Comparative Analysis of Postoperative Sagittal Balance in Expansive Open-Door Laminoplasty versus Laminectomy with Fusion for Multilevel Ossification of Posterior Longitudinal Ligament: A Retrospective Study.

BACKGROUND This single-center study included 80 patients with multilevel cervical ossification of the posterior longitudinal ligament (OPLL) and aimed to compare postoperative sagittal balance following treatment with expansive open-door laminoplasty (LP) vs total laminectomy with fusion (LF). MATERIAL AND METHODS Data of 80 patients with multilevel OPLL treated with LP vs LF between January 2017 and January 2022 were retrospectively analyzed. The basic data, cervical sagittal parameters, and clinical outcomes of the patients were counted in the preoperative and postoperative periods, and complications were recorded. Forty patients underwent LP and 40 underwent LF. Cervical sagittal parameters were compared between and within the 2 groups. Clinical outcomes and complications were compared between the 2 groups. RESULTS At last follow-up, the postoperative C2-C7 Cobb angel, T1 slope (T1S), and C7 slope (C7S) were significantly higher in the LF group than in the LP group (P<0.001). C2-C7 SVA (cSVA) was slightly higher in the LF group (P>0.05) and significantly higher in the LP group (P<0.05). The incidence of postoperative complications in the LP group was significantly lower than in the LF group (P=0.02). The postoperative scores on the Visual Analog Scale (VAS), Neck Disability Index (NDI), and Japanese Orthopedic Association (JOA) were significantly improved in both groups (P<0.001). CONCLUSIONS Both procedures had good outcomes in neurological improvement. After posterior surgery, the cervical vertebrae all showed a tilting forward. Compared to LP, LF may change cervical balance in Cobb angel, T1S. LF has better efficacy in improving cervical lordosis compared with LP. Patients with high T1 slope after surgery may has more axial pain.

Ultrasound-guided erector spinae plane blocks for pain management after open lumbar laminectomy.

PURPOSE: Lumbar spine surgery is associated with significant postoperative pain. The benefits of erector spinae plane blocks (ESPBs) combined with multimodal analgesia has not been adequately studied. We evaluated the analgesic effects of bilateral ESPBs as a component of multimodal analgesia after open lumbar laminectomy. METHODS: Analgesic effects of preoperative, bilateral, ultrasound-guided ESPBs combined with standardized multimodal analgesia (n = 25) was compared with multimodal analgesia alone (n = 25) in patients undergoing one or two level open lumbar laminectomy. Other aspects of perioperative care were similar. The primary outcome measure was cumulative opioid consumption at 24 h. Secondary outcomes included opioid consumption, pain scores, and nausea and vomiting requiring antiemetics on arrival to the post-anesthesia care unit (PACU), at 24 h, 48 h, and 72 h after surgery, as well as duration of the PACU and hospital stay. RESULTS: Opioid requirements at 24 h were significantly lower with ESPBs (31.9 ± 12.3 mg vs. 61.2 ± 29.9 mg, oral morphine equivalents). Pain scores were significantly lower with ESPBs in the PACU and through postoperative day two. Patients who received ESPBs required fewer postoperative antiemetic therapy (n = 3, 12%) compared to those without ESPBs (n = 12, 48%). Furthermore, PACU duration was significantly shorter with ESPBs (49.7 ± 9.5 vs. 79.9 ± 24.6 min). CONCLUSIONS: Ultrasound-guided, bilateral ESPBs, when added to an optimal multimodal analgesia technique, reduce opioid consumption and pain scores, the need for antiemetic therapy, and the duration of stay in the PACU after one or two level open lumbar laminectomy.

Risk factors of instrumentation failure after laminectomy and posterior cervical fusions (PCF).

