Thoracoscopic surgery for thoracic disc herniation.

Technical improvements in endoscopy have had a major effect in the practice of minimally invasive surgery, which is preferable to more invasive surgical procedures for central and hard thoracic disc herniation. Eleven patients underwent surgery between 2002 and 2008. Data was collected from self-reporting questionnaires completed by the patient at each visit before surgery and after surgery at 3,6,12 and 24 months. The questionnaires included in the study were the Oswestry Disability Questionnaire and a visual analog scale(VAS) for the evaluation of pain. In all eleven patients, the thoracoscopic approach was technically performed satisfactorily. There was a significant initial improvement in both the Oswestry score and the VAS pain score at up to nine months(P<0.05). The average relative difference in the Oswestry and VAS score was not significant at 12 and 24 months. The complication rate(pleurisy and lung contusion) in our small study was 18%, which compares favorably with the literature. Video assisted thoracic spine surgery (VATS) clearly provides a minimally invasive and effective alternative to open thoracic surgery. A surgeon must be familiar with the surgical anatomy and the endoscopic techniques to ensure an optimal surgical outcome. Hence, that is one limitation in the practice of thoracoscopic discectomy.

Posterior dynamic stabilization in the treatment of lumbar degenerative disc disease: 2-year follow-up.

BACKGROUND: A prospective pilot study was designed to evaluate the role of a posterior dynamic stabilization technique in the surgical treatment of degenerative disc disease. Posterior dynamic stabilization with a hinged screw is a new concept in the surgical treatment of degenerative disc disease of the lumbar spine. The traditional surgical treatment is to apply a fusion procedure. However, numerous reports showed unsatisfactory clinical outcomes even when patients have satisfactory radiological outcomes following fusion procedures. MATERIAL AND METHODS: The study included patients who were surgically treated with a dynamic stabilization technique due to painful degenerative disc disease. Clinical and radiological findings for the 20 participating patients were analyzed in a 2-year follow-up study. Preoperative and postoperative data at the 3 (rd), 12 (th) and 24 (th) month were collected for both clinical and radiological outcomes. Statistical analyses between preoperative and postoperative data were performed using the Wilcoxon test. RESULTS: The clinical outcome measurements (VAS, ODI) showed significant improvement in all postoperative measurements compared to preoperative values. The mean preoperative visual analogue score (VAS, 7.9) and Oswestry Disability Index (ODI 59.2) significantly decreased to 0.8 for VAS and 9.2 for ODI, at 2 years post-operation (p<0.05). The radiological studies showed no significant changes between pre- and postoperative values, in all parameters. There was no mortality or morbidity. CONCLUSIONS: The results of this pilot study are encouraging. Dynamic stabilization may be an effective technique in the surgical treatment of painful degenerative disc disease. A larger series study, with longer follow-up periods and with control groups is needed to determine the success and safety of posterior dynamic stabilization in the surgical treatment of degenerative disc disease.

Endoscopic resection of a retroperitoneal schwannoma: case report.

INTRODUCTION: Retroperitoneal schwannomas are rare tumors. The symptoms are usually non-specific and these lesions can only be demonstrated with advanced radiological methods. Posterior and anterior approaches can be used to remove retroperitoneal schwannomas. Traditional techniques carry significant risks. CASE REPORT: A 35-year-old man was admitted with a history of right leg pain of 3 months duration. He had received conservative treatment and physical therapy but none of these measures had been helpful. Findings on physical and neurological examinations were all within normal limits. Magnetic resonance imaging revealed a retroperitoneal mass lesion medial to the right psoas muscle at the level of the S1 vertebra. The tumor was removed using an endoscopic transabdominal approach. CONCLUSION: The endoscopic transabdominal approach is a safe, efficient and minimally invasive procedure compared to traditional methods also to remove retroperitoneal schwannomas in selected cases.

Pedicle screw-based posterior dynamic stabilisation of the lumbar spine: in vitro cadaver investigation and a finite element study.

