Total en bloc spondylectomy of locally aggressive vertebral hemangioma in a pediatric patient.

PURPOSE: Vertebral hemangiomas are benign, highly vascular spinal lesions that are extremely rare in the pediatric population. We report a pediatric case of symptomatic vertebral hemangioma treated with total en bloc spondylectomy. Our objective is to demonstrate that en bloc spondylectomy is feasible and addresses some pitfalls of traditional total tumor resection. METHODS: Our patient presented with bilateral lower limb and perineal paresthesia, paraparesis, as well as urinary retention. Locally aggressive vertebral hemangioma was the presumed diagnosis following imaging. The patient received partial angioembolization to reduce the vascularization of the lesion then underwent total en bloc spondylectomy of T8 under intraoperative neuromonitoring. The intervention was well tolerated. RESULTS: Postoperative course was marked by clinical improvement and only transient, treatable complications. On 1-year follow-up, the patient is neurologically intact, and imaging reveals adequate position of hardware, good alignment, and no tumor recurrence. CONCLUSION: Total en bloc spondylectomy is a feasible procedure in pediatric patients. It reduces local recurrence through reduction of tumor cell contamination and residual tumor and thus may avoid postoperative radiotherapy in select cases. It may also enhance functional neurological recovery by allowing circumferential decompression and increased spinal cord blood flow.

Minimally invasive costotransversectomy for the resection of large thoracic dumbbell tumors.

BACKGROUND: Due to their important size and complex localization, the management of thoracic dumbbell tumors is challenging, frequently requiring the need for an anterior approach. Our study aims to first report the feasibility and safety of a single-stage posterior minimally invasive procedure in achieving complete resection of voluminous thoracic dumbbell tumors. METHODS: We retrospectively reviewed the medical records of five consecutive patients, who underwent the minimally invasive resection of a type III thoracic dumbbell tumor in our institution between March 2007 and March 2012. There were two men and three women, with a mean age at diagnosis of 57 years (range 41-68 years). After the placement of a non-expandable tubular retractor under fluoroscopic control, a costotransversectomy was achieved. By moving the retractor in all directions, the tumor was largely exposed and resected with the cavitron ultrasonic surgical aspirator. Clinical and radiological monitoring was performed before discharge, at 6 months, 1 year and 2 years. RESULTS: No major intraoperative complication was reported. Gross total resection was achieved in four patients. The mean operative time was 219 mins (range 75-540 mins) and the mean estimated blood loss was 230 ml (range 50-500 ml). No postoperative complication was reported. The mean length of hospital stay was 3.6 days (range 2-6 days) and all patients were discharged home. Histological analysis confirmed the diagnosis of grade 1 schwannoma in four patients and revealed a hemangiopericytoma in one patient. No tumor recurrence was noted with a mean follow up period of 46 months (range 32-54 months). CONCLUSION: Thoracic dumbbell tumors can be safely and completely resected using a single-stage minimally invasive procedure. The costotransversectomy can be performed through a non-expandable retractor allowing sufficient access to all parts of the tumor.

Cervical spondylosis: a rare and curable cause of vertebrobasilar insufficiency.

BACKGROUND: Spondylotic vertebral artery (VA) compression is a rare cause of vertebrobasilar insufficiency and stroke. CASE DESCRIPTION: A 53-year-old man experienced multiple brief vertebrobasilar transient ischemic attacks (TIAs) and strokes, not apparently triggered by neck movements. Brain magnetic resonance imaging (MRI) documented consecutive infarcts, first in the left then right medial posterior inferior cerebellar artery (PICA) territories. Angiography showed two extracranial right vertebral artery (VA) stenoses, left VA hypoplasia, absence of left PICA and a dominant right PICA. Computed tomography angiography revealed right VA compression by osteophytes at C5-C6 and C6-C7 levels. No further vertebrobasilar insufficiency symptoms occurred in the 65 months following VA surgical decompression. Our literature review found 49 published surgical cases with vertebrobasilar symptoms caused by cervical spondylosis. Forty cases had one or more brief TIAs frequently triggered by neck movements. Three cases presented with stroke without prior TIA, with symptoms suggesting a top of the basilar artery embolic infarcts (one combined with a PICA infarct). Six cases had both TIAs and minor stroke. VA compression by uncovertebral osteophytes at the C5-C6 level was common. Dynamic angiography done in 38 cases systematically revealed worsening of VA stenosis or complete occlusion with either neck extension or rotation (ipsilateral when specified). Contralateral VA incompetence was found in 14 patients. CONCLUSION: Spondylotic VA stenosis can cause hemodynamic TIAs and watershed strokes, especially when contralateral VA insufficiency is combined to specific neck movements. Low-amplitude neck movement may suffice in severe cases. Embolic vertebrobasilar events are less frequent. VA decompression from spondylosis may prevent recurrent ischemic episodes.