BACKGROUND: For patients with multilevel degenerative cervical myelopathy, laminectomy and posterior cervical fusions (PCF) with instrumentation are widely accepted techniques for symptom relief. However, hardware failure is not rare and results in neck pain or even permanent neurological lesions. There are no in-depth studies of hardware-related complications following laminectomy and PCF with instrumentation. METHODS: The present study was a retrospective, single centre, observational study. Patients who underwent laminectomy and PCF with instrumentation in a single institution between January 2019 and January 2021 were included. Patients were divided into hardware failure and no hardware failure group according to whether there was a hardware failure. Data, including sex, age, screw density, end vertebra (C7 or T1), cervical sagittal alignment parameters (C2-C7 cervical lordosis, C2-C7 sagittal vertical axis, T1 slope, Cervical lordosis correction), regional Hounsfield units (HU) of the screw trajectory and osteoporosis status, were collected and compared between the two groups. RESULTS: We analysed the clinical data of 56 patients in total. The mean overall follow-up duration was 20.6 months (range, 12-30 months). Patients were divided into the hardware failure group (n = 14) and no hardware failure group (n = 42). There were no significant differences in the general information (age, sex, follow-up period) of patients between the two groups. The differences in fusion rate, fixation levels, and screw density between the two groups were not statistically significant (p > 0.05). The failure rate of fixation ending at T1 was lower than that at C7 (9% vs. 36.3%) (p = 0.019). The regional HU values of the pedicle screw (PS) and lateral mass screw (LMS) in the failure group were lower than those in the no failure group (PS: 267 ± 45 vs. 368 ± 43, p = 0.001; LMS: 308 ± 53 vs. 412 ± 41, p = 0.001). The sagittal alignment parameters did not show significant differences between the two groups before surgery or at the final follow-up (p > 0.05). The hardware failure rate in patients without osteoporosis was lower than that in patients with osteoporosis (14.3% vs. 57.1%) (p = 0.001). CONCLUSIONS: Osteoporosis, fixation ending at C7, and low regional HU value of the screw trajectory were the independent risk factors of hardware failure after laminectomy and PCF. Future studies should illuminate if preventive measures targeting these factors can help reduce hardware failure and identified more risk factors, and perform long-term follow-up.

Neisseria gonorrhoeae cervical spine epidural abscess requiring spinal decompression and instrumented fusion.

Disseminated gonococcal infection (DGI) is an uncommon complication of Neisseria gonorrhoeae infection, and typically presents with either a triad of tenosynovitis, dermatitis and polyarthralgia, or with extra-axial large joint septic arthritis. Spinal epidural abscess is a rare manifestation of DGI, with only a few previously reported cases, none of which required placement of metalware into the infected space. Here we report a severe case of isolated N. gonorrhoeae cervical spine epidural abscess necessitating surgical source control (C7/T1 laminectomy and debridement) and metalware placement (C6-T2 posterior instrumented fusion). The case was successfully managed by a combination of surgical intervention followed by six weeks of predominantly oral, targeted antimicrobial therapy.

Predictors for spinal deformity following resection of intramedullary tumor via posterior approach: a systematic review and meta-analysis.

PURPOSE: The present study aimed to identify the clinical predictive factors for worsened spinal deformity (SD) following surgical resection via posterior approach for primary intramedullary tumors. METHODS: A systematic search was performed using PubMed, Web of Science, and Scopus databases to extract potential references. Observational studies reporting predictive factors for worsened SD following surgical resection via posterior approach for primary intramedullary tumors were included. The odds ratio (OR) was calculated for dichotomous parameters. RESULTS: Four retrospective cohort studies were included in the meta-analysis. They were comprised of two groups of patients; those who developed SD (n = 87) and those who did not (n = 227). For patients with IMSCTs, age under 25 years as well as age under 13 years were the demographic variables associated with postoperative SD (odds ratio [OR] 3.92; p = 0.0002 and OR 4.22; p = 0.003). In both the fusion and the non-fusion subgroups, preoperative spinal deformity strongly predicted postoperative SD (OR 11.94; p < 0.001), with the risk highly elevated among the non-fusion patients (OR 24.64; p < 0.0002). Thoracolumbar junction involvement was also found to be a predictor of postoperative SD for patients with IMSCT (OR 2.89; p = 0.02). CONCLUSION: This study highlights the importance of considering age, preoperative spinal deformity, and thoracolumbar junction involvement as predictors of postoperative spinal deformity following surgical resection for IMSCT. These findings may provide guidance for the management of these patients, including the development of preoperative planning strategies and the selection of the most appropriate surgical approach for high-risk patients.

