Comparison of the clinical efficacy of percutaneous transforaminal endoscopic discectomy and traditional laminectomy in the treatment of recurrent lumbar disc herniation.

ABSTRACT: A few years ago, percutaneous transforaminal endoscopic discectomy (PTED) began to prevail in clinical treatment of recurrent lumbar disc herniation (RLDH), whereas traditional laminectomy (TL) was treated earlier in RLDH than PTED. This study aimed to compare the clinical efficacy of PTED and TL in the treatment of RLDH.Between November 2012 and October 2017, retrospective analysis of 48 patients with RLDH who were treated at the Cancer Hospital, Chinese Academy of Sciences, Hefei and Department of Orthopaedics, Second Affiliated Hospital of Anhui Medical University. Perioperative evaluation indicators included operation time, the intraoperative blood loss, length of incision and hospitalization time. Clinical outcomes were measured preoperatively, and at 1 days, 3 months, and 12 months postoperatively. The patients' lower limb pain was evaluated using Oswestry disability index (ODI) and visual analog scale (VAS) scores. The ODI is the most widely-used assessment method internationally for lumbar or leg pain at present. Every category comprises 6 options, with the highest score for each question being 5 points. higher scores represent more serious dysfunction. The VAS is the most commonly-used quantitative method for assessing the degree of pain in clinical practice. The measurement method is to draw a 10 cm horizontal line on a piece of paper, 1 end of which is 0, indicating no pain, which the other end is 10, which means severe pain, and the middle part indicates different degree of pain.Compared with the TL group, the operation time, postoperative bed-rest time, and hospitalization time of the PTED group were significantly shorter, and the intraoperative blood loss was also reduced. These differences were statistically significant (P < .01). There were no significant differences in VAS or ODI scores between the two groups before or after surgery (P > .05).PTED and TL have similar clinical efficacy in the treatment of RLDH, but PTED can shorten the operation time, postoperative bed-rest time and hospitalization time, and reduce intraoperative blood loss, so the PTED is a safe and effective surgical method for the treatment of RLDH than TL, but more randomized controlled trials are still required to further verify these conclusions.

Comparision of biportal endoscopic and microscopic decompression in treatment of lumbar spinal stenosis: A comparative study protocol.

BACKGROUND: Microscopic bilateral decompression (MBD) has been suggested as an alternative to open laminectomy and fusion. Recently, percutaneous biportal endoscopic decompression (PBED) has begun to attract attention. The purpose of this retrospective study was to evaluate postoperative pain, functional disability, symptom reduction and satisfaction, and specific surgical parameters between the MBD and PBED techniques in patients with lumbar spinal stenosis (LSS). METHODS: A retrospective review of LSS patients performed with MBD or PBED technique between May 2015 and June 2018 was conducted. Institutional review board approval in People's Hospital of Ningxia Hui Nationality Autonomous Region was obtained prior to conducting chart review and analysis. We received informed consent from all patients before surgery. The primary outcomes assessed were the preoperative to postoperative changes in leg/back pain and disability/function, patient satisfaction with the procedure, and postoperative quality of life. The secondary outcomes including duration of postoperative hospital stay, time to mobilization, postoperative analgesic use, complication rates, and baseline patient characteristics were prospectively collected. RESULTS: The hypothesis was that the PBED technique would achieve better clinical outcomes as compared to the MBD technique in LSS.

Comparison of bilateral decompression via unilateral laminotomy and conventional laminectomy for single-level degenerative lumbar spinal stenosis regarding low back pain, functional outcome, and quality of life - A Randomized Controlled, Prospective Trial.