A novel minimally invasive technique for the treatment of high-grade isthmic spondylolisthesis using a posterior transsacral rod.

STUDY DESIGN: Case report of 3 patients with high-grade isthmic spondylolisthesis treated using a novel minimally invasive technique using a posterior transsacral rod. OBJECTIVE: To assess the efficacy, safety, and advantages of this approach in the treatment of high-grade L5-S1 spondylolisthesis. SUMMARY OF BACKGROUND DATA: Surgical treatment of high-grade isthmic spondylolisthesis at the L5-S1 level is technically demanding. The most commonly used procedure is posterior spinal fusion. In this report, we present a new minimally invasive technique for the treatment high-grade isthmic spondylolisthesis in 3 patients with sagittally balanced spines. MATERIALS AND METHODS: Three patients with high-grade L5-S1 spondylolisthesis underwent L4-S1 fusion with percutaneous pedicle screw fixation supplemented with a transsacral rod implanted through a tubular retractor. We report technical details, clinical, and radiologic results at follow-up. RESULTS: All 3 patients suffered from grade 3 or 4 L5-S1 spondylolisthesis. All patients had neutral sagittal balance on preoperative imaging. There were no postoperative complications and all 3 patients were discharged within 48 hours. At final follow-up (range, 13-18 mo), all patients were pain free off all narcotic pain medication and fusion was observed in all 3 patients. CONCLUSIONS: We have shown the technical feasibility of anterior and posterior fusion for severe L5-S1 spondylolisthesis using a minimally invasive percutaneous technique through a transsacral approach. The main advantage of a posterior transsacral axial rod fixation is that it creates a structurally sound anterior column support, thus eliminating the problems related to bone grafts and eliminating the complications associated with an anterior approach. Our preliminary results suggest that this technique is feasible and seems to be associated with favorable outcome, although larger studies are warranted to verify these findings.

Surgical management of tumors of the cervical spine and craniovertebral junction involving the vertebral artery: A narrative review.

BACKGROUND: The vertebral artery (VA) is in close proximity to bony structures, nerves and nerve sheaths of the cervical spine and craniovertebral junction (CVJ). These structures can be sources of tumors that are responsible for displacement, encasement and sometimes invasion of the VA. Removing these tumors while minimizing the risk of vascular injury requires thorough knowledge of the vascular anatomy, risk factors of vascular injury, the relationships of each tumor type with the VA, and the different surgical approaches and techniques that result in the best outcomes in terms of vascular control, tumoral exposure and resection. OBJECTIVE: To present an overview of preoperative and anatomical considerations, differential diagnoses and various approaches to consider in cases of tumors in close relationship with the VA. METHOD: A review of recent literature was conducted to examine the anatomy of the VA, the tumors most frequently affecting it, surgical approaches, and the necessary pre-operative preparations for ensuring safe and maximal tumor resection. This review aims to underscore the principles of treatment. CONCLUSION: Tumors located at the CVJ and the cervical spine intimately involved with the VA, pose a surgical challenge and increase the risk of incomplete removal of the lesion. Detailed knowledge of the patient-specific anatomy and a targeted pre-operative work-up enable optimal planning of surgical approach and management of the VA, thereby reducing surgical risks and improving extent of resection.

