Surgical tactics of two-segmental cervical degenerative diseases: risk factors retrospective assessment and preoperative planning.

Background: Currently, in the specialized literature there are no substantiated clinical and radiological indications for differentiated use of anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) in the treatment of patients with two-segmental cervical degenerative diseases. The objectives of this study were to (I) identify risk factors that were associated with unsatisfactory results of two-level ACDF and one-level ACCF in the treatment of patients with cervical degenerative diseases despite current perioperative management, and (II) develop a clinical and radiological algorithm for personalized surgical tactics. Methods: We retrospectively identified risk factors for the development of unsatisfactory clinical postoperative results after two-level ACDF (n=81) and one-level ACCF (n=78), operated in the period of 2009-2019 for two-segmental cervical degenerative disease. Results: Satisfactory clinical results after two-level ACDF were noted in cases with total kyphotic deformity of less than 15°; local kyphotic deformity less than 10˚; the absence of circumferential spondylotic cervical stenosis; the absence of a myelopathic lesion at the level of the vertebral body; absence of migrating intervertebral disk (IVD) hernia more than 1/3 of the vertebral body; T1 slope vertebra less than 15°; IVD degeneration according to Suzuki A. 0-II; facet joint (FJ) degeneration according to Okamoto A. I-III; interbody height (IH) more than 2 mm. Satisfactory clinical results after single-level ACCF were registered in cases with IVD degeneration according to Suzuki A. III; FJ degeneration according to Okamoto A. IV-V; IH 3 mm or less; regardless of the cervical lordosis, the angle of local kyphotic deformity and T1 slope, the presence of circumferential spondylotic cervical stenosis, the localization of the myelopathic lesion and the distance of migration IVD herniation. Conclusions: Individual planning and differentiated implementation of ACDF and ACCF in patients with two-segmental cervical degenerative disease, taking into account a comprehensive preoperative clinical and radiological assessment, contributes to the effective elimination of existing neurological symptoms, reducing the intensity of neck pain and upper limbs pain, restoring the functional state and quality of patients' lives in the minimum 24 months postoperative period, as well as reducing the number of postoperative complications and reoperations.

Prospective Randomized Comparison of Minimally Invasive Tlif versus Open Tlif: Clinical Effectiveness and Restoration of Working Capacity in Railway Workers.

STUDY DESIGN: Randomized Clinical Trial. OBJECTIVE: To compare the clinical efficacy and restoration of working capacity after MI (minimally invasive)-TLIF and O (open)-TLIF in railway workers with lumbar degenerative disease. METHODS: 83 patients, who were indicated for two-level lumbar decompression and fusion were randomly assigned to one of two groups: group 1 (n = 44) had MI-TLIF procedure and group 2 (n = 39) had O-TLIF procedure. The functional status was assessed using SF-36, ODI and VAS for back and leg pain, preoperatively, at discharge, and at 3, 6, and 12 months postoperatively. MRI and CT were obtained 1-year follow-up. The percentage of patients who returned to work at 1-year, work intensity and the time to return to work post-operatively were analyzed. RESULTS: At 1-year follow-up, the MI-TLIF group had significantly better ODI, VAS and SF-36 scores compared to the O-TLIF group. The postoperative MRIs revealed a statistically significantly less multifidus muscle atrophy in the MI group compared to the Open group. At 1-year follow-up, a comparable fusion ratio between MI group and Open group was recorded. After MI-TLIF procedure, depending on the workload, patients had a statistically significantly earlier return to work (P < .05) and statistically significantly higher return to work rate compared with the O-TLIF group (P < .05). CONCLUSIONS: The use of two-level MI-TLIF in railway workers has made it possible to significantly improve long-term clinical results, reduce the risk of surgical complications, muscle atrophy and time to return to work compared to O-TLIF.

Simultaneous Versus Staged Surgery For Double Crush Syndrome Of Cervical Radiculopathy And Peripheral Nerve Compression At The Wrist: A Retrospective Single-Center Study.

