A 2-Year Outcomes and Complications of Various Techniques of Lumbar Discectomy: A Multicentric Prospective Study.

STUDY DESIGN: Prospective Study. OBJECTIVES: There are numerous techniques for performing lumbar discectomy, each with its own rationale and stated benefits. The authors set out to evaluate and compare the perioperative variables, results, and complications of each treatment in a group of patients provided by ten hospitals and operated on by experienced surgeons. METHODS: This prospective study comprised of 591 patients operated between February-2017 to February-2019. The procedures included open discectomy, microdiscectomy, tubular microdiscectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy and Destandau techniques with a follow-up of minimum 2 years. VAS (Visual Analogue Score) for back and leg pain, ODI (Oswestry Disability Index), duration of surgery, hospital stay, length of scar, operative blood loss and peri-operative complications were recorded in each group. RESULTS: Post-operatively, there was a significant improvement in the VAS score for back pain as well as leg pain, and ODI scores spanning all groups, with no significant distinction amongst them. When compared to open procedures (open discectomy and microdiscectomy), minimally invasive surgeries (tubular discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) reported shorter operative time, duration of hospital stays, better cosmesis, and lower blood loss. Overall, the complication rate was reported to be 8.62%. Complication rates differed slightly across approaches. CONCLUSION: Minimally invasive surgeries have citable advantages over open approaches in terms of perioperative variables. However, all approaches are successful and provide comparable pain relief with similar functional outcomes at long term follow up.

"Insert flipping technique:" An effective way of restoring segmental lordosis and disc height with tall bullet cages.

Study Design: The study design was a retrospective study. Objective: The objectives of the present study are dual; to describe a simple and effective way of restoring intervertebral disc (IVD) height by the "Insert Flip Technique" of cage insertion and to demonstrate effective restoration of IVD height and segmental lordosis (SL) and their influence on the functional outcome postoperatively. Methods: IVD height and SL were recorded pre- and postoperatively. Each motion segment was instrumented with pedicle screws to allow segmental stabilization. Patients were called for follow-up at 6 weeks, 3 months, and 1 year postoperatively and were assessed clinically for back pain and leg pain (VAS and Oswestry Disability Index scores recorded).The bullet cages are designed such that they are lordotic in the superior-inferior plane and neutral in the mediolateral plane. Usually, the cage is inserted with superior and inferior surfaces of the cage impacting against superior and inferior end plates of the adjacent vertebral body. However, with the proposed technique, the cages were inserted such that the narrower mediolateral surfaces of the cage engaged with superior and inferior vertebral end plates. The cage was then flipped within the disc space such that the superior-inferior surfaces of the bullet cage impacted against the superior and inferior end plates of the vertebral body to create desired lordosis. Results: There was a significant improvement seen in the postoperative Cobb's angle and disc height after placement of a tall bullet cage compared to the preoperative Cobb's angle and disc height. Conclusion: This modification of technique helped in gaining lordosis with taller bullet cages in minimally invasive surgery transforaminal lumbar interbody fusion with no/minimal complication and also reduced the need for bone resection during insertion of the cage.

The current status and surgical outcome of the minimally invasive techniques for lumbar interbody fusion in India: A systematic review and meta-analysis.

Objective: The global shift of trends to minimally invasive spine (MIS) surgery for lumbar degenerative diseases has become prominent in India for few decades. We aimed to assess the current status of MIS techniques for lumbar interbody fusion and their surgical outcomes in the Indian population. Materials and Methods: A systematic review (following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines) was performed using PubMed and Google Scholar till November 2020. The primary (visual analog scale [VAS] and oswestry disability index [ODI] scores; intraoperative blood loss; duration of surgery; duration of hospital stay, and fusion rate) and secondary (wound-associated complications and dural tear/cerebrospinal fluid (CSF) leak) outcomes were analyzed using Review Manager 5.4 software. Results: A total of 15 studies comprising a total of 1318 patients were included for analysis. The pooled mean of follow-up duration was 26.64 ± 8.43 months (range 5.7-36.5 months). Degenerative spondylolisthesis of Myerding grade I/II was the most common indication, followed by lytic listhesis, herniated prolapsed disc, and lumbar canal stenosis. The calculated pooled standard mean difference (SMD) suggested a significant decrease in postoperative ODI scores (SMD = 5.53, 95% confidence interval [CI] = 3.77-7.29; P < 0.01) and VAS scores (SMD = 6.50, 95% CI = 4.6-8.4; P < 0.01). The pooled mean blood loss, duration of postoperative hospital stay, duration of surgery, and fusion rate were 127.75 ± 52.79 mL, 4.78 ± 3.88 days, 178.59 ± 38.69 min, and 97.53% ± 2.69%, respectively. A total of 334 adverse events were recorded in 1318 patients, giving a complication rate of 25.34%. Conclusions: Minimally invasive transforaminal lumbar interbody fusion (TLIF) is the most common minimally invasive technique employed for lumbar interbody fusion in India, while oblique lumbar interbody fusion is in the initial stages. The surgical and outcome-related factors improved significantly after MIS LIF in the Indian population.