Could extended laminectomy effectively prevent spinal cord injury due to spinal shortening after 3-column osteotomy?

OBJECTIVE: To explore whether the laminectomy extension can effectively prevent spinal cord injury (SCI) due to spinal shortening after 3-column osteotomy in goat models. METHODS: A total of twenty healthy goats were included and done with 3-column osteotomy of T13 and L1 under the somatosensory evoked potential (SSEP) monitoring. The samples were divided into two groups. The first group underwent regular laminectomy while the second group underwent an extended laminectomy with an extra 10 mm-lamina cranial to L2. The SSEP measured after 3-column osteotomy was set as the baseline, and the SSEP decreased by 50% from the baseline amplitude and/or delayed by 10% relative to the baseline peak latency was set as positive results, which indicated spinal cord injury. The vertebral column was gradually shortened until the SSEP monitoring just did not show a positive result. The height of the initial osteotomy gap (the distance from the lower endplate of T12 to the upper endplate of L2), the shortened distance (△H), the number of spinal cord angulated and the changed angle of the spinal cord (△α) were measured and recorded in each group. Neurological function was evaluated by the Tarlov scores on day 2 postoperatively. RESULTS: All the goats except one of the first group due to changes in the SSEP during the osteotomy were included and analyzed. In the first group, the height of the initial osteotomy segment and the safe shortening distances were 61.6 ± 2.6 mm and 35.2 ± 2.6 mm, respectively; the spinal cord of 5 goats was angulated (46.4 ± 6.6°), the other four goats were kinked and not angulated. In the second group, the height of the initial osteotomy segment and the safe shortening distances were 59.8 ± 1.5 mm and 43.3 ± 1.2 mm, respectively, and the spinal cord of ten goats were angulated (97.6 ± 7.2°). There was no significant difference in the height of the initial osteotomy segment between the two groups by using Independent-Samples T-Test, P = 0.095 (P > 0.05); there were significant difference in the safe shortening distance and the changed angle of the spinal cord between the two groups by using Independent-Samples T-Test (both [Formula: see text]H and [Formula: see text]α of P < 0.001), the difference between their mean were 8.1 mm and 51.2°. Significant difference was found in the number of spinal cord angulation between the two groups through Fisher's exact test (5/9 vs. 10/10, P = 0.033). CONCLUSIONS: An additional resection of 10 mm-lamina cranial to L2 showed the satisfactory effect in alleviating SCI after 3-column osteotomy. Timely and appropriate extend laminectomy could be a promising therapeutic strategy for SCI attributable to facilitating spinal cord angulation rather than spinal cord kinking and increasing the safe shortening distance.

Unilateral laminotomy with bilateral spinal canal decompression: systematic review of outcomes and complications.

BACKGROUND: Unilateral laminotomy with bilateral spinal canal decompression has gained popularity recently. AIM: To systematically review the literature of unilateral laminotomy with bilateral spinal canal decompression for lumbar spinal stenosis (LSS) aiming to assess outcomes and complications of the different techniques described in literature. METHODS: On August 7, 2022, Pubmed and EMBASE were searched by 2 reviewers independently, and all the relevant studies published up to date were considered based on predetermined inclusion and exclusion criteria. The subject headings "unilateral laminotomy", "bilateral decompression" and their related key terms were used. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles. RESULTS: A total of seven studies including 371 patients were included. The mean age of the patients was 69.0 years (range: 55-83 years). The follow up duration ranged from 1 to 3 years. Rate of postoperative pain and functional improvement was favorable based on VAS, JOA, JOABPEQ, RMDW, ODI and SF-36, for example improved from a range of 4.2-7.5 preoperatively on the VAS score to a range of 1.4-3.0 postoperatively at the final follow up. Insufficient decompression was noted in 3% of the reported cases. The overall complication rate was reported at 18-20%, with dural tear at 3.6-9% and hematoma at 0-4%. CONCLUSION: Unilateral laminotomy with bilateral decompression has favorable short- and mid-term pain and functional outcomes with low recurrence and complication rates. This, however, needs to be further confirmed in larger, long-term follow-up, prospective, comparative studies between open, and minimally invasive techniques.