BACKGROUND: Conventional posterior open lumbar surgery is associated with considerable trauma to the paraspinal muscles. Severe damage to the paraspinal muscles could cause low back pain (LBP), resulting in poor functional outcomes. Thus, several studies have proposed numerous surgical techniques that can minimize damage to the paraspinal muscles, particularly unilateral laminotomy for bilateral decompression. The purpose of this study is to compare the degree of postoperative LBP, functional outcome, and quality of life of patients between bilateral decompression via unilateral laminotomy (BDUL; group U) and conventional laminectomy (CL; group C). METHODS: Of 87 patients who underwent diagnostic and decompression surgery, 50 patients who met the inclusion and exclusion criteria and were followed up for > 2 years were enrolled. The patients were asked to record their visual analog scale pain score after 6, 12, and 24 months postoperatively. BDUL was used for group U, whereas CL was used for group C. The patients were randomly divided based on one of the two techniques, and they were followed up for over 2 years. Functional outcomes were assessed by the Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), and SF-36. RESULTS: Operation time was significantly shorter in group U than in group C (p = 0.003). At 6, 12, and 24 months, there was no significant difference between the two groups in terms of spine-related pain (all p > 0.05). Functional outcomes using ODI and RMDQ and quality of life using SF-36 were not significantly different between the groups (all p > 0.05). CONCLUSIONS: Regarding single-level decompression for degenerative lumbar spinal stenosis, group U had the advantages of shorter operation time than group C, but not in terms of back pain, functional outcome, and quality of life.

Bony decompression vs duraplasty for Chiari I malformation: does the eternal dilemma matter?

PURPOSE: The management of Chiari I malformation (CIM) still raises the problem of the optimal surgical treatment, with special regard to the "eternal dilemma" of the posterior fossa bony decompression alone (PFBD) or with duraplasty (PFBDD). The goal of the present review is to update the results (outcome and complications) of both techniques to better understand the correct indication for each of them. METHODS: A review of the literature has been performed, focusing on the articles and the meta-analyses specifically addressing the problem of PFBD vs PFBDD. Also, the personal authors' experience is briefly discussed. RESULTS: PFBD (usually with C1 laminectomy, often with delamination of the external dural layer) is the most commonly used technique in children, especially if syringomyelia is absent. It ensures a high success rate, with > 80% clinical improvement and about 75% reduction of the syringomyelia, and a very low risk of complications, hospital stay, and costs. A certain risk of recurrence is present (2-12%). PFBDD (with autologous tissues or dural substitutes), on the other hand, is mostly used not only in adults but also in children with large syringomyelia. It is burdened by a higher risk of complications (namely, the CSF-related ones), longer hospital stay, and higher costs; however, it warrants a better clinical improvement (> 85%) and a lower risk of reoperation (2-3.5%). Eight meta-analyses of the literature (three on pediatric series and five in adult series) and one prospective study in children, published in the last decade, largely confirm these findings. CONCLUSION: PFBD and PFBDD are different techniques that are indicated for different types of patients. In children, PFBD has been demonstrated to represent the best choice, although some patients may require a more aggressive treatment. Therefore, the success in the management of CIM, with or without syringomyelia, depends on the correct indication to surgery and on a patient-tailored choice rather than on the surgical technique.

Anterior cervical discectomy and fusion with stand-alone anchored cages versus posterior laminectomy and fusion for four-level cervical spondylotic myelopathy: a retrospective study with 2-year follow-up.

BACKGROUND: The optimal treatment for multi-level cervical spondylotic myelopathy (CSM) remains controversial. Posterior approach is most commonly used, but complicated with insufficient decompression and postoperative axial neck pain. The anterior approach is effective in neural decompression with less surgical trauma. However, the profile of the plate or the possible construct failure may cause dysphagia after surgery. Recently, anterior cervical discectomy and fusion (ACDF) with self-anchored cage is reported to have a superior result over ACDF with anterior plates and screws in three-level CSM. The purpose of the study is to compare the clinical and radiological outcomes of ACDF using stand-alone anchored cages to that of laminectomy with fusion (LF) for treating four-level CSM. METHODS: Twenty-six patients underwent four-level ACDF (Group A) and 32 patients with four-level LF (Group B) were retrospectively reviewed and followed-up for 24 months. Clinical efficacy was evaluated by comparing pre- and post-operative Japanese Orthopedic Association (JOA) and Neck Disability Index (NDI) scores. Operative time, blood loss, fusion, lordosis change and complications were evaluated. RESULTS: There was significantly less blood loss in Group A (163.4 ± 72.1 ml) than Group B (241.0 ± 112.3 ml) (P < 0.05). Both groups demonstrated significant improvements in JOA and NDI scores after surgery with similar operative time. Improvements in cervical lordosis and fused segment lordosis were more pronounced in Group A (11.3 ± 5.9°, 9.7 ± 5.3°) than Group B (5.8 ± 4.6°, 5.5 ± 4.5°) (P < 0.05). Loss of lordosis in the cervical spine and fused segment was more prominent in Group A (11.7 ± 2.2°, 6.7 ± 3.2°) than Group B (7.5 ± 3.8°, 3.7 ± 3.4°) (P < 0.05) at the final follow-up. Complication rate in Group A and Group B was 57.69 and 18.75%, respectively. CONCLUSIONS: ACDF using a stand-alone anchored cage showed similar clinical results to LF for the treatment of four-level CSM, with better lordosis correction and less blood loss. However, ACDF was associated with more loss of lordosis after surgery and more non-unions.