Multimodal Applications of 3D-Navigation in Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion: Impacts on Precision, Accuracy, Complications, and Radiation Exposure.

BACKGROUND: Three-dimensional (3D)-navigation in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is an evolving procedure. It is used not only for its accuracy of pedicle screw fixation but also for other major steps in transforaminal lumbar interbody fusion. Multimodal outcomes of this procedure are very limited in the literature. The purpose of this study was to examine the application of 3D-navigation in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). METHODS: Patients who underwent single-level MI-TLIF using 3D-navigation between January 2017 and July 2019 were evaluated for navigation setting time, radiation exposure, volume of nucleus pulposus excised, cage placement, accuracy of pedicle screw placement, and cranial facet-joint violation. RESULTS: One hundred and two patients with a mean age of 60.2 years met the inclusion criteria. The mean presetting time of navigation was 46.65 ± 9.45 minutes. Radiation exposure, fluoroscopy use, and fluoroscopy time were 15.54 ± 0.65 mGy, 4.43 ± 0.87 Gy.cm², and 97.6 ± 11.67 seconds, respectively. The mean amount of nucleus pulposus excised from all quadrants was quantified. The cage was centrally placed in 87 patients, with 95.4% showing a Grade 0 pedicle breach and 94.6% showing Grade 0 cranial facet-joint violation. CONCLUSION: Registration and setting up 3D-navigation takes additional time. The amount of exposure to the patient is much less compared to routine computed tomography, and, importantly, the operating team is protected from radiation. Navigated MI-TLIF has high rates of accuracy with regard to placement of percutaneous pedicle screws and cages with the added advantage of protection of the cranial facet-joint.

Cervical facet joint effusion: A sign of instability in cervical degenerative spondylolisthesis.

Aims: The aim of this study was to trace the association between cervical facet joint effusion and cervical degenerative spondylolisthesis (CDS). CDS has not received as much attention as its lumbar counterpart. Identification of features of instability on magnetic resonance imaging (MRI) is crucial to avoid missing presence of CDS. Materials and Methods: The authors retrospectively reviewed cervical spine MRI scans and upright lateral flexion-extension radiographs of 17 consecutive patients at a single institution between January 2017 and June 2018 that revealed CDS. Presence of cervical facet joint effusion and CDS was recorded. Data were analyzed to deduce possibility of an association between cervical facet joint effusion and CDS. Results: Seventeen patients fulfilled the inclusion criteria of cervical spondylotic myelopathy associated with CDS. Out of these, 10 patients revealed facet joint effusion at C3-C4 (4 patients) and C4-C5 (6 patients) levels. The mean age of patients was 65.8 years (49-79) and M:F was 2.2:1. Amount of facet joint effusion varied and ranged from 1.6 mm to 4.7 mm on the axial images. Ten patients (58.82%) demonstrated facet joint effusion associated with mobile CDS. Seven patients (41.17%) with CDS and without facet effusion did not demonstrate mobility of more than 0.5 mm in flexion-extension radiographs. Conclusion: The current study acknowledges the association of "cervical facet effusion" and CDS. Clinically measurable facet joint effusion on MRI suggests the need for further attempts to diagnose CDS.

Should Q-CT Be the Gold Standard for Detecting Spinal Osteoporosis?