Replantation of lamina spinous process ligament complex and miniature titanium plate shaping internal fixation in the treatment of tumors in the spinal canal.

OBJECTIVE: Purpose This study aims to explore the clinical efficacy of laminospinous process ligament complex reimplantation combined with mini-titanium plate fixation in the treatment of thoracolumbar intraspinal tumors. METHODS: A retrospective analysis was performed on 43 cases of intraspinal tumors treated with thoracolumbar intraspinal tumor resection from August 2018 to March 2021, and 27 cases underwent laminospinous process ligament complex reimplantation combined with micro titanium plate shaping. Fixation (laminar replantation group), and 16 patients underwent laminectomy combined with pedicle screw internal fixation (laminectomy group). The operation time, blood loss, drainage tube removal time, cerebrospinal fluid leakage, spinal instability, and the incidence of secondary spinal stenosis were compared between the two groups. The pain VAS score, ODI score, and modified Macnab at the last follow-up were compared between the two groups. And the laminar fusion rate of the laminoplasty group was measured. RESULTS: Both groups successfully completed the surgery and obtained complete follow-up. The incidence of cerebrospinal fluid leakage and secondary spinal canal stenosis in the laminectomy group was lower than that in the laminectomy group, and the difference was statistically significant (P < 0.05). There was no statistically significant difference in the incidence of spinal instability between the two groups (P > 0.05). The operation time and intraoperative blood loss in the laminectomy group were less than those in the laminectomy group, and the drainage tube removal time was earlier than that in the laminectomy group. The difference was statistically significant (P < 0.05). At the final follow-up, there was no statistically significant difference in the pain VAS score, ODI score, and modified Macnab between the two groups (P > 0.05), but they were all significantly improved compared with preoperative ones. Fusion evaluation was conducted on the laminoplasty group. Two years after surgery, the fusion rate was 97.56% (40/41). CONCLUSIONS: The application of laminospinous process ligament complex reimplantation combined with mini titanium plate fixation during thoracolumbar intraspinal tumor resection can effectively reconstruct the spinal canal and posterior column structure, reduce the incidence of cerebrospinal fluid leakage and secondary spinal stenosis. The laminar fusion rate is high.

Emergency surgical decompression for spontaneous spinal epidural hematoma in octogenarians: risk factors, clinical outcomes, and complications.

PURPOSE: Spontaneous spinal epidural hematoma (SSEH) is a rare but disabling disease. Although several cases have been reported in the literature, their treatment remains unclear, especially in patients with advanced age. We, therefore, aimed to describe the clinical outcomes of cervical SSEH in octogenarians with an acute onset of neurological illness undergoing laminectomy. METHODS: Electronic medical records from a single institution between September 2005 and December 2020 were retrieved. Data on patient demographics, neurological conditions, functional status, surgical characteristics, complications, hospital course, and 90-day mortality were also collected. RESULTS: Twenty-two patients aged ≥ 80 years with SSEH undergoing laminectomy were enrolled in this study. The mean Charlson comorbidity index was 9.1 ± 2.0, indicating a poor baseline reserve. Ten individuals (45.5%) were taking anticoagulant agents with a pathologic partial thromboplastin time (PTT) of 46.5 ± 3.4 s. Progressive neurological decline, as defined by the motor score (MS), was observed on admission (63.8 ± 14.0). The in-hospital and 90-day mortality were 4.5% and 9.1%, respectively. Notably, the MS (93.6 ± 8.3) improved significantly after surgery (p < 0.05). Revision surgery was necessary in 5 cases due to recurrent hematoma. Anticoagulant agents and pathological PTT are significant risk factors for its occurrence. Motor weakness and comorbidities were unique risk factors for loss of ambulation. CONCLUSIONS: Laminectomy and evacuation of the hematoma in octogenarians with progressive neurological decline induce clinical benefits. Emergent surgery seems to be the "state of the art" treatment for SSEH. However, potential complications associated with adverse prognostic factors, such as the use of anticoagulants, should be considered.

