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Introduction Spine fracture in association with traumatic dural tear is a serious injury. A traumatic dural tear is difficult to determine based on initial clinical presentation and radiological imaging even with magnetic resonance imaging (MRI). However, during decompression surgery, cerebrospinal fluid leaks surrounding the injured segments are usually confirmed by directly visualizing them. For preoperative planning and intraoperatively limiting further damage to the dural and neurological structures, early detection of traumatic dural tears before surgery is important. This study aims to determine the prevalence, implication, risk factors, and complications of traumatic dural tears in patients who have undergone surgical treatment for thoracic and lumbar fractures. We believe our retrospective study would identify more accurate risk factors for traumatic dural tears and aid us with preoperative planning and operative precaution. Methods This study retrospectively included all patients who had thoracic and lumbar fractures and had posterior instrumentation and decompression surgery at three hospitals in the Northern region of Malaysia from January 2018 to December 2020. Fractures associated with pathological spine including metastatic, severe osteoporosis, ankylosing spondylitis, metabolic bone disease, those with missing data, and iatrogenic dural tears were excluded from this study. Preoperative and postoperative neurological assessments based on the American Spinal Injury Association (ASIA) impairment scale, blood loss volume, duration of the surgery, and post-surgery complications were gathered from medical records. Interpedicular distance, ratio of central canal diameter, laminar fracture gap, and pedicle fractures were identified and measured. The obtained data was analyzed using Pearson's chi-square and Fisher's exact test for categorical variables, and independent t-test/Mann-Whitney test for numerical variables. Result This study comprised a total of 93 patients who had fractures in their thoracic and lumbar regions. The mean age of the patients was 38 years. The number of patients with traumatic dural tears was 20 (21.5%). There was an association between the presence of dural tears and preoperative neurological deficits (P<0.001). Wider mean interpedicular distance (P=0.004), increased central canal diameter ratio (P<0.001), and displaced laminar fracture (P<0.001) were significantly higher in patients with traumatic dural tears. Multiple logistic regression analysis showed both incomplete (P=0.002) and complete (P=0.037) preoperative neurological deficit, increase of central diameter ratio of encroachment (P=0.011), and presence of >2mm laminar fracture gap (P=0.015) had a significant association with a traumatic dural tear. This study found that patients with traumatic dural tears had longer surgical times and statistically larger mean blood loss volumes when compared to patients without dural tears (P<0.001). There is no significant association between the complications following the surgery and the presence of a dural tear (P>0.05). Conclusion This study shows that the presence of preoperative neurological deficits, wider interpedicular distance, severe canal encroachment, and wide separation of laminar fracture may indicate the likelihood of traumatic dural tear in spine fracture. These factors will enable surgeons to enhance their operational planning and make early preparations for the management of dural tears.
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Introduction: Triangular working area otherwise known as the Kambin triangle is designated as a safe place to position the instrument during the operation, with minimal risk to exiting nerves. This study aims to improve understanding and increase the safety of various transforaminal intradiscal procedures at L3/L4, L4/L5, and L5/S1 levels. Methods: A cross-sectional analysis involving 102 MRIs that met the inclusion criteria was obtained and analyzed at the L3/L4, L4/L5, and L5/S1 discs level. For each level, the Kambin triangle was measured. By evaluating those measurements, the viability of this method was determined. Results: Safe working zone approach angles were consistently getting wider from L3 to S1 levels. It was statistically significant to be wider for the left side for the mean angle of lateral nucleus trajectory at the L4/L5 level and L5/S1. The entry point is at 32, 45, and 55-60 mm from the midline, and the instrument should be directed at 12°, 20°, and 27° medially for the lateral nucleus at L3/L4, L4/L5, and L5/S1, respectively. The center of the nucleus pulposus entry point is at 64, 77, and 85 mm from the midline with a medial inclination of 40°, 47°, and 52°, respectively, for L3/L4, L4/L5, and L5/S1. For the posterior nucleus pulposus, the skin should be pierced 90, 140, and 180 mm from the midline and directed medially at 53°, 61°, and 68°, respectively, for L3/L4, L4/L5, and L5/S1. The posterior annulus fibrosis entry point is 172, 355, and 450 mm with a medial inclination of 69°, 80°, and 84° at L3/L4, L4/L5, and L5/S1, respectively. The sagittal inclination is 3° cephalad at L3/L4, 10° caudally at L4/L5, and 27° caudally at L5/S1. Conclusions: Preoperative MRI assessment is important to determine the angle of trajectory for the safe entry point for intradiscal procedure via transforaminal approach.
