proprioception in the extremities with preservation of strength. Imaging of the cervical spine demonstrated a large fluid collection at the laminectomy site causing cord compression. The fluid collection was thought to represent a seroma based on clinical presentation, imaging, and laboratory testing. The patient was admitted to inpatient rehabilitation with improvement in function allowing discharge to home. Conclusion/clinical relevance: Seromas are a complication following cervical instrumentation that can cause compression of the adjacent spinal cord resulting in functional decline. The seroma, in this case, led to the loss of vibration and proprioception with resultant ataxia, signs that are not routinely identified on ISNCSCI exam; therefore, this highlights the need to broaden the neurological examination when evaluating a patient with spinal cord injury who has experienced a neurological setback.