STUDY DESIGN: Retrospective single-center study. OBJECTIVES: to evaluate the results of surgical treatment in patients with double crush syndrome associated with cervical radiculopathy and upper limb peripheral nerve compression after staged and simultaneous operations. SUMMARY OF BACKGROUND DATA: Currently, choosing the optimal diagnostic and therapeutic modalities in treating patients with double crush syndrome remains unresolved. METHODS: The study included 79 patients with double crush syndrome (cervical radiculopathy and syndrome of Guyon's canal or Carpal tunnel syndrome). Two independent groups were studied: In the Staged Group (n=35), we performed a cervical decompression with stabilization and peripheral nerve decompression at separate days due to ongoing clinical symptoms (average interval between interventions being 22 (18;26) days). In the Simultaneous Group (n=33), we performed both the cervical spine surgery, as well as the peripheral nerve procedures in one surgical session. Total operative time, estimate blood loss, length of hospitalization, complications and clinical data (NDI score, SF-36, VAS neck pain score, VAS arm pain score, Disabilities of Arm, Shoulder and Hand (DASH) score, Macnab scale) were compared. We used the Mann-Whitney (MW) test for intergroup comparisons, Wilcoxon criterion for dependent samples, and Fisher's exact test for binomial parameters. RESULTS: There was a significantly lower operative time, duration of inpatient treatment and temporary disability in the Simultaneous Group (P=0.01, P=0.04 and P=0.006 respectively). Comparative analysis did not reveal significant intergroup differences using NDI, VAS and DASH (P>0.05), whereas, at discharge, significantly better clinical parameters were appreciated for the Simultaneous Group using SF-36 and Macnab scores (P=0.04 and P=0.03, respectively). At Last Follow-up, an intra-group analysis revealed comparable clinical effectiveness between the two approaches (P>0.05). CONCLUSION: Comparison of the effectiveness of simultaneous and staged surgery revealed comparable long-term clinical outcomes. However, simultaneous surgery conveys clinically important advantages in terms of surgical time, anesthesia duration, length of hospitalization and patient disability. LEVEL OF EVIDENCE: 3.

Treatment of the two-level degenerative cervical disk diseases based on algorithmic anterior approach: a multicenter prospective study.

To analyze the effectiveness of an algorithmic anterior approach to the surgical treatment of patients with two-level cervical degenerative disk disease based on the preoperative clinical and imaging parameters. The study included 244 patients with two-level cervical degenerative disk disease. Three groups of patients were evaluated at 3 neurosurgical centers between 2016-2019. The prospective group (Group I, n = 126) consisted of patients who were treated using an algorithm to decide whether they should be treated with a two-level Total Disk replacement (TDR), Anterior Cervical Discectomy and Fusion (ACDF) and hybrid technique. The control group (Group II, n = 118) consisted of patients who underwent two-level anterior decompression with TDR, ACDF and hybrid stabilization between 2005-2015. Visual Analogue Scale (VAS) neck pain, VAS upper limbs pain, Neck Disability Index (NDI), SF-36, Macnab and Nurick scales were collected. Perioperative complications were identified. At 2 years of follow up Group I had significantly better clinical outcomes based on VAS neck pain score (p = 0.02), VAS upper limbs pain (p = 0.04), NDI score (p = 0.02), SF-36 score (p = 0.01), satisfaction with surgery on the Macnab scale (p < 0.001) and outcome of surgery based on Nurick scale (p < 0.001). Complication rate was lower in Group I, 6.3% compared to 24.6% in Group II, p = 0.0001. The algorithmic anterior approach to the surgical treatment of patients with two-level cervical degenerative disk disease resulted in significant improvement of functional outcomes and a decrease in complications at a minimum 2 years of follow-up.

Laminectomy with Laminar Reconstruction for Resection of Intradural Tumors at the Thoracolumbar Junction: A Technical Note.