Return-to-Duty Rates Following Minimally Invasive Spine Surgery Performed on Active Duty Military Patients in an Ambulatory Surgery Center.

BACKGROUND: Low back pain is a primary health care utilization driver in the US population. Health care evaluation visits for low back pain are as common as medical evaluation for the common cold. Low back pain is the most common reason for reductions in activities of daily living and work activity in the general population. Although these statistics are compelling, in the military population, there is arguably a significantly greater economic impact on the military population, as the cost to train, retain, and deploy a service member is a tremendous cost. METHODS: The current study retrospectively examines surgical outcomes, return to duty, and patient-centric outcomes among 82 active duty or reserve military patients who underwent an outpatient minimally invasive spine surgery Laminotomy Foraminotomy Decompression for the treatment of lumbar spinal stenosis in an ambulatory surgery center. FINDINGS: Overall, our results indicate that within the 82 active duty military service members, 100% of the service members return to duty within 3 mo. Additionally, there was a significant reduction in self-reported pain and disability 12 mo postoperative, whereas the average length of surgery was 62 min with an average estimated blood loss of 30.64 mL. DISCUSSION: The current study indicates that minimally invasive procedures for the treatment of lumbar spinal stenosis in an ambulatory surgery center setting are an effective option for active duty servicemen to reduce return-to-duty rates and symptomatic back-related pain and disability.

The learning curve for veterinary surgery residents performing hemilaminectomy surgeries in dogs.

OBJECTIVE To describe the learning curve for veterinary surgery residents performing hemilaminectomy surgeries in dogs. DESIGN Retrospective case review and learning curve evaluation. SAMPLE 13 individuals who completed a 3-year surgery residency program at a university teaching hospital and who had no prior experience performing hemilaminectomies. PROCEDURES The 13 residents performed hemilaminectomies on 399 dogs between July 2006 and July 2013. Medical records were reviewed, and operative time was recorded. Data were examined with a linear mixed-effects model to quantify fixed and random effects, a curve-fitting technique to find the best-fit curve, and a segmented 2-phase linear model to describe the domains and learning rates for 2 phases of learning. RESULTS The linear mixed-effects model indicated that increasing patient body weight and increasing surgical complexity (graded on the basis of number and contiguity of hemilaminectomy sites) were associated with longer operative times and that increasing exposure number was associated with shorter operative times. The monoexponential and biexponential parametric curves were of similar quality in modeling the data. The segmented 2-phase linear model showed an early phase of learning during which operative time decreased rapidly and a late phase when operative time decreased more gradually. CONCLUSIONS AND CLINICAL RELEVANCE The learning curve for the residents suggested that for early exposures, instruction in the form of direct supervision provided substantial benefit. By the tenth exposure, the benefit of instruction diminished and ongoing improvement was primarily a result of refinement. If validated by further study, this understanding of a 2-phase learning curve may inform the design of training programs in veterinary surgery.

Laminectomy and fusion versus laminoplasty for the treatment of degenerative cervical myelopathy: results from the AOSpine North America and International prospective multicenter studies.