Vertebral artery stenosis from osteophyte: A systematic review and case series.

BACKGROUND: Rotational vertebral artery syndrome, also referred to as Bow Hunter's syndrome (BHS), manifests when the vertebral artery (VA) is compressed following head rotation. This compression is often caused by an osteophyte and may lead to symptoms of a posterior stroke. This systematic review aims to shed light on the current management strategies for BHS resulting from osteophytes. Additionally, we present two illustrative cases where the VA compression by an osteophyte was effectively resolved by complete resection of the problematic bone spur. METHODS: A literature search was conducted across Embase, PubMed and Medline in September 2023. Keywords related to vertebral artery [MESH], vertebrobasilar insufficiency [MESH] and osteophyte [MESH] were the focus of this review. Risk of bias in retained studies was assessed using the Joanna Briggs Institute Critical Appraisal tools for Qualitative Research. A narrative synthesis of our findings is presented. RESULTS: A total of 30 studies were included in this review. Vertigo was the most reported symptom by patients (n = 16). On imaging, the VA was often compressed at C4-5 (n = 10) and C5-6 (n = 10) with no evident side predominance observed. Anterior cervical discectomy and fusion (ACDF, n = 13) followed by anterior decompression without fusion (n = 8) were the most performed surgical procedures to manage BHS. CONCLUSION: Surgical decompression of the VA is a safe and effective intervention for patients experiencing symptomatic osteophytic compression during head rotation. This procedure restores normal vascular function and reduces the risk of ischemic events. This review highlights the importance of timely diagnosis and intervention in such cases.

Specific plasma biomarker signatures associated with patients undergoing surgery for back pain.

BACKGROUND CONTEXT: Intervertebral disc degeneration (IDD) affects numerous people worldwide. The role of inflammation is increasingly recognized but remains incompletely resolved. Peripheral molecules could access neovascularized degenerated discs and contribute to the ongoing pathology. PURPOSE: To assess a large array of plasma molecules in patients with IDD to identify biomarkers associated with specific spinal pathologies and prognostic biomarkers for the surgery outcome. DESIGN: Prospective observational study combining clinical data and plasma measures. PATIENT SAMPLE: Plasma samples were collected just before surgery. Extensive clinical data (age, sex, smoking status, Modic score, glomerular filtration rate, etc.) were extracted from clinical files from 83 patients with IDD undergoing spine surgery. OUTCOME MEASURES: Recovery 2 months postsurgery as assessed by the treating neurosurgeon. METHODS: Over 40 biological molecules were measured in patients' plasma using multiplex assays. Statistical analyses were performed to identify associations between biological and clinical characteristics (age, sex, Body Mass Index (BMI), smoking status, herniated disc, radiculopathy, myelopathy, stenosis, MODIC score, etc.) and plasma levels of biological molecules. RESULTS: Plasma levels of Neurofilament Light chain (NfL) were significantly elevated in patients with myelopathy and spinal stenosis compared to herniated disc. Plasma levels of C- reactive protein (CRP), Neurofilament Light chain (NfL), and Serum Amyloid A (SAA) were negatively associated, while CCL22 levels were positively associated with an efficient recovery 2 months postsurgery. CONCLUSIONS: Our results show that CRP and CCL22 plasma levels combined with the age of the IDD patient can predict the 2-month postsurgery recovery (Area Under the Curve [AUC]=0.883). Moreover, NfL could become a valuable monitoring tool for patients with spinal cord injuries.

Can Pelvic Incidence Change After Lumbo-Pelvic Fixation for Adult Spine Deformity, and Would the Change be Affected by the Type of Pelvic Fixation?