OBJECTIVE: To introduce a new laminar reconstruction technique to treat primary spinal cord tumors. METHODS: Laminectomy and laminoplasty techniques have been used to treat intradural spinal tumors. The advantage of laminectomy is its superior exposure of the spinal cord, whereas the advantage of laminoplasty is the reconstruction of the dorsal roof of the spine. In this technical note, we present a technique that combines a full laminectomy to maximize exposure, with a reconstructive technique to repair the lamina. This technique restores the posterior ligamentous complex to preserve spinal biomechanics. RESULTS: In this illustrative case, a 55-year-old woman with severe back pain radiating to the right lower extremity was found to have an intradural tumor at the T12-L1 spinal level. Given the transitional level of the spine and potentially high biomechanical stresses on the posterior support structures, we used a T12 laminectomy to resect the tumor, followed by reconstruction using miniplates. The patient tolerated the surgery well, without any complications. She was discharged home and was doing well during the 3 months follow-up visit. Appropriate patient consent was obtained. CONCLUSIONS: Laminectomy and laminar reconstruction allow maximum visualization and manipulation of the tumor, followed by restoration of the dorsal roof of the spinal ring, and is an effective technique for treating spinal cord tumors.

5-aminolevulinic acid, fluorescein sodium, and indocyanine green for glioma margin detection: analysis of operating wide-field and confocal microscopy in glioma models of various grades.

Introduction: Surgical resection remains the first-line treatment for gliomas. Several fluorescent dyes are currently in use to augment intraoperative tumor visualization, but information on their comparative effectiveness is lacking. We performed systematic assessment of fluorescein sodium (FNa), 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX), and indocyanine green (ICG) fluorescence in various glioma models using advanced fluorescence imaging techniques. Methods: Four glioma models were used: GL261 (high-grade model), GB3 (low-grade model), and an in utero electroporation model with and without red fluorescence protein (IUE +RFP and IUE -RFP, respectively) (intermediate-to-low-grade model). Animals underwent 5-ALA, FNa, and ICG injections and craniectomy. Brain tissue samples underwent fluorescent imaging using a wide-field operative microscope and a benchtop confocal microscope and were submitted for histologic analysis. Results: Our systematic analysis showed that wide-field imaging of highly malignant gliomas is equally efficient with 5-ALA, FNa, and ICG, although FNa is associated with more false-positive staining of the normal brain. In low-grade gliomas, wide-field imaging cannot detect ICG staining, can detect FNa in only 50% of specimens, and is not sensitive enough for PpIX detection. With confocal imaging of low-intermediate grade glioma models, PpIX outperformed FNa. Discussion: Overall, compared to wide-field imaging, confocal microscopy significantly improved diagnostic accuracy and was better at detecting low concentrations of PpIX and FNa, resulting in improved tumor delineation. Neither PpIX, FNa, nor ICG delineated all tumor boundaries in studied tumor models, which emphasizes the need for novel visualization technologies and molecular probes to guide glioma resection. Simultaneous administration of 5-ALA and FNa with use of cellular-resolution imaging modalities may provide additional information for margin detection and may facilitate maximal glioma resection.

A standardized anesthetic/analgetic regimen compared to standard anesthetic/analgetic regimen for patients with high-risk factors undergoing open lumbar spine surgery: a prospective comparative single-center study.

The objective of the study is to improve the results of patients undergoing lumbar spine surgery who are at high risk for anesthesia and/or surgical complications. Two independent groups were compared: the study group (SG, n = 40) (standardized neuroanesthetic protocol with multimodal analgesia) and the control group (CG, n = 40) (intravenous anesthesia based on propofol and fentanyl). The data were collected using prospective observation of early and long-term results of lumbar fusion. After 24 months, the level of functional state and quality of life were studied. Patients in the SG did not have statistically significant changes in intraoperative hemodynamics; the best indicators of cognitive functions were noted. The effectiveness of the SG compared with the CG was confirmed by a statistically significantly lower amount of perioperative opioid drugs required (p = 0.01) and a minimal level of incisional pain (p < 0.05). An intergroup comparison of the adverse effects of anesthesia revealed a significantly lower number in the SG (n = 4) compared to the CG (n = 16) (p = 0.004). The number of postoperative surgical complications was comparable (p = 0.72). Intergroup comparison showed improved ODI, SF-36, and the Macnab scale at 24 months after surgery in the SG compared to the CG (p < 0.05). Long-term clinical results correlated with the level of incisional pain in the first three postoperative days. Our standardized neuroanesthetic protocol ensured effective treatment of postoperative incisional pain, significantly decreased the perioperative use of opioids, reduced adverse anesthesia events, and improved long-term clinical results in patients with high risk factors for anesthetic complications who undergoing open lumbar spine surgery.