STUDY DESIGN: Prospective comparative study. OBJECTIVE: Refinement of the guidelines for screening of osteoporosis and considering quantitative computed tomography (Q-CT) for detecting spinal osteoporosis. SUMMARY OF BACKGROUND DATA: Spinal osteoporosis is often underestimated and under-evaluated due to either lack of availability of the diagnostic modality or lack of awareness about the possibility of overestimation by dual X-ray absorptiometry (DXA) scan. There is a need for reconsidering osteoporosis evaluation with a site specific and patient specific inclination. METHODS: Post-menopausal women that underwent bone mineral density (BMD) evaluation from January-2018 to December-2020 with either Q-CT or DXA were evaluated. Comparison studies of the distribution of age and T-scores of the bone densities obtained from the two study groups: age-matched, sex-matched, and common skeletal site of interest (L1-4 vertebrae) were performed. Mann-Whitney U test, correlation and regression analyses were performed and bell curves were plotted. RESULTS: Of the 718 women evaluated, 447 underwent Q-CT and 271 underwent DXA. There was no significant difference among the age distribution of the two study groups (P-value > 0.05). The mean and mode T-scores obtained by Q-CT and DXA were found to be -2.71, -3.8 and -1.63, -1.7 respectively. A highly significant difference in the T-scores was observed in the Q-CT and DXA groups (P-value < 0.0001). Among those who were screened by Q-CT, 58.16% were osteoporotic, 37.58% were osteopenic, and 4.25% were normal. The respective percentages in the DXA group were 30.63%, 49.82%, and 19.55%. CONCLUSION: Q-CT provides more precise estimation of cancellous bone mineral density than DXA. With the reliance on DXA for spinal BMD estimation being questionable, new standards have to be established for spinal osteoporosis evaluation. Q-CT can be a better alternative to replace DXA as the gold standard for the evaluation of spinal osteoporosis.Level of Evidence: 2.

Quiescent Andersson Lesion Simplifies Deformity Correction: A Case Report.

CASE: We present a case of ankylosing spondylitis with sagittal imbalance and having a suspicious Andersson lesion (AL) on magnetic resonance imaging (MRI) at D12-L1. The segment did not reveal any potential mobility on erect radiographs and supine MRI. L2 pedicle subtraction osteotomy was planned. However, intraoperatively after positioning, the AL widely opened up. This made us reassess the treatment strategy; an interbody fusion was performed, and the correction was achieved using a cantilever mechanism without performing an osteotomy. CONCLUSION: A quiescent AL can affect preoperative planning. However, understanding the pathology, reassessing the situation, and reformulating the plans intraoperatively resulted in a successful outcome.

A 2-Year Outcomes and Complications of Various Techniques of Lumbar Discectomy: A Multicentric Retrospective Study.

OBJECTIVES: Various techniques of performing lumbar discectomy are prevalent, each having its rationale and claimed benefits. The authors ventured to assess the perioperative factors, outcomes, and complications of each procedure and compare among them with 946 patients contributed by 10 centers and operated by experienced surgeons. METHODS: This was a retrospective study of patients operated using open discectomy, microdiscectomy, microendoscopic discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques with a follow-up of minimum 2 years. The inclusion criteria were age >18 years, failed conservative treatment for 4-6 weeks, and the involvement of a single lumbar level. RESULTS: There was a significant improvement in the visual analog scale score of back, leg, and Oswestry Disability Index scores postoperatively across the board, with no significant difference between them. Minimally invasive procedures (microendoscopic discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) had shorter operation time, hospital stay, better cosmesis, and decreased blood loss compared with open procedures (open discectomy and microdiscectomy). The overall complication rate was 10.1%. The most common complication was recurrence (6.86%), followed by reoperation (4.3%), cerebrospinal fluid leak (2.24%), wrong level surgery (0.74%), superficial infection (0.62%), and deep infection (0.37%). There were minor differences in incidence of complications between techniques. CONCLUSION: Although minimally invasive techniques have some advantages over the open techniques in the perioperative factors, all the techniques are effective and provide similar pain relief and functional outcomes at the end of 2 years. The various rates of individual complications provide a reference value for future studies.

Comparison of Applied Anatomy at L4-L5 and L5-S1 in Context of Tubular Decompression for Lumbar Canal Stenosis.