Spinal epidural fibrosis following hemostatic agent employment.

OBJECTIVE: Failed Back Surgery Syndrome (FBSS) refers to a subset of patients who have new or persistent pain after spinal surgery for back or leg pain. Epidural fibrosis (EF) is a common cause of FBSS. Many agents aiming to prevent EF have been tested. However, hemostatic agents are readily available at hospitals, easy to reach and frequently used. For these reasons, oxidized regenerated cellulose, polysaccharide hemostat, hemostatic thrombin-gelatin matrix and chitosan linear polymer were evaluated for their effects on epidural fibrosis on rats after laminectomy. METHODS: 40 Sprague-Dawley rats were randomly divided into 5 equal groups including the control group where only the laminectomy was performed. The other 4 groups received hemostatic agents after laminectomy. The rats were euthanized 45 days later and were assessed by a blinded observer to grade the fibrosis level. RESULTS: The study revealed that oxidized regenerated cellulose, polysaccharide hemostat and hemostatic thrombin-gelatin matrix lowered the epidural fibrosis grade which was statistically significant (p < 0.001). Although chitosan linear polymer created fibrosis similar to the control group it was not proven to be statistically significant (p = 0.8999). However, when compared with other hemostatic agents it resulted in a higher fibrosis grade (p < 0.001). CONCLUSION: The results obtained from this experimental study revealed that Pahacel, Sealfoam and Surgiflo, were effective in reducing epidural fibrosis after laminectomy in rats.

Technical note: Novel use of recombinant tissue plasminogen activator for the evacuation of an acute extensive spinal epidural haematoma in a patient with coagulopathy.

Spontaneous extensive spinal epidural haematoma poses a unique challenge for the neurosurgeon. Performing extensive laminectomies to remove all of the compressive haematoma can destabilise the patient's spinal column, which may require fixation. This is further complicated in patients with significant coagulopathy. We present a novel use of recombinant tissue plasminogen activator (rt-PA) in a patient with therapeutic coagulopathy, presenting with myelopathy secondary to an acute extensive spinal epidural haematoma. To the best of our knowledge, this is the first case of acute multilevel spinal epidural haematoma that has been successfully evacuated via single level laminectomy and topically applied rt-PA.

Spinal segmental myoclonus following spinal surgery.

A 44-year-old male was admitted with L5/S1 spondylodiscitis complicated by a posterior epidural abscess that was compressing the thecal sac with severe narrowing of the canal and compression of the cauda equine. He underwent computed tomography (CT) guided drainage followed by L5/S1 decompression laminectomy and was started on a 6-week course of intravenous antibiotics with good response. He remained well and afebrile with inflammatory markers showing improvement. During this period, he developed intermittent myoclonic movements of right lower limb with severe pain over the back radiating to the gluteal region which hindered his rehabilitation potential. He was diagnosed with spinal segmental myoclonus based on clinical findings and history of recent spinal surgery. He was successfully treated with a course of clonazepam and continues to make functional improvements during his rehabilitation program.

Spinal intradural arachnoid cyst as a complication of insertion of an interspinous device.

Spinal intradural arachnoid cysts (SACs) account for approximately 10% of total arachnoid cysts, and iatrogenic attribution is rare. A 50-year-old male presented with low back pain and severe radiating pain in his right leg along the S1 dermatome. He had an interspinous device (ISD) inserted 10 years earlier. Plain radiographs showed breakage and angular movement of the ISD at L4/5. Magnetic resonance imaging (MRI) of the lumbosacral spine disclosed multiple intradural cystic tumors in the entire lumbar region. He underwent removal of the ISD, laminectomy, and resection of the intradural cyst. The pathologic finding of the cystic tumor was compatible with arachnoid cyst. Antibodies to parasites, including cysticercosis, were negative in both the serum and cerebrospinal fluid (CSF). The ventral surface of the implant was clearly broken.