Clinical and radiological outcomes of one-level cervical corpectomy with an expandable cage for three-column uncomplicated subaxial type «B¼ injures: a multicenter retrospective study.

PURPOSE: To evaluate the clinical and radiological results of the operative management of three-column uncomplicated type «B¼ subaxial injures treated with a one-level cervical corpectomy with an expandable cage. METHODS: This study included 72 patients with a three-column uncomplicated type «B¼ subaxial injures who met the inclusion criteria, underwent a one-level cervical corpectomy with an expandable cage at one of three neurosurgical departments between 2005 and 2020, and were followed up for clinical and radiological outcomes at a minimum 3-yr follow-up. RESULTS: There was a decrease in the VAS pain score from an average of 80 mm to 7 mm (p = 0.03); a decrease in the average NDI score from 62 to 14% (p = 0.01); excellent and good outcomes according to Macnab's scale were 93% (n = 67/72). There was an average change in the cervical lordosis (Cobb method) from -9.10 to -15.40 (p = 0.007), without significant loss of lordosis (p = 0.27). There was no significant degeneration of the adjacent levels by 3 years post-op. The fusion rate, using the Cervical Spine Research Society criteria, was poor: it was 62.5% (n = 45/72), and using the CT criteria, it was 65.3% (n = 47/72). 15.4% patients (n = 11/72) suffered complications. Statistical difference between the fusion and pseudoarthrosis (according to X-ray criteria) subgroups showed that there were no statistically significant differences in the smoking status, diabetes, chronic steroid use, cervical injury level, subtypes of AO type B subaxial injuries and types of expandable cage systems. CONCLUSIONS: One-level cervical corpectomy with an expandable cage, despite a poor fusion rate, can be considered a feasible and relatively safe method for treating three-column uncomplicated subaxial type «B¼ injures, with the benefit of immediate stability, anatomical reduction, and direct decompression of the spinal cord. While no one in our series had any catastrophic complications, we did note a high complication rate.

Minimally invasive decompression alone versus fusion surgery for acute lumbar disk herniation combined incomplete cauda equina syndrome.

STUDY DESIGN: Retrospective single center study. BACKGROUND: Cauda equine syndrome (CES), which caused by acute lumbar disc herniation (LDH), often requires urgent surgical treatment. Currently, there is no standard defining the type of surgery, and approaches to the treatment of patients are based on the experience of the surgeon. PURPOSE: to compare the clinical efficacy of minimally invasive decompression alone (Decompression alone group) and transforaminal lumbar interbody fusion (Fusion group) in the treatment of the incomplete CES, caused by acute LDH. PATIENTS AND METHODS: 89 patients with acute incomplete CES associated with LDH either underwent decompression alone and fusion surgery from January 2005 to January 2020 in single-center, and data were collected and retrospectively analyzed. The patients were divided into 2 groups according to the operation technics: the Decompression alone group (n = 46) and the Fusion group (n = 43). The perioperative clinical data (neurological deficit, control of the urinary bladder sphincter, ODI scale, SF-36) was used to assess the efficacy of the respective surgical methods before operation and with a minimum follow-up 24 months. RESULTS: Verified statistical significance more bleeding, longer surgery time and hospital stay, in the Fusion group than in the Decompression alone group. The postoperative clinical data dramatic improved after Decompression alone and Fusion surgery. At early postoperative period registered better clinical outcomes according to ODI, SF-36 after Decompression alone surgery, but at minimum follow-up 24 months verified better in the Fusion group. The number of revision interventions in the Decompression alone group was 28.3% (n = 13), in Fusion group - 9.3% (n = 4) (p = 0.02). CONCLUSIONS: The prevalence of acute incomplete CES due to LDH in our series was registered in 1.02% of patients (124 of 12087). In the Fusion group, in the long-term period, there were better clinical outcomes and fewer revision surgical interventions compared with Decompression alone.