BACKGROUND CONTEXT: It remains unclear whether cervical laminoplasty (LP) offers advantages over cervical laminectomy and fusion (LF) in patients undergoing posterior decompression for degenerative cervical myelopathy (DCM). PURPOSE: The objective of this study is to compare outcomes of LP and LF. STUDY DESIGN/SETTING: This is a multicenter international prospective cohort study. PATIENT SAMPLE: A total of 266 surgically treated symptomatic DCM patients undergoing cervical decompression using LP (N=100) or LF (N=166) were included. OUTCOME MEASURES: The outcome measures were the modified Japanese Orthopaedic Association score (mJOA), Nurick grade, Neck Disability Index (NDI), Short-Form 36v2 (SF36v2), length of hospital stay, length of stay in the intensive care unit, treatment complications, and reoperations. METHODS: Differences in outcomes between the LP and LF groups were analyzed by analysis of variance and analysis of covariance. The dependent variable in all analyses was the change score between baseline and 24-month follow-up, and the independent variable was surgical procedure (LP or LF). In the analysis of covariance, outcomes were compared between cohorts while adjusting for gender, age, smoking, number of operative levels, duration of symptoms, geographic region, and baseline scores. RESULTS: There were no differences in age, gender, smoking status, number of operated levels, and baseline Nurick, NDI, and SF36v2 scores between the LP and LF groups. Preoperative mJOA was lower in the LP compared with the LF group (11.52±2.77 and 12.30±2.85, respectively, p=.0297). Patients in both groups showed significant improvements in mJOA, Nurick grade, NDI, and SF36v2 physical and mental health component scores 24 months after surgery (p<.0001). At 24 months, mJOA scores improved by 3.49 (95% confidence interval [CI]: 2.84, 4.13) in the LP group compared with 2.39 (95% CI: 1.91, 2.86) in the LF group (p=.0069). Nurick grades improved by 1.57 (95% CI: 1.23, 1.90) in the LP group and 1.18 (95% CI: 0.92, 1.44) in the LF group (p=.0770). There were no differences between the groups with respect to NDI and SF36v2 outcomes. After adjustment for preoperative characteristics, surgical factors and geographic region, the differences in mJOA between surgical groups were no longer significant. The rate of treatment-related complications in the LF group was 28.31% compared with 21.00% in the LP group (p=.1079). CONCLUSIONS: Both LP and LF are effective at improving clinical disease severity, functional status, and quality of life in patients with DCM. In an unadjusted analysis, patients treated with LP achieved greater improvements on the mJOA at 24-month follow-up than those who received LF; however, these differences were insignificant following adjustment for relevant confounders.

An Interlaminotomy New Zealand White Rabbit Model to Evaluate Novel Epidural Strategies.

OBJECTIVE: The New Zealand White (NZW) rabbit model is an established animal model for examining surgical methods to prevent epidural scar formation after spine surgery. As most approaches include complete laminectomy of the rabbit vertebra, this procedure is associated with high morbidity and mortality rates. We examined a less invasive technique, the microsurgical interlaminotomy, for testing epidural substance application in the rabbit spine. METHODS: Surgery was performed in the cadaver rabbit spine to evaluate the approach before performing it in NZW rabbits. All surgical procedures were performed under an operation microscope. Female rabbits with a mean weight of 4770 g ± 240 g were used. Neurologic symptoms were analyzed based on predefined scores. After resection of the spinal process, the caudal part of the upper lamina was resected using a drill and a 1-mm Kerrison punch. The yellow ligament was resected resulting in a dural exposure of ∼ 5 × 10 mm. RESULTS: Eight pilot interlaminotomies were performed on three cadaveric spines to establish the surgical approach. Twenty-one NZW rabbits were then operated on using the interlaminotomy model. Three rabbits (14.3%) died during surgery due to anesthesia-related complications. Two rabbits (9.5%) showed partial paresis of the lower extremities and one (4.8%) a complete paraplegia. The remaining 15 rabbits (71.4%) had an uneventful recovery without neurologic symptoms. The mean surgical duration was 88 +/- 28 minutes. CONCLUSION: The rabbit interlaminotomy model is associated with few neurologic deficits and a relatively short operating time.