MicroRNA-29a Mitigates Laminectomy-Induced Spinal Epidural Fibrosis and Gait Dysregulation by Repressing TGF-ß1 and IL-6.

Spinal epidural fibrosis is one of the typical features attributable to failed back surgery syndrome, with excessive scar development in the dura and nerve roots. The microRNA-29 family (miR-29s) has been found to act as a fibrogenesis-inhibitory factor that reduces fibrotic matrix overproduction in various tissues. However, the mechanistic basis of miRNA-29a underlying the overabundant fibrotic matrix synthesis in spinal epidural scars post-laminectomy remained elusive. This study revealed that miR-29a attenuated lumbar laminectomy-induced fibrogenic activity, and epidural fibrotic matrix formation was significantly lessened in the transgenic mice (miR-29aTg) as compared with wild-type mice (WT). Moreover, miR-29aTg limits laminectomy-induced damage and has also been demonstrated to detect walking patterns, footprint distribution, and moving activity. Immunohistochemistry staining of epidural tissue showed that miR-29aTg was a remarkably weak signal of IL-6, TGF-ß1, and DNA methyltransferase marker, Dnmt3b, compared to the wild-type mice. Taken together, these results have further strengthened the evidence that miR-29a epigenetic regulation reduces fibrotic matrix formation and spinal epidural fibrotic activity in surgery scars to preserve the integrity of the spinal cord core. This study elucidates and highlights the molecular mechanisms that reduce the incidence of spinal epidural fibrosis, eliminating the risk of gait abnormalities and pain associated with laminectomy.

Unilateral Biportal Endoscopic Laminectomy for Treating Cervical Stenosis: A Technical Note and Preliminary Results.

Objective: The objective of this study was to introduce a surgical technique for the percutaneous decompression of cervical stenosis (CS) using a unilateral biportal endoscopic approach and characterize its early clinical and radiographic results. Materials and Methods: Nineteen consecutive patients with CS who needed surgical intervention were recruited. All enrolled patients underwent unilateral biportal endoscopic laminectomy (UBEL). All patients were followed postoperatively for >1 year. The preoperative and final follow-up evaluations included the Japanese Orthopedic Association (JOA) score for neurological assessment, visual analogue scale (VAS) for axial pain and C2-C7 Cobb angle for cervical sagittal alignment. The postoperative complications were analyzed. Results: Thirteen males and six females were included in the analysis. The mean follow-up period was 16.3 ± 2.6 months. The mean operative time was 82.6 ± 18.4 min. Postoperative MRI and CT revealed ideal neural decompression of the treated segments in all patients. Preoperative VAS and JOA scores improved significantly after the surgery, and cervical lordosis was preserved on the postoperative images. Conclusions: UBEL was an effective surgical method for CS, which may also minimize iatrogenic damage to the posterior tension band (PTB) and help to maximize the preservation of the cervical lordosis.

The effectiveness of organic vegetable oils with high biocompatibility in preventing epidural fibrosis: An experimental study.

Background and purpose:

Epidural fibrosis after all spinal surgeries is an important surgical issue. Various biological and non-biological materials have been tried to inhibit epidural fibrosis, which is deemed to be the most important cause of pain after spinal surgery. Olive oil, nigella sativa oil and soybean oil employed in oral nutrition in clinics involving liquid fatty acids, palmatic acid, linoleic acid, stearic acid and palmitoleic acid. The effectiveness of olive oil, nigella sativa oil and soybean oil on epidural fibrosis was researched on for the first time in laminectomy model.

