Journal of Spine

Almost all spine surgeons tout minimally Invasiveness in spine surgery as a beneficial focus. The meaning of minimally invasiveness, however, is actually a concept with different meanings for each surgeon. To some, it is the use of smaller incisions using standard surgical approaches, the use of tubular retractors, and/or the use of surgical magnification with a microscope, or an endoscope. Minimally invasiveness often advertises the use of lasers as a sexy and high tech surgical tool to tout their state- of- the- art surgical technique in minimally invasiveness, but it is not used as a needed part of the surgery unless visually used with endoscopes under irrigation.

Study design: A retrospective single-center study

Objective: To report the clinical and radiological outcomes of palliative single posterior reconstruction surgery for the treatment of metastatic spinal tumor in different regions of the spine.

Summary of background data: The indications of surgical procedures, whether anterior, posterior or a combination of these, for patient with metastatic spinal tumor are still controversial, and all procedures have their pros and cons.

Methods: A retrospective analysis involving 53 patients (34 male, 19 female, 66.4 ± 9.8 years old) who underwent palliative single posterior reconstruction surgery for metastatic spinal tumor. 10 patients were affected in the cervical region (C2-7), 27 in the thoracic region (Th1-10), and 16 in the thoracolumbar/lumbosacral region (Th11-L5). Common primary tumors were prostate, lung, and thyroid cancers. Clinical evaluation of pain level, neurological function, ambulatory ability, and complications was carried out for the different sites, and correction angle and loss of correction were evaluated radiologically.

Results: 86% of the patients experienced pain relief, 70% improved by one or more Frankel grades, and 75% became ambulatory at follow-up, regardless of the affected region. The cervical group demonstrated a significantly greater correction angle (8.00 ± 4.84 degrees) compared to other groups (thoracic: 3.42 ± 4.97 degrees, thoracolumbar/ lumbosacral: 3.62 ± 4.31 degrees) and also exhibited a smaller loss of correction (0.33 ± 3.31 degrees) compared to other groups (thoracic: 2.80 ± 2.46 degrees, thoracolumbar/lumbosacral: 2.85 ± 3.10 degrees).

Conclusion: Palliative single posterior reconstruction surgery provided good clinical and radiological outcomes at any region. Therefore, this procedure can be a choice of surgical treatment for metastatic spinal tumor, because of its lower invasiveness, for immunocompromised cancer patients.

Introduction: We report a case of a 49-year-old man who sustained a left brachial plexus injury and traumatic brain injury after a motor vehicle accident and subsequently developed a giant left cervical pseudomeningocele. The patient suffered multiple fractures in the cervical and thoracic ribs, transverse processes and the scapula. Physical examination revealed a giant left supraclavicular mass restricting his ability to turn his head ipsilaterally, with head tilted to the right, consistent with complete plexus avulsion. Neurological examination showed progressive muscular atrophy and a positive Tinel’s sign and paresthesias of the left hand.

Methods: MRI and CT revealed a giant cervical pseudomeningocele. Left hemilaminectomy and partial medial facetectomy were performed for an extradural repair of the cyst. Three days later, the pseudomeningocele recurred; C6-T2 cervical laminectomy and a combined intra- and extradural repair of CSF leak with tensor fascia lata graft were performed. One day after the second surgery, the patient developed acute communicating hydrocephalus (CH) with progressive neurological decline.

Results: Ventriculoperitoneal shunt placement successfully resolved neurological symptoms associated with CH. The patient continued receiving treatment for neuropathic pain and spams in the left upper arm at one-year follow up.

Conclusion: We present one of the few documented cases of acute CH after a successful repair of a giant cervical pseudomeningocele. It is important for physicians to be aware of changes in CSF flow dynamics that occur in patients with traumatic brain injury. A repair of a large chronic pseudomeningocele can lead to acute CH in patients and cause rapid neurological decline. It is critical for clinicians to be mindful of the potential complication of acute hydrocephalus in patients who undergo repair of a large chronic pseudomeningocele secondary to trauma.

Purpose: Complications from RA can involve the thoracolumbar spine and cause severe spine instability and sagittal deformity. We present a surgical strategy to restore sagittal balance in a patient with chronic rheumatoid arthritis.

Methods: A retrospective chart review was performed.