STUDY DESIGN: Retrospective review. OBJECTIVE: To assess the change in pelvic incidence (PI) after lumbo-pelvic fixation and the differential impact of the type of pelvic fixation: S2-alar-iliac screws (S2AI) versus Iliac screws (IS) on postoperative PI. SUMMARY OF BACKGROUND DATA: Recent studies suggest that changes occur to the previously assumed fixed PI after spino-pelvic fixation. METHODS: Adult spine deformity (ASD) patients who underwent spino-pelvic fixation with≥4 levels of fusion were included. Preoperative and postoperative PI, lumbar lordosis (LL), thoracic kyphosis, pelvic tilt, sacral slope, PI-LL mismatch, and the Sagittal Vertical Axis (SVA) were analyzed on EOS imaging. A significant PI change was established at≥6°. Patients were categorized based on the type of pelvic fixation (S2AI vs. IS). RESULTS: One-hundred-forty-nine patients were included. Of these, 77(52%) had a>6° change in their PI postoperatively. In patients with high preoperative PI (>60°), 62% had a significant PI change compared with 33% of patients with normal PI (40°-60°) and 53% in patients with low PI (<40°; P =0.01). PI was likely to decrease in patients with high baseline PI (>60°) and to increase in patients with low baseline PI (<40°). Patients with a significant PI change had a higher PI-LL. Patients in the S2AI group (n=99) and those in the IS group (n=50) were comparable at baseline. In the S2AI group, 50 (51%) patients had>6° change in their PI compared with 27(54%) patients in the IS group( P =0.65). In both groups, patients with high preoperative PI were more prone to significant postoperative changes ( P =0.02 in IS, P =0.01 in S2AI). CONCLUSION: PI changed significantly in 50% of patients postoperatively, especially in those with high/low preoperative PI and those with severe baseline sagittal imbalance. This occurs similarly in patients with S2AI and those with IS screws. Surgeons should keep in mind these anticipated changes while planning ideal LL, as this impacts postoperative PI-LL mismatch. LEVEL OF EVIDENCE: 4.

Using artificial intelligence to quantify dynamic retraction of brain tissue and the manipulation of instruments in neurosurgery.

PURPOSE: There is no objective way to measure the amount of manipulation and retraction of neural tissue by the surgeon. Our goal is to develop metrics quantifying dynamic retraction and manipulation by instruments during neurosurgery. METHODS: We trained a convolutional neural network (CNN) to analyze microscopic footage of neurosurgical procedures and thereby generate metrics evaluating the surgeon's dynamic retraction of brain tissue and, using an object tracking process, evaluate the surgeon's manipulation of the instruments themselves. U-Net image segmentation is used to output bounding polygons around cerebral parenchyma of interest, as well as the vascular structures and cranial nerves. A channel and spatial reliability tracker framework is used in conjunction with our CNN to track desired surgical instruments. RESULTS: Our network achieved a state-of-the-art intersection over union ([Formula: see text]) for biological tissue segmentation. Multivariate statistical analysis was used to evaluate dynamic retraction, tissue handling, and instrument manipulation. CONCLUSION: Our model enables to evaluate dynamic retraction of soft tissue and manipulation of instruments during a surgical procedure, while accounting for movement of the operative microscope. This model can potentially provide the surgeon with objective feedback about the movement of instruments and its effect on brain tissue.

How Does Spino-Pelvic Fixation Affect Post-Operative Compensatory Mechanisms in Adult Spinal Deformity?

STUDY DESIGN: Retrospective single-center multi-surgeon cohort study. OBJECTIVES: Compare the post-operative changes in the compensatory mechanisms of the sagittal balance according to the type of pelvic fixation: S2-Alar-iliac screws (S2AI) vs iliac screws (IS) in patients with Adult spine deformity (ASD). METHODS: ASD patients who underwent spino-pelvic fixation and remained with a PI-LL >10° mismatch post-operatively were included. Pre-operative and 1-year-follow-up PI, Lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), thoracic kyphosis (TK), femur obliquity angle (FOA), knee flexion angle (KFA) and ankle flexion angle (AFA) were analyzed on EOS imaging. Patients were categorized based on their pelvic fixation type (S2AI vs IS), and the pre-operative to 1-year-post-operative changes (ΔX°) in the compensatory mechanisms were compared between groups. RESULTS: Patients with S2AI (n = 53) and those with IS (n = 26) screws were comparable at baseline. ΔSS averaged 9.87° in the S2AI compared to 13.2° in the IS (P = .001), whereas the ΔKFA reached 6.01° in the S2AI as opposed to 3.06° in the IS (P = .02). The ΔPT was comparable between both groups (6.35°[S2AI group] vs 5.21°[ISgroup], P = .42). ΔTK, ΔLL, ΔFOA and ΔAFA were comparable between both groups. CONCLUSION: The type of pelvic fixation impacts significantly the post-operative compensatory mechanisms in patients with ASD. Patients with S2AI screws are more likely to compensate their remaining post-operative PI-LL mismatch through their knees and less likely through their pelvis compared to patients with IS, despite similar changes in PT. This could be explained by an increased SI joint laxity in ASD patient and the lower resistance of the iliac connectors to the junctional mechanical stresses, allowing for sacro-iliac joint motion in patients with IS.