BACKGROUND: Tubular over-the-top decompression is getting popular in the management of lumbar canal stenosis (LCS). While L4-L5 is the most common level affected and operated for LCS, it is not uncommon to encounter patients with stenosis at L5-S1. No previous study has described the technical challenges of tubular decompression at the L5-S1 level as compared to at the L4-L5 level. METHODS: This observational study was done on 40 consecutive patients older than 45 years who underwent magnetic resonance imaging (MRI) for back-related issues. The following radiological parameters: interlaminar angle, tube angle, laminar thickness ratio at the isthmus, and the laminar length ratio were evaluated at the L4-L5 level (group A) and the L5-S1 level (group B). The hypothesis behind the study was that if these patients were subjected to tubular decompression, then there will be technical differences between doing the surgery at the L4-L5 and L5-S1 levels. RESULTS: The mean age of the patients was 56.8 years (46-72) and the male to female ratio was 3:2. The mean interlaminar angle in group A was 71° and in group B was 102°. The tube angle in group A and group B was 36.8° and 49.7°, respectively. The laminar thickness ratio (L4:L5) was 1.34:1 and the laminar length ratio (L4:L5) was 1:1.42 in group A and B, respectively. CONCLUSION: Tubular decompression at the L5-S1 level has its own challenges because of the different anatomy of the L5 lamina compared to that of the L4 lamina. The wide interlaminar angle of L5 as compared to L4 dictates more oblique tube docking (tube angle) and more extensive table tilting to reach the contralateral lateral recess, thus making it challenging. The authors recommend that surgeons be conscious of this fact while performing tubular decompression at the L5-S1 level. CLINICAL RELEVANCE: This article provides information regarding technical challenges of doing surgery at L5-S1 level as compared to L4-L5 level. LEVEL OF EVIDENCE: 3.

Decade-Wise Computed Tomography-Based Morphometric Measurements of a Single Lumbar Spinal Motion Segment L4-5.

BACKGROUND: A spinal motion segment comprises facet joints and intervertebral disc. A complex interplay of biomechanical factors occurs between them with degeneration giving rise to numerous pathological conditions. We conducted a study to find a correlation between facet joint orientation and intervertebral discs with age. METHODS: A cross-sectional study of 203 consecutive subjects undergoing a computed tomography scan of abdomen and pelvis were included. Subjects were divided into 5 groups based on age (group I: 18-30 years; group II: 31-40 years; group III: 41-50 years; group IV: 51-60 years; group V: 61-70 years). Using 3-dimensional reconstruction images, orientation of lumbar facet joints at the L4-5 level was measured. Similarly, adjacent disc heights at L3-4 and L4-5 were measured and their ratio was documented. RESULTS: The study included 106 males and 97 females. A positive correlation was noted between age and sagittal facet orientation until age 60 years. However, after age 60 years, a negative correlation with age was seen, which was statistically significant. Similarly, the disc height ratios show a progressive decline in their values with age. However, this decline was statistically significant only after age 60 years. CONCLUSION: The gradual change of facet joint orientation from sagittal to coronal as the age crosses from 30 to 60, to beyond 60, with a simultaneous and parallel diminishing in the disc height probably is one of the attributes of the phenomenon of autostabilization of a motion segment.

Outcomes of Discectomy in Young Adults With Large Central Lumbar Disc Herniations Presenting With Predominant Leg Pain.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Discectomy alone or discectomy with fusion have been 2 polarized options in the management of large lumbar disc herniations presenting with leg-dominant pain in young patients. The objective of the study was to evaluate the outcomes of discectomy in young patients with large central lumbar disc herniation (CLDH) presenting with predominant leg pain. MATERIAL AND METHODS: Young patients (<45 years) presenting with predominant leg pain and MRI confirmed diagnosis of CLDH between April 2007-January 2017 were included in the study. All patients underwent tubular microdiscectomy. Outcomes of surgery were evaluated using visual analogue score (VAS) for leg and back pain, Oswestry Disability Index (ODI), and Macnab's criteria. RESULTS: Ninety patients fulfilled the inclusion criteria. The mean age of patients was 34.9 years (range 19-45 years). Mean follow-up was 5.09 years (range 2-10 years). The incidence of CLDH in young adults was 30% and incidence among all "operated" lumbar disc herniations was 15.9%. The mean VAS for leg pain improved from 7.48 ± 0.9 to 2.22 ± 0.84 (P < .05) and the mean ODI changed from 60.53 ± 7.84 to 18.33 ± 6.20 (P < .05). Fifty-nine patients (65.6%) reported excellent, 25 patients (27.8%) reported good, 3 patients each (3.3%) as fair and poor outcomes respectively. CONCLUSION: Discectomy alone for CLDH with predominant leg pain is associated with high success rate and low need for a secondary surgical procedure. Patient selection in terms of leg-dominant pain may be the main attribute for lower incidence of recurrence, postoperative back-pain, and instability needing a secondary procedure. Minimally invasive discectomy may provide an added advantage of preserving normal spinal anatomy, thus minimizing the need for primary spinal fusion in these patients.