Results: We report the case of a 53-year-old woman with RA and severe back pain. She had dynamic instability of her lumbar spine with spondylolithesis at L3-L4 and L4-L5 as well as hypermobility at the C1-2 level without rheumatoid pannus. On 36-inch standing films, she had a sagittal vertical axis (SVA) of 219 mm. She underwent anterior and posterior instrumented fusion to restore her sagittal imbalance, which resulted in excellent relief of her back pain and marked improvement in ambulation and function.

Conclusion: Patients with RA can develop severe sagittal deformity that could be the source of back pain. In patients with advanced RA, chronic inflammation could lead to ligament laxity that can result in spinal deformity under axial load. This deformity is amenable to reconstruction without the utilization of an osteotomy, which can produce excellent pain relief and restoration of function.

Background: Transpedicular screw fixation in the Axis is difficult due to its relation with adjacent anatomic features. Successful placement requires a sufficient understanding of axis pedicle.

Objective: The aim was to assess length and width of the C2 pedicle in Moroccan population in order to evaluate the safety of pedicle screw fixation.

Patients and methods: We evaluated the C2 pedicle morphology using computed tomography (CT) imaging in 100 patients (30 females and 70 males; age range, 18–70; mean, 36,2 ± 11,9 years). Axial CT cutting was made at 1.25 mm intervals. The measurements of C2 pedicles were performed on CT images using its measurement tools. The pedicle transverse width was defined as the mediolateral diameter of the pedicle isthmus. Pedicle length (distance from the posterior cortex of the lateral mass to the middle of the vertebral body).

Results: The overall mean pedicle transverse widths (PTW) were 5.3 mm (4.1 to 7.1 mm), in males were 5.2 ± 0.5 mm and 5 ± 0.4 mm in females. The overall mean pedicle lengths (PL) were ranged from 19,7 to 26.7 mm with average 22.5 mm. The mean PL in female was 21.8 ± 1.4 mm and 22.8 ± 1.7 mm in male. The mean PTW and PL were greater in males than in females at both sides, and this difference was statistically significant. On the other hand, they were not correlated to age in our adult patients.

Conclusion: Our findings suggest that there were significant differences between individuals and ethnics. The preoperative CT scans undergoing cervical transpedicular fixation should be thoroughly analyzed for successful pedicle screws placement.

Dynamic stabilization devices were developed to reduce spinal hypermobility while preserving a certain degree of physiological motion. Our goal was to assess radiographic and clinical outcomes of patients treated with surgical decompression and stabilization with the LimiflexTM implant.

We investigated the effect of LimiFlex implantation on post-operative translation and angulation in 36 patients with spinal stenosis and degenerative spondylolisthesis Meyerding Grade I treated with decompression and dynamic stabilization.

Significant improvements following lumbar decompression were observed. The average Oswestry Disability Index (ODI) score fell from 45.9 Pre-operatively to 29.6 at dismissal and 26.5 at first follow up. The average visual analog scale (VAS) score fell from 7 Pre-operatively to 3 at dismissal and 3 at follow up. Pre-operatively the median translation within the operated segment was 2.0 mm. Post-operatively the translation was reduced to 0.7 mm (p=0.006, Student’s t-test). Pre-operatively the median rotation within the operated segment was 4.6°. Post-operatively the rotation was reduced to 3.5° (p=0.08, Student’s t-test). The re-operation rate was 6 out of 36 (16.7%).

Here we provide evidence suggesting that the dynamic paraspinous stabilization implant LimiflexTM is well tolerated in patients with degenerative spondylolisthesis and lumbar spinal canal stenosis. Our data show that within 3 months after the operation it limits hypermobility in the operated segment. This might be well suited in cases such as spinal stenosis with Grade I degenerative spondylolisthesis, where instability at the operated segment is likely to happen, but a patient is not indicated for a spinal fusion.

Background: Spinal Cord injury, whether traumatic or non-traumatic, is a devastating and debilitating neurological condition and the incidence of spinal cord injury is increasing with time. It was aimed to look into the epidemiology of spinal cord injury in Bangladesh as a preliminary step towards the prevention of this condition and the related complications.

Methods: Records of all admitted patients with spinal injuries from January 2011 to June 2016 were collected from the medical records of the Center for Rehabilitation of the Paralysed (CRP) hospital. Records were found of total 2184 respondents and data were analyzed by Statistical Package of Social Science (SPSS) 16 version and Microsoft Excel Software 2007 version.