Fifty adult male Wistar albino rats weighing between 300 and 400 grams were used in the research. A total of 5 groups were formed: sham (Group I) (n = 10), no application was created; Group II (n = 10) 1 cc saline; Group III (n = 10) 1 cc olive oil; Group IV (n = 10) 1 cc nigella sativa oil; Group V (n = 10); 1 cc soybean oil was applied topically to the epidural region after laminectomy. The total spine of the rats was dissected, histopathological and immuno­chemical measurements were conducted. Neuro-histopathological results were scored semi-quantitatively in terms of vascular modification, neuron degeneration, gliosis and bleeding criteria.

The lowest level of fibrosis and connective tissue proliferation was observed in the group where nigella sativa oil was used after the operation, followed by the group treated with olive oil and lastly with the group given soybean oil.

Nigella sativa oil and olive oil are very efficient for lowering the degree of epidural fibrosis and adhesions following laminectomy and can be employed as a simple, inexpensive and highly biocompatible material in clinical practice.

Risk Factors for Poor Outcomes of Thoracic Ossification of Ligamentum Flavum After Laminectomy.

BACKGROUND Thoracic ossification of ligamentum flavum (TOLF) is a common pathological change of the thoracic ligamentum flavum. Identifying the risk factors for poor prognosis is critical for choosing suitable surgical methods. MATERIAL AND METHODS A total of 64 patients with TOLF after laminectomy were reviewed between January 2010 and April 2018 at the Department of Spine Surgery of the Third Hospital of Hebei Medical University. The Japanese Orthopaedic Association (JOA) scale was used to evaluate the neurological function of patients. According to the average JOA improvement rate, the patients were divided into the good prognosis group (Group GP) and the poor prognosis group (Group PP). Multivariate logistic regression analysis was used to identify the risk factors for poor outcomes. RESULTS The average JOA improvement rate was 53.04±24.29%. Group GP comprised 33 patients, while Group PP comprised 31 patients. Duration of preoperative symptoms (P=0.005), intramedullary high signal intensity (P=0.001), dural ossification rate (P=0.002), and sagittal configuration of ossification (P=0.012) were significantly higher in Group PP than in Group GP. Multivariate logistic analysis showed that duration of preoperative symptoms (P=0.022), intramedullary high signal intensity (P=0.010), dural ossification (P=0.007) and sagittal configuration of ossification (P=0.029) were risk factors for poor outcomes of TOLF after laminectomy. CONCLUSIONS After surgical treatment of TOLF, the symptoms of some patients either recovered slowly or did not recover. Longer than 17 months of preoperative symptoms, intramedullary high signal intensity, dural ossification, and sagittal configuration of ossification were the risk factors for poor outcomes of TOLF after laminectomy.

Treatment of spontaneous spinal epidural hematoma in children: analysis of 25 cases.

INTRODUCTION: Spontaneous spinal epidural hematoma (SSEH) is a rare neurosurgical emergency, presenting as sudden onset of back pain and weakness of lower extremities. Many patients have no definite cause. Some cases of SSEH caused by vascular malformation have been reported. The treatment strategy remains controversial. This study aimed to analyze the causes of SSEH and proposed a treatment strategy according to clinical outcomes of patients at a single institution. METHODS: A total of 25 cases of SSEH under 18 years of age treated between March 2004 and July 2021 were retrospectively analyzed. RESULTS: The mean age of the first SSEH onset was 7.1 years. The most common location was cervicothorax. Nine patients suffered from multiple episodes. Twenty-three patients underwent spinal digital subtraction angiography (DSA), of which seven (30.4%) patients had positive findings: three cases had epidural artery venous fistula (AVF), two cases had epidural artery venous malformation (AVM), and two cases had abnormal concentration of contrast agent. Seventeen patients received surgery. Eleven patients (44%) were diagnosed as vascular malformation by either DSA or pathology. The follow-up rate was 80%, with 20 patients (80%) achieving satisfactory clinical outcome. Risk factors for poor clinical outcome included multiple episodes (p = 0.028) and higher Aminoff-Logue score (p = 0.005). CONCLUSION: Spinal epidural vascular malformation is a significant cause of SSEH. Spinal DSA is necessary. Surgery should be recommended for patients with multiple episodes, positive findings on DSA, or severe neurological deficits. Conservation therapy can be considered for other patients, but long-time follow-up is necessary.