Use of Zipper Ratcheting Straps as a Bailout for Postoperative Cerebrospinal Fluid Leaks: Our Experience.

STUDY DESIGN: Technical note. OBJECTIVES: Management of postoperative cerebrospinal fluid (CSF) leaks is a challenge. Reexploration increases the morbidity risks. The main objective was to evaluate the outcomes of noninvasive zipper-like system (Zip surgical skin closure system, ZipLine Medical, Inc, Campbell, CA, USA) as a bailout technique for postoperative CSF leaks. METHODS: Retrospective case series. Consecutive patients with postoperative CSF leaks that occurred secondary to spinal surgeries performed between January 2017 and September 2018 were part of the study. All these patients were managed conservatively by reinforcement with zipper ratcheting straps over the sutured surgical wound. Successful clinical outcomes included cessation of CSF leaks and adequate wound healing in the postoperative period and at follow-up. RESULTS: Ten patients underwent the application of zipper ratcheting straps. The mean follow-up was 6 months (range 6 months to 1 year). In 7 cases, the dural tears were recognized postoperatively and in 3 cases, the tears were noted intraoperatively and repaired and reinforced with fibrin sealants. None of the patients developed wound soakage or subsequent CSF leak from the wound after the application of zipper ratcheting straps. CONCLUSIONS: Zipper ratcheting straps as augmentation to sewing of the wound seem to be a good alternative and bailout in treating patients with postoperative CSF leaks. The ease of its application, the ability in minimizing the complications associated with CSF leaks, and negating the need of surgical reexploration makes it a worthy option.

The Practice of Continuation of Anti-platelet Therapy During the Perioperative Period in Lumbar Minimally Invasive Spine Surgery (MISS): How Different Is the Morbidity in This Scenario?

STUDY DESIGN: Cohort. OBJECTIVE: To evaluate perioperative morbidity in patients undergoing minimally invasive spine surgery of the lumbar spine while continuing the antiplatelet drug (APD) perioperatively as compared with those not continuing these drugs and those not on these drugs. SUMMARY OF BACKGROUND DATA: While discontinuation of antiplatelet drugs carries with it the risk of thrombosis of the cardiac stents, myocardial infarction, peripheral vascular occlusion, cerebro-vascular events and other thrombotic complications, continuation of these drugs has the risk of intra spinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression. METHODS: This institutional review board approved study included 1587 patients from 2011 to 2018. Perioperative parameters were analyzed for 216 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy, 240 patients who continued to take APD daily through the perioperative period and 1131 patients who were never exposed to APD therapy. The operative time, intraoperative estimated blood loss, length of hospital stay, incidence of clinically evident hematoma, and transfusion of blood products were also recorded and compared in three cohorts. RESULTS: The patients who continued taking APD in the perioperative period had a longer length of hospital stay on average (2.5 ±â€Š0.67 vs. 1.59 ±â€Š0.76 and 1.67 ±â€Š0.83, P < 0.05), whereas there was no significant difference in the operative time, estimated blood loss, the amount of blood products transfused, and overall intra and postoperative complication rate. There were no instances of postoperative wound soakage or neurological deficit suggestive of possible spinal epidural hematomas in either of the study groups. CONCLUSION: The current study has observed no appreciable increase in perioperative morbidities including bleeding related complication rates in patients undergoing lumbar minimally invasive spine surgery while continuing to take APD compared with patients who either discontinued APD prior to surgery or those not taking APD. LEVEL OF EVIDENCE: 4.

Degenerative Spondylolisthesis: When to Fuse and When Not to? A New Scoring System.