Pneumorrhachis and pneumocephalus resulting from pneumothorax: illustrative case.

BACKGROUND: Pneumorrhachis and pneumocephalus are rare conditions in which air is found within the spinal canal and brain, respectively. It is mostly asymptomatic and can be located in the intradural or extradural space. Intradural pneumorrhachis should prompt clinicians to search and treat any underlying injury of the skull, chest, or spinal column. OBSERVATIONS: A 68-year-old man presented with a history of cardiopulmonary arrest together with pneumorrhachis and pneumocephalus following a recurrent pneumothorax. The patient reported acute headaches with no other neurological symptoms. He was managed conservatively with bed rest for 48 hours following thoracoscopic talcage of his pneumothorax. Follow-up imaging showed regression of the pneumorrhachis, and the patient reported no other neurological symptoms. LESSONS: Pneumorrhachis is an incidental radiological finding that self-resolves with conservative management. However, it can be a complication resulting from a serious injury. Therefore, close monitoring of neurological symptoms and complete investigations should be performed in patients with pneumorrhachis.

Unusual presentation of a common neurosurgical shunt procedure in an adult patient.

Ventriculoperitoneal shunt surgery is one of the treatments of hydrocephalus. It involves placing a shunt from the cerebral ventricles to the peritoneum serving as a drainage point. Infection and catheter blockage are some of the possible complications resulting from this procedure. In some cases, other incidents such as peritoneal shunt migration have also been described. Here, we present the case of a 73-year-old male patient treated with ventriculoperitoneal shunt for a normal pressure hydrocephalus. After an initial blockage of the ventricular catheter, a revision surgery was performed with only mild improvement of his neurological symptoms. A repeat shunt series X-ray showed a migration of the distal catheter into the scrotum through an inguinal hernia. He was successfully treated with a laparoscopic repair of the inguinal hernia and repositioning of the distal catheter into the peritoneal cavity. Scrotal migration and hydrocele are unusual presentations and complications of ventriculoperitoneal shunts. Close follow-up of patients with a ventriculoperitoneal shunt should be performed if they experience worsening of their neurological symptoms. Shunt integrity should be assessed and any complications should be managed.

CT guided percutaneous vertebroplasty of C2 osteolytic lesion: a case report and technical note.

Vertebroplasty is a minimally invasive treatment option for osteolytic spinal lesions. It provides pain relief and stability with established good results. In this paper, we describe a new CT guided percutaneous vertebroplasty technique using a direct lateral approach between the carotid sheath and the vertebral artery, that can be safely performed under conscious sedation in an outpatient setting. We report the case of a patient presenting a lytic lesion of C2 treated using the CT guided percutaneous vertebroplasty under conscious sedation. Local anesthesia using approximately 10 mL of lidocaine 1% was delivered in the skin, soft tissues and to the periosteum of C2. With the patient in dorsal decubitus on the CT table, a bone biopsy needle was introduced laterally, through the parotid and between the carotid artery and vertebral artery. The entry point on C2 was right under the lateral mass of C1 and anterolaterally to the vertebral vascular foramen. The procedure was well tolerated by the patient. No neurological changes were noted per-operatively. No immediate or short-term complications were noted. Patient was observed on a stretcher for 2 hours with nursing supervision before being discharged home. Patient reported satisfactory pain control at 6-month follow-up. CT guided percutaneous vertebroplasty under conscious sedation can be safely performed in an outpatient setting.