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Introduction: Stress level among the caregivers is often related to caregivers' lack of knowledge and skill to care for the patients. A health education program to the caregivers is one of the important elements in increasing the knowledge and skills in managing patients at home. The specific objectives of this study were to determine caregiver's stress level in managing post total knee replacement (TKR) patients pre and post of a health education program. Materials and Methods: A clinical intervention trial design was conducted in Hospital Universiti Sains Malaysia (HUSM) with a sample size of 32 caregivers. A validated Zarit Burden Interview (ZBI) questionnaire was used to measure the stress level pre and post of the health education program on the management of patients post-TKR surgery which was adopted from Fresno Surgical Hospital in California. Results: The findings showed that there was a significant difference between pre and post level of stress (p ≤ 0.001). Conclusion: This study revealed the positive outcome of the health education program. It reduced the stress level among the caregivers in caring for their relatives with post-TKR surgery.
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Introduction: Endoscopic surgery is one of the methods that achieve the goal of decompression while minimizing collateral tissue damage. Its efficacy and safety have been supported by numerous studies. There is a plethora of studies on lumbar stenosis regarding the outcomes and related issues in endoscopic spine surgery. However, few studies evaluated the outcome of the decompressive lumbar spine surgery. The present study aims to analyze the outcome of a unilateral approach to endoscopic surgery for lumbar stenosis using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and MacNab's criteria. Methods: This is a retrospective study (level IV) conducted between January 2009 and December 2013 on 60 patients who underwent endoscopic interlaminar decompressive spine surgery (Destandau method) for lumbar degenerative spinal stenosis in the Hospital Universiti Sains Malaysia. The clinical outcome was measured pre-operatively and post-operatively for VAS: for back and leg pain, motor and sensory grading, the ODI, and MacNab's criteria. A paired t-test was used for statistical analysis. Results: The mean age of patients was 60.82 years comprising 23 males (38.3%) and 37 females (61.7%). The mean follow-up period was 30.1 months (range = 17.2-43 months). The mean operation time was 183.6 min (ranging from 124.8 to 242.4 min), and the mean blood loss was 150.18 mL (ranging from 30.82 to 269.54 mL). Post-operatively, mean hospital stay was 2.45 days (ranging from 1.34 to 3.56 days). The most frequently involved level was L4/L5 in 51 patients (52.6%), followed by L3/L4 in 19 patients (19.6%), L5/S1 in 24 patients (24.7%), and L2/L3 in three patients (3.1%). Improvement in the post-operative VAS for back and leg pain and the ODI for pre-operation and post-operation was statistically significant (p < 0.001). Conversely, the reduction in neurological status was statistically insignificant. Based on MacNab's criteria, 88.4% showed excellent to good outcomes. Conclusion: To summarize, unilateral percutaneous endoscopic spine surgery to achieve the bilateral decompression in lumbar stenosis provides excellent yet safe and effective outcomes. It improves back and leg pain and patients' function significantly.
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We describe a series of three patients who sustained multiplanar sacral fracture with spinopelvic dissociation treated with bilateral triangle osteosynthesis supplemented with a gullwing plate. Multiplanar sacral fracture causes the sacrum to divide into two parts which in severe cases, fracture displacement results in neurological injury. Spinopelvic fixation supplemented with a gullwing plate surgical treatment is still a viable option with an acceptable outcome. The average waiting time prior to surgery is 3 weeks.