STUDY DESIGN: A prospective cohort. OBJECTIVE: The objective of this study was to develop a scoring system for lumbar degenerative spondylolisthesis (LDS) that would guide decision-making. BACKGROUND: The management protocol for LDS has been under debate, with no guidelines. Most studies oversimplify LDS as a homogenous entity. MATERIALS AND METHODS: A retrospective analysis of 131 patients who underwent surgery for LDS between July 2007 and October 2011 with a minimum follow-up of 3 years was carried out on the basis of clinical, radiologic, and technical factors. A scoring system was conceptualized. Clinical: back pain score-2, age younger than 70 years-1, high-demand activity-1. Radiologic: segmental kyphosis-1.5, segmental dynamic translation-1, disk height >50% of adjacent level-1, facet effusion-1, sagittal facet-orientation-1. Technical: feasibility to decompress without causing instability-1.5. Its reliability was ascertained by a univariate analysis. The benchmark was set at 5.5 according to the Youden Index. This was followed by a prospective study for reliability analysis between November 2011 and January 2017 of 52 patients who underwent stand-alone decompression in LDS with a minimum follow-up of 24 months. Outcomes were evaluated using the Oswestry Disability Index and the Visual Analog Scale. Interobserver variability was determined. None of the patients in the retrospective or prospective group had undergone any lumbar surgery previously. RESULTS: The mean Oswestry Disability Index and Visual Analog Scale of both the groups in the retrospective and the stand-alone decompression groups in prospective studies showed significant improvement. The interobserver reliability was high, with a κ value of 0.847. CONCLUSIONS: The proposed scoring system helps view LDS as a heterogenous condition and assists in tailoring treatment for individual patients. For a select subgroup of patients with LDS, minimally invasive decompression (unilateral laminotomy and bilateral decompression using a minimally invasive surgery tubular retractor system) without fusion is adequate. LEVEL OF EVIDENCE: Level III.

Are There Differences Between Patients with Extreme Stenosis and Non-extreme Stenosis in Terms of Pain, Function or Complications After Spinal Decompression Using a Tubular Retractor System?

BACKGROUND: Micro-tubular decompression in extreme lumbar spinal stenosis is challenging because it is technically difficult to achieve adequate decompression. Whether the results of micro-tubular decompression related to pain, function, and complications in lumbar spinal stenosis of the extreme and non-extreme varieties are different has not yet been conclusively established. QUESTIONS/PURPOSES: Are there differences between patients with extreme stenosis and non-extreme stenosis in terms of (1) VAS back or leg pain, (2) Oswestry Disability Index (ODI), or (3) complications when they were treated with spinal decompression using a tubular retractor system? METHODS: Between January 2007 and January 2017, one surgeon performed 325 single-level lumbar micro-tubular decompressions without fusion. Of those, 43% (140 of 325) had extreme stenosis (defined as the absence of cerebrospinal fluid signal and a grey homogeneous dural sac with unrecognizable rootlets and posterior epidural fat in T2 weighted axial MRI image) and the rest had non-extreme stenosis. During this time, we used tubular retractors for these procedures in patients with simple lumbar spinal stenosis who had persistent symptoms despite conservative treatment for neurogenic claudication. No alternate form of decompression was performed in the study period. Patients with complex lumbar spinal stenosis associated with a deformity or instability who were treated with instrumented fusion were excluded. A total of 14% (20 of 140) patients in the extreme stenosis group and 15% (28 of 185) patients in the non-extreme stenosis group were lost to follow-up before 2 years; the remaining 120 patients with extreme stenosis and 157 patients with non-extreme stenosis were analyzed at a mean follow-up of 33 ± 5 months in this retrospective, comparative study. The groups were not different at baseline in terms of preoperative VAS score for back pain, age, gender, BMI or the percentage who had diabetes or who smoked. However, patients with extreme stenosis had higher preoperative ODI scores and higher preoperative VAS score for leg pain compared with the non-extreme group. There was a higher proportion of men in the non-extreme stenosis group (56% [104 of 185] versus 50% [71 of 140]; p = 0.324). Study endpoints were VAS score for leg and back pain, ODI, and complications, all of which were ascertained by chart review. With the numbers available, we could detect with 80% power at p < 0.05 a difference of 0.93 cm of 10 cm on a 10-cm VAS scale for VAS leg pain; a difference of 1.00 cm of 10 cm on a 10-cm VAS scale for VAS back pain and a difference of 2.12 cm of 100 cm on a 100-cm ODI scale. RESULTS: In terms of pain, both groups improved after surgery, but there was no between-group difference in terms of the VAS scores at the most recent follow-up. VAS back pain improved from a mean of 3 ± 1 to 2 ± 1 in the extreme stenosis group and from 3 ± 1 to 1 ± 1 in the non-extreme stenosis group (p = 0.904); VAS leg pain improved from 7 ± 1 to 1 ± 1 versus 6 ± 1 to 1 ± 1, respectively (p = 0.537). ODI scores likewise improved in both groups, with no between-group difference in the ODI scores at latest follow-up (66 ± 7 to 19 ± 2 in the extreme stenosis group versus 59 ± 5 to 19 ± 2 in the non-extreme stenosis group (p = 0.237). Complications in the group with extreme stenosis occurred in six patients (incidental dural tears in two patients, urinary retention in three patients, and Syndrome of Inappropriate Anti Diuretic Hormone secretion (SIADH) in one patient); complications in the non-extreme stenosis occurred in two patients (incidental dural tears in two patients). CONCLUSIONS: The results in terms of improvement in VAS for leg and back pain and ODI scores were not different between patients with extreme and non-extreme stenosis. Micro-tubular decompression can be thus considered an alternative for patients with extreme stenosis. Future studies, ideally multicentre, comparative trials, are needed to confirm our preliminary results. LEVEL OF EVIDENCE LEVEL: III, therapeutic study.

