Change in pelvic incidence due to sacral stress fracture following multilevel instrumented fusion.

Multilevel-instrumented fusion is a common surgical technique used to treat adult spinal deformity (ASD), but it can occasionally lead to rare complications such as sacral insufficiency fractures. The impact of sacral fractures on spinopelvic parameters, particularly pelvic incidence (PI), has not been thoroughly investigated even though they have been documented in the literature. Here, we present a case of a patient who underwent a Th11-sacrum instrumented fusion for ASD. She underwent a revision surgery 18 months after the first procedure to treat proximal junctional pain brought on by a localised kyphosis of the rods. An asymptomatic sacral fracture was discovered during the radiological evaluation: the PI had increased from 71° to 103° between the 2 surgical procedures.

'Tumour-like' lesion caused by cervical discal instability.

We present the case of a man in his 40s who sought medical attention due to central cord syndrome. MRI findings demonstrated contrast uptake, spinal swelling, syrinx formation and narrowing of the spinal canal. We encountered two potential scenarios:when malignancy is suspected, the patient would undergo a biopsy. However, if the lesion is ultimately determined to be benign, the patient would have been subjected to an avoidable risk of neurological damage associated with the procedure. Conversely, addressing the lesion as a result of a degenerative process (discal instability), performing an anterior approach for interbody fusion with an underlying malignant process could lead to substantial delays in the diagnosis, finally producing a poor outcome. A comprehensive imaging workup was conducted to rule out malignancy. We hypothesised that discal instability was responsible for the observed findings. The patient was successfully treated with anterior cervical decompression and fusion, without complications. Follow-up evaluations confirmed remission of the condition.

A novel less invasive endoscopic-assisted procedure for complete reduction of low-and high-grade isthmic spondylolisthesis performed by anterior and posterior combined approach.

PURPOSE: The optimal surgical management of low- and high-grade isthmic spondylolisthesis (LGS and HGS -IS) is debated as well as whether reduction is needed especially for high-grade spondylolisthesis. Both anterior and posterior techniques can be associated with mechanical disadvantages as hardware failure with loss of reduction and L5 injury. We purpose a novel endoscopic-assisted technique (Sled technique, ST) to achieve a complete reduction in two surgical steps: first anteriorly through a retroperitoneal approach to obtain the greatest part of correction and then posteriorly to complete reduction in the same operation. METHODS: ST efficacy and complications rate were evaluated through a retrospective functional and radiological analysis. RESULTS: Thirty-one patients, 12 male (38.7%) and 19 female (61.3%), average age: 45.4 years with single level IS underwent olisthesis reduction by ST. Twenty-three IS involved L5 (74.2%), 7 L4 (22.5%) and 1 L3 (3.3%). No intraoperative complications were recorded. One patient required repositioning of a pedicle screw. A significant improvement of functional and radiological parameters (L4-S1 and L5-S1 lordosis) outcomes was recorded (p < 0.001). CONCLUSION: ST provides a complete reduction in the slippage in LGS and HGS. The huge anterior release as well as the partial reduction in the slippage by the endoscopic-assisted anterior procedure, because of the cage is acting as a "guide rail", facilitate the final posterior reduction, always complete in our series, minimizing mechanical stresses and neurological risks. CLINICALTRIALS: gov Identifier: NCT03644407.

Successful salvage strategy using anterior retroperitoneal approach in failed posterior lumbar interbody fusion. A retrospective analisys on lumbar lordosis and clinical outcome.

OBJECTIVE: Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) are among the most popular surgical options for lumbar interbody fusion. If non-union occurs with consequent pain and reduced quality of life, revision surgery should correct any previous technical errors, avoiding further complications. The aim of this study was to analyze technical advantages, radiological and clinical outcomes of anterior approaches (ALIF) in case of failed PLIF or TLIF. METHODS: Retrospective analysis of consecutive patients with persistent low back pain after failed PLIF/TLIF where salvage ALIF through an anterior retroperitoneal miniopen video-assisted technique was performed. Surgical, clinical and radiological data were analysed. Uni and multivariate statistical analysis were applied. RESULTS: Thirty-six patients (average age: 47.1 years) were included. Mean follow-up was 34.4 months. In 30 patients (83.3%) a posterior surgical step was necessary. Non-union (86.1%), cage migration (5.5%), infection (8.3%) were the causes of revision surgery. In 22 patients (61.1%) the involved level was L5-S1, in 12 patients (33.4%) L4-L5, in 1 patient (2.7%) L3-L4. One patient (2.7%) had two levels (L4-L5 and L5-S1) involved. No major intraoperative complications were recorded. Significant correlation between clinical and radiological outcomes (L4-S1 and L5-S1 lordosis improvement) were observed (postoperative VAS and L5-S1, p = 0.038). CONCLUSIONS: Salvage ALIF is a safe option that can significantly ameliorate residual pain achieving primary interbody stability with an ideal segmental lordosis according to pelvic parameters. The advantages of a naive anterior approach fulfils the main objectives of a revision surgery in order to significantly increase the chances of definitive fusion.

New Trends in Spinal Surgery: Less Invasive Anatomical Approach to the Spine. The Advantages of the Anterior Approach in Lumbar Spinal Fusion.

AIM: To describe the history of the anterior approach to the lumbar spine from the beginning to the minimal invasive techniques that the authors have developed, and to discuss its advantages and drawbacks. MATERIAL AND METHODS: The authors collected published data on the evolution of the anterior approach in the lumbar spine, and described its potential in different pathologies focusing on minimally invasive techniques. RESULTS: Several successful techniques of anterior lumbar approach have been developed over the years, leading to a progressive less invasive anatomical exposure of the spine. Anterior approaches of the lumbar spine gained popularity as an alternative to posterior routes in the management of tumors, infections, traumas, degenerative or deformity diseases and as a salvage procedure after posterior surgery. CONCLUSION: Advantages of the retroperitoneal anterior approach of the lumbar spine are well accepted: it preserves the anatomical structures of the abdomen and posterior tension band, avoiding muscle dissection. The implantation of lordotic cages with larger footprint improves local lordosis and fusion rate even in revision surgery. Drawbacks of traditional retroperitoneal approaches may be: vascular injury, deep venous thrombosis, risk of retrograde ejaculation in male in case of L5-S1 dissection. Therefore, several minimal invasive techniques have been developed to decrease the risks related to the traditional approaches. However, a long learning curve is required to achieve good skills and to manage possible technical concerns and complications.