Results: Among 2184 respondents 86.8% (n=1897) were male; most of the patients were in their 3rd decade which consisted 25.7%, 1513 (69.2%) of the respondent were from rural area. About 52% (n=1136) had the diagnosis of traumatic paraplegia and 42.6% (n=932) had traumatic tetraplegia. 992 of the participants (45.4%) had fall from height and Road traffic accident was the second common cause having the distribution of 567 patients (25.9%). Regarding the extent of injury, 59.8% (n=1292) participants had complete injury that is category A in ASIA scale.

Conclusion: Despite being a single center based study, this extensive epidemiological data can direct as a base line and further large scale study would better to generalize the result.

Introduction: The ability to identify and treat pain generators in the lumbar spine is helped by incorporating diagnostic and therapeutic injections, followed by visualizing the pain generator with an endoscope. Although improvements in imaging are getting very sophisticated, visualization of the source of the pain generators is currently only possible with an endoscope. This has opened the door to more options for cost effective surgical treatment in staged manner by treating the pain source.

Materials and methods: An FDA approved system endoscopic system and technique developed by A. Yeung in 1997, using a multichannel endoscope for the transforaminal approach to visualize the disc and foramen, is featured. After anesthetizing the disc foramen, and targeting the axilla of the foramen in the vicinity of the exiting and traversing nerve, known to spine surgeons as the “hidden zone” of MacNab, the technique has evolved to surgically provide pain relief for stratified conditions for patient selection. The standard translaminar approach to the disc and the spinal segment will usually miss visualizing the patho-anatomy of pain in this “hidden zone”, an area harboring common causes of “failed back surgery syndrome”. Recent minimally invasive techniques of decompression and fusion may help resolve the pain source, but fusion has its surgical morbidities and high costs. A less invasive highly successful transforaminal endoscopic method with 25-year data supports this technique.

Discussion: Transforaminal Endoscopic Spine Surgery, the YESS™ technique, is effective using mobile cannulas to visualize and target the pain source. New instrumentation, techniques, specially configured endoscopes with different size working channels; facilitate effective surgical treatment of the pain generator. Incorporating visualization of the disc cavity to treat painful annular tears adds to the effectiveness of the procedure. The surgeon can also treat spinal stenosis with foraminoplasty by decompressing the ventral facet of the superior articular process as well as the axilla containing the exiting and traversing nerve. The purpose of this study is to demonstrate that the physiology of pain can be visualized as a pain generator. Patho-anatomy is identified and surgically decompressed. Diagnostic and therapeutic injections also aid in identifying pain generators by epidurography performed with the transforaminal approach.

Conclusion: Interventional pain management, often the first line of minimally invasive treatment, provides pain relief only by targeting injections to block nerves. Visualizing the patho-anatomy with an endoscope targeting the patho-anatomy by the same interventional needle trajectories, however, provides a surgical option to decompress and ablate the pain generators.

Symptomatic thoracic ossification of the ligamentum flavum is rare, and a modality for its treatment has not yet been fully established; most reported patients complained of myelopathy. Herein, the authors will report on an extremely rare presentation of thoracic ossification of the ligamentum flavum, along with clinical outcomes. The patient complained of chest discomfort and myelopathy symptoms for 1 year secondary to thoracic ossification of the ligamentum flavum. He underwent one surgical procedure. Postoperatively, his symptoms such as chest discomfort and myelopathy improved completely. As of this report, the patient has had a good postoperative recovery, had good overall health, and adapted well to his social activities.

Background: Epidural steroid injection is an innocuous and efficient modality of treatment for chronic low back ache due to a multitude of causes, its use being on the rise in recent times. However, a note needs to be made regarding the potentially serious complications following epidural steroid injection including epidural space infection. This condition requires a high index of suspicion for early diagnosis and treatment.

Case presentation: A 39-year-old lady presented, following a second episode of epidural steroid injection, with change in nature and increased severity of low back ache. Magnetic Resonance Imaging (MRI) of the lumbosacral spine showed a T1 hypointense, T2 hyperintense peripherally enhancing epidural collection at L3-L5 level for which she underwent laminectomy and evacuation of collection with complete relief of pain. Intraoperatively, there was a non-foul smelling, thick, yellowish pus which turned out to be positive for Staphylococcus aureus.

Conclusion: Spinal epidural abscess is a rare complication following epidural steroid injection which requires a high degree of suspicion for early detection and treatment, to prevent permanent neurological sequela.