Feasibility and Outcomes of Tubular Decompression in Extreme Stenosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To report the feasibility, nuances, technical tips as well as outcomes of managing single-level grade D (extreme stenosis) and to compare the outcomes with nonextreme stenosis using the tubular retractor system. SUMMARY OF BACKGROUND DATA: Minimally invasive decompression in extreme stenosis is a challenge due to technical difficulty, feasibility of adequate decompression, and a steep learning curve. METHODS: Consecutive patients from January 2007 to January 2017 presenting with neurogenic claudication secondary to single-level spinal stenosis operated using tubular retractors were included in the study. The patients were divided into two groups; extreme-stenosis and nonextreme stenosis. The outcomes of surgery were evaluated and compared using visual analogue score (VAS) for leg and back pain, Oswestry disability index (ODI), and MacNab's criteria. RESULTS: A total of 325 patients (out of 446 patients after excluding the multilevel cases) fulfilled the inclusion criteria. One hundred forty patients were cases of extreme stenosis and 185 were nonextreme stenosis. The mean VAS for back and leg pain for extreme stenosis improved from 3.23 ±â€Š1.30 to 2.15 ±â€Š0.91 and 7.33 ±â€Š0.78 to 1.66 ±â€Š1.03 respectively as compared with nonextreme stenosis where the mean VAS for back and leg pain improved from 3.01 ±â€Š1.15 to 1.86 ±â€Š1.10 and 6.57 ±â€Š1.00 to 1.54 ±â€Š1.12 respectively. The mean ODI changed from 66.47 ±â€Š7.53 to 19.95 ±â€Š2.90 in extreme stenosis as compared with nonextreme stenosis where mean ODI changed from 59.05 ±â€Š5.08 to 19.88 ±â€Š2.67. As per MacNab's criteria 102 (of 120 patients) and 139 (of 157 patients) reported excellent and good outcomes in extreme and nonextreme stenosis respectively. CONCLUSION: Tubular decompression is feasible in patients with extreme-stenosis with no difference in the outcomes as well as complication rates when compared with a cohort of nonextreme stenosis. LEVEL OF EVIDENCE: 3.

Outcomes of Coccygectomy Using the "Z" Plasty Technique of Wound Closure.

STUDY DESIGN: Technical note. OBJECTIVES: Coccygectomy for chronic coccydynia has a high rate of successful clinical outcome. However, the procedure is associated with increased incidence of wound dehiscence and surgical site infection. The main objective was to evaluate the clinical outcomes of coccygectomy using the Z plasty technique of wound closure. METHODS: Patients with chronic coccydynia refractory to conservative treatment underwent coccygectomy followed by Z plasty technique of wound closure between January 2013 and February 2018. Primary outcome measure was evaluation of the wound healing in the postoperative period and at follow-up; secondary outcome measure included visual analogue scale (VAS) score for coccygeal pain. RESULTS: Ten patients (male:female 6:4) fulfilled the inclusion criteria. The mean age of patients was 40.78 years (range 19-55 years). The mean follow-up was 1.75 years (range 6 months to 5 years). All wounds healed well with no incidence of wound dehiscence or surgical site infections. The mean VAS improved from 7.33 ± 0.5 to 2.11 ± 1.2 (P < .05). Nine patients reported excellent outcomes and 1 patient reported poor outcome with regards to relief from coccydynia. CONCLUSION: Z plasty technique of wound closure is recommended as procedure of choice to avoid wound healing problems and surgical site infections associated with coccygectomy. Coccygectomy remains a successful treatment modality for chronic coccydynia.

Is Long-Segment Fixation a Rule in Fractures Associated With Ankylosing Spondylitis?