Postoperative MRI Visualization of the Cervical Spine Following Cervical Disc Arthroplasty: A Prospective Single-Center Comparison of a Titanium and Cobalt-Chromium Prosthesis.

STUDY DESIGN: Prospective non-randomized single-center cohort study. OBJECTIVES: To analyze the quality of postoperative magnetic resonance imaging of 2 structurally different cervical disc arthroplasty devices at the index and adjacent levels. METHODS: A non-randomized, comparative, prospective, single-center study included 40 patients (23 men and 17 women) aged 32 (26-40) years. Two study groups were utilized: in the first (n = 20), a titanium prosthesis was used; in the second (n = 20), a cobalt-chromium implant was used. Evaluation of MRI studies before and after surgery was performed using sagittal and axial T2 weighted images by 2 specialists who were blinded to the prosthesis that was used. To determine the quality of an MRI image, the classification of Jarvik 2000, the radiological and orthopedic scales for assessing artifacts were used. RESULTS: There was good-to-excellent inter-observer agreement for all of the MR parameters used for the titanium and satisfactory-to-good for the cobalt chromium group. The analysis of the quality of postoperative imaging using the Jarvik 2000 scale showed a statistically significant deterioration in MR images in the cobalt chromium group (P < 0.001), compared to the titanium (P = 0.091). Following a single-level total arthroplasty, the titanium group had better MRI images according to radiological and orthopedic scales (P < 0.001). CONCLUSION: Titanium cervical disc arthroplasty devices result in superior postoperative MR imaging, as compared to cobalt chromium prostheses, as the latter significantly reduces image quality due to the pronounced ferromagnetic effect.

Seven bypasses simulation set: description and validity assessment of novel models for microneurosurgical training.

OBJECTIVE: Microsurgical training remains indispensable to master cerebrovascular bypass procedures, but simulation models for training that accurately replicate microanastomosis in narrow, deep-operating corridors are lacking. Seven simulation bypass scenarios were developed that included head models in various surgical positions with premade approaches, simulating the restrictions of the surgical corridors and hand positions for microvascular bypass training. This study describes these models and assesses their validity. METHODS: Simulation models were created using 3D printing of the skull with a designed craniotomy. Brain and external soft tissues were cast using a silicone molding technique from the clay-sculptured prototypes. The 7 simulation scenarios included: 1) temporal craniotomy for a superficial temporal artery (STA)-middle cerebral artery (MCA) bypass using the M4 branch of the MCA; 2) pterional craniotomy and transsylvian approach for STA-M2 bypass; 3) bifrontal craniotomy and interhemispheric approach for side-to-side bypass using the A3 branches of the anterior cerebral artery; 4) far lateral craniotomy and transcerebellomedullary approach for a posterior inferior cerebellar artery (PICA)-PICA bypass or 5) PICA reanastomosis; 6) orbitozygomatic craniotomy and transsylvian-subtemporal approach for a posterior cerebral artery bypass; and 7) extended retrosigmoid craniotomy and transcerebellopontine approach for an occipital artery-anterior inferior cerebellar artery bypass. Experienced neurosurgeons evaluated each model by practicing the aforementioned bypasses on the models. Face and content validities were assessed using the bypass participant survey. RESULTS: A workflow for model production was developed, and these models were used during microsurgical courses at 2 neurosurgical institutions. Each model is accompanied by a corresponding prototypical case and surgical video, creating a simulation scenario. Seven experienced cerebrovascular neurosurgeons practiced microvascular anastomoses on each of the models and completed surveys. They reported that actual anastomosis within a specific approach was well replicated by the models, and difficulty was comparable to that for real surgery, which confirms the face validity of the models. All experts stated that practice using these models may improve bypass technique, instrument handling, and surgical technique when applied to patients, confirming the content validity of the models. CONCLUSIONS: The 7 bypasses simulation set includes novel models that effectively simulate surgical scenarios of a bypass within distinct deep anatomical corridors, as well as hand and operator positions. These models use artificial materials, are reusable, and can be implemented for personal training and during microsurgical courses.