Pedicle screw-based dynamic constructs either benefit from a dynamic (flexible) interconnecting rod or a dynamic (hinged) screw. Both types of systems have been reported in the literature. However, reports where the dynamic system is composed of two dynamic components, i.e. a dynamic (hinged) screw and a dynamic rod, are sparse. In this study, the biomechanical characteristics of a novel pedicle screw-based dynamic stabilisation system were investigated and compared with equivalent rigid and semi-rigid systems using in vitro testing and finite element modelling analysis. All stabilisation systems restored stability after decompression. A significant decrease in the range of motion was observed for the rigid system in all loadings. In the semi-rigid construct the range of motion was significantly less than the intact in extension, lateral bending and axial rotation loadings. There were no significant differences in motion between the intact spine and the spine treated with the dynamic system (P>0.05). The peak stress in screws was decreased when the stabilisation construct was equipped with dynamic rod and/or dynamic screws.

The course of spinal tuberculosis (Pott disease): results of the multinational, multicentre Backbone-2 study.

We aimed to describe clinical, laboratory, diagnostic and therapeutic features of spinal tuberculosis (ST), also known as Pott disease. A total of 314 patients with ST from 35 centres in Turkey, Egypt, Albania and Greece were included. Median duration from initial symptoms to the time of diagnosis was 78 days. The most common complications presented before diagnosis were abscesses (69%), neurologic deficits (40%), spinal instability (21%) and spinal deformity (16%). Lumbar (56%), thoracic (49%) and thoracolumbar (13%) vertebrae were the most commonly involved sites of infection. Although 51% of the patients had multiple levels of vertebral involvement, 8% had noncontiguous involvement of multiple vertebral bodies. The causative agent was identified in 41% of cases. Histopathologic examination was performed in 200 patients (64%), and 74% were consistent with tuberculosis. Medical treatment alone was implemented in 103 patients (33%), while 211 patients (67%) underwent diagnostic and/or therapeutic surgical intervention. Ten percent of the patients required more than one surgical intervention. Mortality occurred in 7 patients (2%), and 77 (25%) developed sequelae. The distribution of the posttreatment sequelae were as follows: 11% kyphosis, 6% Gibbus deformity, 5% scoliosis, 5% paraparesis, 5% paraplegia and 4% loss of sensation. Older age, presence of neurologic deficit and spinal deformity were predictors of unfavourable outcome. ST results in significant morbidity as a result of its insidious course and delayed diagnosis because of diagnostic and therapeutic challenges. ST should be considered in the differential diagnosis of patients with vertebral osteomyelitis, especially in tuberculosis-endemic regions. Early establishment of definitive aetiologic diagnosis and appropriate treatment are of paramount importance to prevent development of sequelae.

Effects of cervical spine posture on axial load bearing ability: a biomechanical study.

OBJECT: The authors conducted a study to assess the effects of cervical posture on the loadbearing ability of the cervical spine. METHODS: Twelve cervical spine specimens obtained in 12 adult sheep were tested. The specimens were randomly separated into two groups. In Group I the specimens were fixed in a lordotic posture, and in Group II they were fixed in a straight posture. Axial compressive loads were applied at a constant rate of 5 cm/minute. Load-to-failure, time-to-failure, piston displacement at failure, and failure modes were recorded. Statistical analyses were performed to detect differences between the groups. There was no significant difference in load-to-failure values between the two groups. However, the time-to-failure and the piston displacement values for the straight spines were significantly less than those for the lordotic spines. Additionally, the straight spines failed predominantly through ventral elements, whereas the lordotic spines predominantly failed dorsally. CONCLUSIONS: It is concluded that a loss of a lordosis increases the risk of injury to the cervical spine following axial loading.

A novel approach to the surgical treatment of lumbar disc herniations: indications of simple discectomy and posterior transpedicular dynamic stabilization based on carragee classification.

Surgery of lumbar disc herniation is still a problem since Mixter and Barr. Main trouble is dissatisfaction after the operation. Today there is a debate on surgical or conservative treatment despite spending great effort to provide patients with satisfaction. The main problem is segmental instability, and the minimally invasive approach via microscope or endoscope is not necessarily appropriate solution for all cases. Microsurgery or endoscopy would be appropriate for the treatment of Carragee type I and type III herniations. On the other hand in Carragee type II and type IV herniations that are prone to develop recurrent disc herniation and segmental instability, the minimal invasive techniques might be insufficient to achieve satisfactory results. The posterior transpedicular dynamic stabilization method might be a good solution to prevent or diminish the recurrent disc herniation and development of segmental instability. In this study we present our experience in the surgical treatment of disc herniations.