STUDY DESIGN: Technical report. OBJECTIVE: We describe the outcomes of percutaneous vertebroplasty in 3-columnar thoraco-lumbar fracture secondary to hyper-extension injury in 3 patients with ankylosing spondylitis (AS). Thoraco-lumbar hyperextension injuries in AS are generally unstable as they involve all 3 spinal columns and traditionally require long-segment posterior instrumented stabilization. METHODS: Three cases of AS with severe medical comorbidities underwent percutaneous vertebroplasty for hyper-extension injury involving all 3 columns. Visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were documented preoperatively, postoperatively, and at the last follow-up. RESULTS: Excellent improvements in VAS and ODI scores were achieved. The patients have no complaints and are independent and mobile at 2 years follow-up. CONCLUSION: Vertebroplasty is an excellent option in such medically unfit patients with similar diagnosis and should be performed as early as possible before profound instability or neurological insult sets in, which would necessitate bigger and morbid surgeries.

Denosumab: A potential new treatment option for recurrent Aneurysmal Bone Cyst of the spine.

ABCs are expansile osteolytic lesions typically containing blood-filled spaces separated by fibrous septae. Standard treatment includes surgical resection or curettage and packing; however, for some spinal lesions, the standard approach is not optimal. One therapeutic strategy is to treat spinal ABC with an agent that targets a pathway that is dysregulated in a disease with similar pathophysiology. Denosumab, a human monoclonal antibody to RANKL is effective in the treatment of GCT's. Spinal ABCs are a therapeutic challenge and local recurrence is a concern. We report a case of aggressive recurrent ABC of dorsal spine in a 14-year old female with progressive neurologic deficit who underwent surgical excision and decompression with a recurrence in a short period for which a decompression and fixation was done. She had a recurrence after an asymptomatic period of 6 months and neurologic worsening. Having ruled out use of embolization and radiotherapy, a remission was achieved by treatment with Denosumab using the regimen for GCTs for a duration of 6 months. Follow-up MRI and CT scans at 24 months following inception of Denosumab depicted complete resolution and no recurrence. We conclude that Denosumab can result in symptomatic and radiological improvement in the recurrent locally aggressive ABC and may be useful in selected cases. Long-term results are mandatory to confirm the efficacy of Denosumab and to evaluate local recurrence after stopping Denosumab.

The Use of Tubular Retractors for Translaminar Discectomy for Cranially and Caudally Extruded Discs.

BACKGROUND: The conventional interlaminar approach is adequate for access to most disc herniations in lumbar spine surgery. The access to cranially and caudally migrated disc fragments, by conventional interlaminar fenestration, requires an extension of the fenestration with the potential destruction of the facet joint complex and consequent postsurgical instability. To describe the technique and results of the translaminar technique of targeted discectomy using tubular retractors for the surgical treatment of cranially and caudally extruded discs. MATERIALS AND METHODS: The study period extended from January 2008 to December 2014. All patients with lumbar herniated discs who failed conservative management were selected for surgery and underwent routine erect radiographs and magnetic resonance imaging (MRI) of the lumbar spine. The patients with cranially or caudally migrated discs were included in this study. The technique involves approaching migrated disc through an oval window (sculpted through an 18 mm tubular retractor using a burr) in the lamina precisely over the location of the migrated disc as predicted by the preoperative MRI (inferior lamina for inferior migration and superior lamina for superior migration). The perioperative parameters studied were operative time, blood loss, complications, Oswestry Disability Index (ODI), and visual analog scale (VAS) for leg pain before surgery and at last followup. In the study, 4 patients underwent a postoperative computed tomography-scan with a three-dimensional reconstruction to visualize the oval window and to rule out any pars fracture. All technical difficulties and complications were analyzed. RESULTS: 17 patients in the age group of 41-58 years underwent the translaminar technique of targeted discectomy. The migration of disc was cranial in 12 patients and caudal in 5 patients. Fourteen of the affected discs were at the L4-L5 level and three were at the L5-S1 level. The mean VAS (leg pain) scale improved from 8 to 1 and the mean ODI changed from 59.8 to 23.6. There were no intraoperative or postoperative complications encountered in this study. Furthermore, no patient in the present study required a conventional laminotomy or medial facetectomy. There was no evidence of iatrogenic pars injury or instability at the last followup. There were no recurrences till the last followup. CONCLUSIONS: The targeted translaminar approach preserves structures important for segmental spinal stability thus causing minimal anatomical disruption. This approach allows access to the extruded disc fragment and intervertebral disc space comparable to classical approaches.