Spontaneous spinal epidural hematoma related to amphetamine abuse: A case report.

BACKGROUND: Spontaneous spinal epidural hematoma (SSEH) is a rare condition that is typically associated with hypertension, the use of antithrombotic or sympathomimetic drugs. Here, we report a case of SSEH attributed to the use of amphetamines. CASE DESCRIPTION: A 27-year-old amphetamine user presented with the sudden onset of paraplegia (Frankel A) following amphetamine use. An MRI revealed C7-T2 spinal cord compression due to an epidural hematoma. Following a negative angiogram, the SSEH was removed, and the patient markedly recovered. Notably, by exclusion, the etiology for the SSEH was attributed to the use of amphetamines. CONCLUSION: Here, we demonstrate the case of a 27-year-old male who presented paraplegic due to an acute C7- T2 SSEH secondary to amphetamine abuse.

Minimally Invasive Approach for Complete Resection of a Cervical Intramedullary Tumor via a Dorsal Root Entry Zone Using Fixed Tubular Retractor.

We describe the surgical aspects of the resection of a large 2cm intramedullary ependymoma at the C6-7 level associated with an extensive syrinx using a unilateral minimally invasive approach through a fixed tubular retractor. A gross total resection was achieved. Total operative time was 5 hours. Estimated blood loss was less than 100 cc. Postoperative evolution was favorable, with the improvement of the patient's neurological status. There was no cerebrospinal fluid (CSF) fistula. Hospital stay was four days. All narcotics were stopped on day 1 after surgery. Post-operative MRI showed no residual tumor. At the six-month follow-up, there was continued improvement in his neurological status. Scoliosis films did not reveal any cervicothoracic kyphosis.

Surgical management of high-grade lumbar spondylolisthesis associated with Hajdu-Cheney syndrome: illustrative case.

BACKGROUND: Hajdu-Cheney syndrome (HCS) is a rare connective tissue disorder characterized by severe bone demineralization. In the spine, it is associated with the early onset of severe osteoporosis and can cause spondylolisthesis. Spinal instrumentation in the setting of severe osteoporosis is challenging because of poor resistance of vertebrae to biomechanical stress. OBSERVATIONS: A 59-year-old woman with known idiopathic HCS presented with a grade 4 L5-S1 spondylolisthesis and right L5 pedicle fracture associated with a left L5 pars fracture, causing a progressive L5 radiculopathy that was worse on the left side than the right side and bilateral foot drop. The authors performed decompressive lumbar surgery, which included a complete L5 laminectomy and resection of the left L5 pedicle. This was followed by multilevel lumbosacral instrumentation using cement-augmented fenestrated pedicle screws as well as transdiscal sacral screws and bilateral alar-iliac fixation. Postoperatively, the radicular pain resolved, and the left foot drop partially recovered. LESSONS: Stabilization of high-grade spondylolisthesis in the setting of bone demineralization disorders is challenging. The use of different instrumentation techniques is important because it increases biomechanical stability of the overall instrumentation construct.

Cervical Spine Reconstruction with Chest Tube Technique After Metastasis Resection: A Single-Center Experience.

BACKGROUND: The silastic tube technique, in which a chest tube is placed into the vertebral body defect and impregnated with polymethyl methacrylate, showed good results in patients with lumbar and thoracic neoplastic diseases. There has been only 1 study about the effectiveness and safety of this technique in patients with cervical metastases. We aimed to report our experience in using this technique to reconstruct the spine after corpectomy for cervical metastasis. METHODS: All patients with cervical spinal metastasis who underwent surgical treatment using a chest tube impregnated with polymethyl methacrylate in conjunction with anterior cervical plate stabilization were retrospectively recruited. Demographics, tumor histology, revised Tokuhashi score, preoperative and postoperative American Spinal Injury Association score, preoperative and postoperative ambulatory status, perioperative complications, and survival time were collected. RESULTS: This study included 16 patients. The most common primary tumor site was the lung (6 patients; 37.5%). The mean (SD) survival time was 408 (795) days (range, 1-2797 days), and the median survival time was 72 days (95% confidence interval 28-116 days). Four patients (25%) died within 30 postoperative days. There was no surgical site infection or instrument failure after the surgery. Five patients (31.2%) lived >180 days, and 3 patients (18.8%) lived >360 days. One patient (6.2%) was still alive at the end of the study. CONCLUSIONS: The silastic tube technique in conjunction with anterior cervical plate stabilization might be safe, effective, and cost-effective for patients with cervical spine metastasis.