Molecular and Genetic Mechanisms of Spinal Stenosis Formation: Systematic Review.

Spinal stenosis (SS) is a multifactorial polyetiological condition characterized by the narrowing of the spinal canal. This condition is a common source of pain among people over 50 years old. We perform a systematic review of molecular and genetic mechanisms that cause SS. The five main mechanisms of SS were found to be ossification of the posterior longitudinal ligament (OPLL), hypertrophy and ossification of the ligamentum flavum (HLF/OLF), facet joint (FJ) osteoarthritis, herniation of the intervertebral disc (IVD), and achondroplasia. FJ osteoarthritis, OPLL, and HLF/OLFLF/OLF have all been associated with an over-abundance of transforming growth factor beta and genes related to this phenomenon. OPLL has also been associated with increased bone morphogenetic protein 2. FJ osteoarthritis is additionally associated with Wnt/ß-catenin signaling and genes. IVD herniation is associated with collagen type I alpha 1 and 2 gene mutations and subsequent protein dysregulation. Finally, achondroplasia is associated with fibroblast growth factor receptor 3 gene mutations and fibroblast growth factor signaling. Although most publications lack data on a direct relationship between the mutation and SS formation, it is clear that genetics has a direct impact on the formation of any pathology, including SS. Further studies are necessary to understand the genetic and molecular changes associated with SS.

An Algorithmic Posterior Approach to the Treatment of Multilevel Degenerative Cervical Spine Disease: A Multicenter Prospective Study.

BACKGROUND: The choice of surgical method for the treatment of multilevel degenerative cervical spine disease is based on the assessment of neurological symptoms and anatomical source of compression. However, such decision-making process remains complex and poorly defined. PURPOSE: To analyze the effectiveness of an algorithmic posterior approach to the surgical treatment of patients with multilevel degenerative disease of the cervical spine based on the preoperative clinical and imaging parameters. STUDY DESIGN: Prospective nonrandomized multicenter cohort study. METHODS: The study included 338 patients with multilevel degenerative disease of the cervical spine. Two groups of patients were evaluated at 3 neurosurgical centers between 2015 and 2019. The prospective group (Group I, n = 214) consisted of patients who were treated using an algorithm to decide whether they should be treated with an instrumented arthrodesis or a nonfusion procedure. The control group (Group II, n = 124) consisted of patients who underwent posterior decompression with or without stabilization between 2007 and 2014. A total of 192 patients in Group I and 112 in Group II had more than 2 years of follow-up. Visual analog scale (VAS) neck pain, Neck Disability Index (NDI), MacNab and Nurick Scales were collected. Perioperative complications were identified. RESULTS: At 2-year follow-up, Group I had significantly better clinical outcomes based on VAS neck pain score (P = 0.02), NDI score (P = 0.01), satisfaction with surgery on the MacNab Scale (P < 0.001), and outcome of surgery based on the Nurick Scale (P < 0.001). Complication rate was lower in Group I, 5.7% compared with 34.8% in Group II, P = 0.004. CONCLUSIONS: The algorithmic posterior approach to the surgical treatment of patients with multilevel degenerative disease of the cervical spine resulted in significant improvement of functional outcomes and a decrease in complications at a minimum 2 years of follow-up.

Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF) Compared with Open TLIF for Acute Cauda Equina Syndrome: A Retrospective Single-Center Study with Long-Term Follow-Up.