Low occurrence of long-term subsequent fusion in pediatric patients following decompressive surgery for Chiari malformation: an institutional review.

OBJECTIVE: Chiari I malformation is treated with suboccipital craniectomy with cervical laminectomy, a procedure which has been associated with the possibility of pre-existing or iatrogenic occipitocervical instability. The long-term risk of subsequent spinal deformity and need for occipito cervical fusion after standard Chiari decompression in pediatric patients has not yet been characterized. METHODS: We queried our institutional electronic database for patients aged 18 and under, with at least 5 years of follow-up, that underwent surgical decompression for Chiari I malformation. Occurrence of subsequent occipitocervical fusion at follow-up comprised the primary endpoint. Cases with myelomeningocele, Chiari II, or fusion at time of decompression were excluded. RESULTS: A total of 30 patients (median age 5.5 years, 60% males) were analyzed. Age distribution was as follows: n = 3 for 0-1 years, n = 11 for 1-5 years, n = 4 for 5-10 years, and n = 12 for 10-18 years. Median tonsillar descent below the foramen magnum was 12.5 mm (interquartile range [IQR]: 10.8-19.5 mm). Syringomyelia was observed in 43%, retroflexion of the dens in 55%, basilar invagination in 6.7%, and medullary kinking in 27%. The median clivo-axial angle was 142° (132-150°). The majority of patients underwent C1 laminectomy (n = 24, 80%), followed by C1-C2 laminectomy (n = 4, 13%), while one patient had C1-upper C2 and C1-C3 laminectomy each, respectively. At a median follow-up of 6.3 years, there was only one patient (3.3% of overall cohort) that underwent subsequent occipitocervical fusion. The patient (4-year-old male) initially had a suboccipital craniectomy with C1 laminectomy and duraplasty and presented with recurrence of posterior headaches and neck pain 4 months after original surgery. We proceeded with occiput-C2 fusion with subsequent resolution of his symptoms. CONCLUSION: Current analysis shows that in the absence of clinical or imaging features suggestive of craniocervical instability, Chiari I decompressive surgery is associated with very low long-term risk of requiring occipitocervical fusion. This observance can be used to guide surgical treatment decisions, especially in young children with Chiari I malformations.

Improvement rates, adverse events and predictors of clinical outcome following surgery for degenerative cervical myelopathy.

PURPOSE: To investigate improvement rates, adverse events and predictors of clinical outcome after laminectomy alone (LAM) or laminectomy with instrumented fusion (LAM + F) for degenerative cervical myelopathy (DCM). METHODS: This is a post hoc analysis of a previously published DCM cohort. Improvement rates for European myelopathy score (EMS) and Neck Disability Index (NDI) at 2- and 5-year follow-ups and adverse events are presented descriptively for available cases. Predictor endpoints were EMS and NDI scores at follow-ups, surgeon- and patient-reported complications, and reoperation-free interval. For predictors, univariate and multivariable models were fitted to imputed data. RESULTS: Mean age of patients (LAM n = 412; LAM + F n = 305) was 68 years, and 37.4% were women. LAM + F patients had more severe spondylolisthesis and less severe kyphosis at baseline, more surgeon-reported complications, more patient-reported complications, and more reoperations (p ≤ 0.05). After imputation, the overall EMS improvement rate was 43.8% at 2 years and 36.3% at 5 years. At follow-ups, worse EMS scores were independent predictors of worse EMS outcomes and older age and worse NDI scores were independent predictors of worse NDI outcomes. LAM + F was associated with more surgeon-reported complications (ratio 1.81; 95% CI 1.17-2.80; p = 0.008). More operated levels were associated with more patient-reported complications (ratio 1.12; 95% CI 1.02-1.22; p = 0.012) and a shorter reoperation-free interval (hazard ratio 1.30; 95% CI 1.08-1.58; p = 0.046). CONCLUSIONS: These findings suggest that surgical intervention at an earlier myelopathy stage might be beneficial and that less invasive procedures are preferable in this patient population.