Giant supratentorial atypical teratoid/rhabdoid tumor presentation: a case of a five-year-old child with favorable outcome and review of the literature.

Atypical teratoid/rhabdoid tumor of the central nervous system is a highly malignant neoplasm and that usually arises in the posterior fossa, survival from this is frequently poor. We present a unique case in a 21-month-old girl who had an atypical teratoid/rhabdoid tumor with cystic components located in the right fronto-parietal lobe. The patient underwent radical surgical intervention followed by chemotherapy. It consisted of five chemotherapeutic agents, but the patient did not receive any radiotherapy. The postoperative course was uneventful and the patient was followed-up by cranial magnetic resonance imaging every 3 months. Two years later at the last follow-up visit, there was no evidence of a tumor relapse on MRI, and the examination was symptom free. It is possible the favorable outcome of the patient resulted from a rapid diagnosis, prompt management, radical surgical intervention and aggressive chemotherapy.

Percutaneous endoscopic discectomy for far lateral lumbar disc herniations: prospective study and outcome of 66 patients.

BACKGROUND: Extraforaminal disc herniations represent up to 11% of all lumbar herniated discs. Numerous surgical approaches have been described. Percutaneous endoscopic discectomy (PED) is one of the minimally invasive techniques; after mastering this procedure it is a practical method that is used for treatment of foraminal or extraforaminal disc herniation. The outcome of PED for treatment of foraminal or extraforaminal disc herniation has been studied. METHOD: A total of 66 patients with foraminal or extraforaminal lumbar disc herniation was treated by applying the PED technique between January 1998 and June 2005. The positions of the herniated disc levels were L2-3 (n=5, 8%), L3-4 (n=19, 28%) and L4-5 (n=42; 64%). The selected patients had no previous surgery, appropriate conservative therapies were done before the operations, and MRI was the main diagnostic method with the clinical findings. Evaluation of the patients with clinical examinations, visual analogue pain scale (VAS) and Oswestry scale was performed preoperatively, on postoperative day 7 and in the postoperative 6-12 months period. RESULTS: In two patients (n=1, L4-5 and n=1, L3-4) disc material could not be removed with PED, so discectomy was performed with microscopic visualization during the same session. Three patients (n=3, L4-5) were reoperated on three to six months after primary surgery due to recurring disc problems with microscope visualization. In two patients (n=2, L4-5) root nerves were partially damaged, and in two patients (n=2, L4-5) root nerves were impinged by the working channel. These 4 patients had dysesthesias from just after surgery to a mean of 45 days after surgery. One of recurrent cases was among these patients. Neurological examinations showed minimal muscle weakness of the quadriceps femoris and diminished sensation of the L4 dermatomal area in patients with partial nerve root damage. This patient improved and the neurologic examination became normal with disappearance of the dysesthesia. There was no sign of reflex sympathetic dystrophy (RDS). With these two patients VAS and Oswestry scales scores decreased significantly early in the postoperative follow-up. The postoperative 6-month average scores are favourable in comparison with the average score at postoperative day 7. The postoperative 12-month scores showed no significant differences to those of postoperative month 1. CONCLUSION: Percutaneous endoscopic discectomy is a minimally invasive method and offers many benefits to the patient, but extensive surgical practice is needed to become a capable surgeon. Consequently this technique can only be a treatment option on appropriate patients. This study reconfirmed that the removal of fragmented disc material is achieved and offers a pain-free status.

Open-window laparotomy during a transperitoneal approach to the lower lumbar vertebrae: new method for reducing complications.

There are numerous approaches for exploring the lower lumbar vertebrae, and the anterior transperitoneal route is one of the most popular. Like all surgical techniques, this approach has advantages and disadvantages. It provides direct access to the target tissue through a small incision, exposes the anterior portion of the vertebrae well, and permits good visualization of the major vessels, thus reducing risk of vascular injury and life-threatening hemorrhage. However, compared to the extraperitoneal route, the transperitoneal approach carries higher risks for peritoneal complications. This article describes a new practical method for creating an extraperitoneal passageway or "window" during transperitoneal approaches to the lower lumbar vertebrae. Isolation of the peritoneal cavity and its contents with this technique can reduce peri- and postoperative abdominal complications.