OBJECTIVES: In a retrospective study, we sought to compare the clinical efficacy and postoperative magnetic resonance imaging (MRI) scans of minimally invasive (MI) and open (O) transforaminal lumbar interbody fusion (TLIF) in the treatment of cauda equina syndrome (CES) caused by lumbar disc herniation. METHODS: In total, 116 patients with CES associated with disc herniation underwent decompression and stabilization surgery from January 2005 to January 2020 in a single-center study, and data were collected and retrospectively analyzed. The patients were divided into the O-TLIF and the MI-TLIF group. The perioperative clinical data and MRI assessment were used to assess the efficacy of the respective surgical methods preoperatively and with a minimum follow-up of 30 months. RESULTS: As expected, the O-TLIF group had statistically significantly longer surgery times and hospital stay, more bleeding, and perioperative surgical complications than the MI-TLIF group. At a minimum follow-up period of 30 months, the MI-TLIF group had significantly better Oswestry Disability Index, visual analog scale, and Short-Form-36, and neurologic CES symptoms than the O-TLIF group. The postoperative MRIs revealed a statistically significant difference in the multifidus muscle area in MI group compared with the O group. CONCLUSIONS: In patients with acute CES caused by disc herniation, MI-TLIF, with decreased disruption of paravertebral tissues and postoperative pain syndrome, results in earlier mobilization and rehabilitation with better long-term clinical outcomes compared with O-TLIF.

Case Report: Full-Endoscopic Surgery for Bullet Wounds of the Spine: A Report of Three Cases.

Objectives: To determine the feasibility and evaluate effectiveness of full-endoscopic surgery in gunshot wound of the spine. Methods: Three clinical cases of lumbar and thoracic spine bullet wounds made by firearms and traumatic weapons are described. Percutaneous endoscopic surgery was performed to extract bullet from the spinal canal. The results are compared to the data from literature. Results: Percutaneous endoscopic approach to spinal canal with a possibility to extract a bullet, decompression of nerve roots, defect closure of the dura mater is demonstrated. Conclusion: Good clinical outcomes allows to recommend percutaneous endoscopic surgery to manage similar lumbar and thoracic spine bullet wounds at the tertiary care level.

Minimally invasive corpectomy and percutaneous transpedicular stabilization in the treatment of patients with unstable injures of the thoracolumbar spine: Results of retrospective case series.

OBJECTIVE: The objective of this study was to analyze the results of surgical treatment of patients with unstable injuries of the thoracolumbar spine using simultaneous minimally invasive corpectomy and percutaneous transpedicular stabilization. MATERIALS AND METHODS: The retrospective study included 34 patients with isolated single-level unstable injuries of the thoracolumbar spine (5 or more points according to the Thoracolumbar Injury Classification and Severity Score (TLICS), operated on from the moment of injury from 8 to 24 h using the technique of minimally invasive corpectomy and percutaneous transpedicular stabilization simultaneously. The technical features of surgery, clinical data (pain level according to the Visual Analog Scale, quality of life according to the SF-36 questionnaire, subjective satisfaction with the operation according to the MacNab scale, and the presence of complications), and instrumental data (angle of segmental kyphotic deformity and sagittal index to and after surgery). The assessment of clinical data was carried out before surgery, at discharge, after 6 months, and in the long-term period, on average, 30 months after surgery. RESULTS: When evaluating the clinical data, a significant decrease in the severity of pain syndrome was found on average from 90 mm to 5.5 mm in the late follow-up (P < 0.001), as well as a significant improvement in the physical and psychological components of health according to the SF-36 questionnaire on average from 28.78 to 39.26 (P < 0.001), from 36.93 to 41.43 (P = 0.006), respectively. In the long-term period, according to the MacNab scale, the patients noted the result of the operation: excellent - 18 (52.9%), good - 13 (38.3%), and satisfactory - 3 (8.8%); no unsatisfactory results were registered. Four (11.8%) perioperative surgical complications were registered, which were successfully treated conservatively. A significant restoration of the sagittal profile with an insignificant change in blood pressure was recorded in the long-term postoperative period. An average follow-up assessment of 30 months according to the American Spinal Injury Association scale showed the presence of E and D degrees in 85.4% of patients. CONCLUSION: Minimally invasive corpectomy with percutaneous transpedicular stabilization in the treatment of patients with unstable injuries of the thoracolumbar spine can effectively eliminate kyphotic deformity and prevent the loss of its reduction with a low number of postoperative surgical complications. The technique has minimal surgical trauma with the possibility of early postoperative rehabilitation and provides a significant stable reduction in vertebrogenic pain syndrome, improvement of neurological deficits, and restoration of the quality of life of patients and in the follow-up.

