Cortical bone trajectory screws fixation in lumbar adjacent segment disease: A technique note with case series.

Lumbar adjacent segment disease after lumbar fusion surgery often requires surgical intervention. However, subsequent surgical treatment often needs to expose and remove all of the previous instruments. This additional surgery leads to significant post-operative pain, muscular fibrosis, poor wound healing and infection, etc. From October 2015 to March 2016, we collected six cases underwent cortical bone trajectory screws fixation with minimal invasive inter-body cage fusion for lumbar adjacent segment disease. Patients in the study all had improvement after surgery without recurrence or instruments failure during follow-up. The technique negates removal of pre-existing instruments and when combined with minimal invasive fusion surgery, the wound length, blood loss and soft tissue damage could be reduced compared with traditional surgery. We introduce the surgical procedures in detail and wish this technique could be an option for spine surgeons who encounter a similar situation.

Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction.

BACKGROUND: Early surgical decompressive craniectomy (less than 24 hours) for malignant middle cerebral artery infarction (MCA) provides life-saving benefits. Detection of the infarction territory with computed tomography (CT) scan is usually less sensitive and delayed than diffusion-weighted imaging (DWI) that is capable of defecting the infarction territory in as little as 5 minutes after onset. Based on the DWI and clinical neurologic evaluations, ultra-early (less than 6 hours) decompressive craniectomy for malignant MCA infarction may be very helpful in improving mortality and morbidity rates. METHODS: We treated 52 patients with malignant MCA infarction. Clinical neurologic presentation was evaluated using the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Scale (GCS). The infarction territory was evaluated by either DWI or CT. Patients were divided into three groups (Group A: ultra-early, Group B: craniectomy beyond 6 hours, and Group C: no operation). Anterior temporal lobectomy was performed according to the ICP levels (ICP >30 mm Hg) after decompressive craniectomy. RESULTS: Group A had statistically lower mortality rates than Groups B and C (8.7% in Group A, 36.7% in Group B and 80% in Group C). Group A patients also had better prognosis of conscious recovery on the 7th day of onset (91.7% in Group A, 55% in Group B and 0% in Group C). Group A had statistically better Barthel Indexes than Group B, p < 0.05. Group A and Group B had better GOS levels than Group C, p < 0.001. Diagnosis by CT was accurate in only 33% of patients while the accuracy of DWI to detect malignant MCA infarction was 100% within 6 hours of onset. In surgical Group A and B, thirteen patients underwent anterior temporal lobectomy, and 67% survived. All patients with ICP levels of more than 30 mm Hg who did not undergo further anterior temporal lobectomy died. CONCLUSIONS: Patients who underwent decompressive surgery had better outcomes than patients who did not have the operation. Ultra-early intervention with decompressive craniectomy with ICP monitoring before neurologic conditions become worse may reduce the mortality rate, increase the conscious recovery rate, and improve neurologic sequels for malignant MCA infarction. DWI with clinical neurologic evaluation (NIHSS, hemiplegia, down-hill GCS) provides for early diagnosis and treatment of malignant MCA infarction. Anterior temporal lobectomy may further reduce intraoperative ICP and reduce mortality, especially when the infarction is at multiple arterial territories.