Anterior Longitudinal Ligament Flap Technique: Description of Anterior Longitudinal Ligament Opening During Anterior Lumbar Spine Surgery and Review of Vascular Complications in 189 Patients.

BACKGROUND: One of the main concerns of anterior lumbar spine approaches are vascular complications. The aim of our study is to provide technical details about a flap technique using the anterior longitudinal ligament (ALL) when approaching the lumbar spine via an anterior corridor. This can help decrease complications by protecting the adjacent vascular structures. We also include a retrospective cohort review. METHODS: This is a retrospective bicentric study: 189 patients with a mean age of 44.2 years underwent anterior lumbar spine surgery using the ALL flap technique. Patients were diagnosed with degenerative pathologies. We treated 239 lumbar levels primarily at the L4-5 and L5-S1: 88 single-level anterior lumbar interbody fusions, 9 two-level ALIFs, 51 total disk replacements (TDR), and 41 hybrid constructs (i.e., ALIF L5S1 and TDR L4L5). Anterior approaches were performed by two senior spine surgeons. The ALL flap technique was utilized in all of these cases, by carefully dissecting the ALL, with the flap suspended using sutures. As such, this ALL flap provided a "safe corridor" to avoid any potential vascular laceration. RESULTS: The operative and early surgical complication rate was 3.2%. There was no arterial injury. There were only 2 minor venous lacerations (1.05%). No blood transfusion was required. Neither lacerations happened during disk space preparation. CONCLUSIONS: Here, we provide technical details about a simple and reproducible technique using the ALL as a flap, which may help spine surgeons minimize vascular injuries during ALIF or even TDR surgeries.

Single-Stage Posterior Approach for the En Bloc Resection and Spinal Reconstruction of T4 Pancoast Tumors Invading the Spine.

STUDY DESIGN: Retrospective cohort study. PURPOSE: This study aimed to evaluate the outcomes of patients who had T4 Pancoast tumors invading the spine and underwent en bloc resection and spinal stabilization through a single-stage posterior approach. OVERVIEW OF LITERATURE: Surgical resection for Pancoast tumors affecting the spine has been successfully performed in two stages involving spinal reconstruction and tumor resection. However, reports have rarely presented the results of en bloc resection combined with spinal stabilization for T4 Pancoast tumors invading the spine through a single-stage posterior approach. METHODS: Patients who had T4N0M0 Pancoast tumors invading the spine and underwent a single-stage posterior approach were retrospectively recruited. The following data were obtained and examined: demographics, tumor histology, preoperative and postoperative therapy, complications, spinal reconstruction technique, tumor resection extent, survival time, and disease recurrence. RESULTS: Eighteen patients were included. The mean population age was 61±17 years, and the most common pathological type was adenocarcinoma (61.1%). Complete resection (R0) was obtained in 15 patients (83.3%), positive surgical margins (R1) were found in three patients (16.7%), and the 90-day mortality rate was 0%. Postoperative major complications were detected in 12 patients (66.7%), who required reoperation. The mean survival time was 67±24 months, but the median survival time was not reached. Among the patients, 10 (55.6%) are still alive at the end of the study. The 2- and 5-year actual survival rates were 59% (95% confidence interval [CI], 35.7%-82.3%) and 52.5% (95% CI, 28.4%-76.6%), respectively. CONCLUSIONS: En bloc resection and spinal stabilization through a single-stage posterior approach might be effective for T4 Pancoast tumors invading the spine.