Clinical-Instrumental Results and Analysis of Functional Activity Restoration in Professional Athletes After Lumbar Total Disk Replacement.

OBJECTIVE: To analyze the clinical and biomechanical outcome of professional athletes after lumbar total disk replacement, with a focus on restoration of the functional activity. METHODS: This nonrandomized retrospective single-center study included 11 professional athletes who underwent lumbar disc replacement surgery using the prosthesis M6-L (Spinal Kinetics, Schaffhausen, Switzerland). The average postoperative follow-up was 3.18 ± 1.14 years. The following outcomes were evaluated: intensity of pain in the lumbar spine and lower limbs, Oswestry Disability Index, Short-Form 36, complications, time of return to previous sports activity, range of movement, degree of lumbar lordosis, degenerative changes of the adjacent levels, and degree of heterotopic ossification. RESULTS: The operated patients reported significant decrease of pain on visual analog scale (P < 0.001) as well as significant improvement of Oswestry Disability Index (P = 0.001) and Short-Form 36 (P < 0.001). For the duration of follow-up, the patients maintained segmental range of motion at L4-L5 (P = 0.04) and L5-S1 (P = 0.03) levels. There was also some statistically insignificant increase of global lumbar lordosis (P = 0.84). We did not identify any significant degeneration of the adjacent intervertebral disks (P > 0.05) or progression of the facet joint degenerative changes at the implantation level and in the adjacent segments (P > 0.05). One patient (9.1%) developed grade I heterotopic ossification 5 years after surgery and in 1 patient (9.1%), a lesion of superior hypogastric plexus was recorded. The average time of return to previous sports activity was 9.72 ± 3.03 weeks. CONCLUSIONS: Total lumbar disc replacement using M6-L prosthesis in professional athletes made it possible to achieve statistically significant reduction of pain and facilitated early return to normal sports activities. In our opinion, preservation of movement of the operated lumbar segment can help to reduce the mechanical stress with beneficial impact on the rate of degeneration of the adjacent level.

Intraoperative Confocal Laser Endomicroscopy Ex Vivo Examination of Tissue Microstructure During Fluorescence-Guided Brain Tumor Surgery.

BACKGROUND: Noninvasive intraoperative optical biopsy that provides real-time imaging of histoarchitectural (cell resolution) features of brain tumors, especially at the margin of invasive tumors, would be of great value. To assess clinical-grade confocal laser endomicroscopy (CLE) and to prepare for its use intraoperatively in vivo, we performed an assessment of CLE ex vivo imaging in brain lesions. METHODS: Tissue samples from patients who underwent intracranial surgeries with fluorescein sodium (FNa)-based wide-field fluorescence guidance were acquired for immediate intraoperative ex vivo optical biopsies with CLE. Hematoxylin-eosin-stained frozen section analysis of the same specimens served as the gold standard for blinded neuropathology comparison. FNa 2 to 5 mg/kg was administered upon induction of anesthesia, and FNa 5 mg/kg was injected for CLE contrast improvement. Histologic features were identified, and the diagnostic accuracy of CLE was assessed. RESULTS: Of 77 eligible patients, 47 patients with 122 biopsies were enrolled, including 32 patients with gliomas and 15 patients with other intracranial lesions. The positive predictive value of CLE optical biopsies was 97% for all specimens and 98% for gliomas. The specificity of CLE was 90% for all specimens and 94% for gliomas. The second FNa injection in seven patients, a mean of 2.6 h after the first injection, improved image quality and increased the percentage of accurately diagnosed images from 67% to 93%. Diagnostic CLE features of lesional glioma biopsies and normal brain were identified. Seventeen histologic features were identified. CONCLUSIONS: Results demonstrated high specificity and positive predictive value of ex vivo intraoperative CLE optical biopsies and justify an in vivo intraoperative trial. This new portable, noninvasive intraoperative imaging technique provides diagnostic features to discriminate lesional tissue with high specificity and is feasible for incorporation into the fluorescence-guided surgery workflow, particularly for patients with invasive brain tumors.