Laminoplasty instead of laminectomy as a decompression method in posterior instrumented fusion for degenerative cervical kyphosis with stenosis.

BACKGROUND: Posterior laminectomy with instrumented fusion is a standard procedure for treating degenerative cervical kyphosis with stenosis (DCKS). Two major disadvantages of the surgery are adhesion of the dural membrane with significant disfiguring of cervical spine and a small fusion bed around the lateral mass. One of the advantages of laminoplasty over laminectomy is the protection of the dural membrane from adhesion through preservation of posterior bony elements. This study presents the surgical outcomes of laminoplasty, instead of laminectomy, as a decompression method applied in posterior instrumented fusion for DCKS. METHODS: A consecutive single center series of twenty cases between 2008 and 2011 were retrospectively reviewed. They were diagnosed as DCKS and received anterior cervical fusion followed by expansive open door laminoplasty and lateral mass or pedicle screw instrumented fusion. We collected the functional scores and changes of cervical curvature on the basis of dynamic lateral films preoperatively and postoperatively. We used computed tomography scans and magnetic resonance imaging (MRI) to evaluate the status of fusion and decompression. RESULTS: The mean age at the time of surgery was 67.6 ± 15.2 years. Half of the patients were older than 75 years. All functional scores and cervical lordotic curvatures markedly improved. No recurrence of spinal cord compression was caused by closure of opened laminae, according to MRI study that was conducted 12 months postoperatively. No pseudarthrosis or hardware loosening was observed 24 months postoperatively. CONCLUSION: The surgical aims for DCKS are adequate decompression, correction of kyphosis, and solid instrumented fusion. Laminoplasty applied in cervical fusion as a decompression method seems to lead to a favorable functional recovery and reduces the complications of perineural adhesion that typically occur after laminectomy. In addition, laminoplasty affords an additional fusion bed at the hinge side and this advantage benefits solid fusion mass formation for the patients who suffered from DCKS.

Patient outcomes for a minimally invasive approach to treat lumbar spinal canal stenosis: is microendoscopic or microscopic decompressive laminotomy the less invasive surgery?

OBJECTIVE: We performed a study to compare the severity of surgical stress between microscopic and microendoscopic decompressive laminotomy performed via a unilateral approach in patients with lumbar spinal canal stenosis (LSCS). MATERIALS AND METHODS: A total of 41 patients received decompressive laminotomy for lumbar spinal stenosis. Twenty patients received microscopic decompressive laminotomy (MDL), and 21 patients received microendoscopic decompressive laminotomy (MEDL). The pre- and postoperative Japanese Orthopaedic Association (JOA), and Visual Analogue Scale (VAS) lower leg pain scores were evaluated. The other variables studied were the length of the operation, blood loss, length of hospital stay, the reaction of the CRP and WBC levels, the dosage of non-steroidal anti-inflammatory drugs (NSAIDs) used and surgical complications. RESULTS: The clinical analyses of the surgical outcomes were evaluated after a minimum two-year follow-up. The pre-and postoperative JOA scores and VAS in the MDL and MEDL groups were statistically similar. There were statistically significant differences found between the lengths of the operation time, blood loss, length of hospital stay, the reaction of CRP, and the pain indicated by the dosage of NSAIDs. The length of the operation time was longer in the MEDL group, and the other variables were greater in the MDL group. CONCLUSIONS: The MEDL procedure is less invasive and safer than the MDL procedure. Hence, MEDL is an effective technique for treating symptomatic LSCS patients.

[Thromboprophylaxis and platelet aggregation inhibitors in spinal surgery: perioperative management]. / Thromboseprophylaxe und Aggregationshemmer in der Wirbelsäulenchirurgie: perioperative Management.

BACKGROUND: The perioperative use of anticoagulants (AC) and platelet aggregation inhibitors (PAI) in the field of spinal surgery suggests an increased rate of epidural bleeding. However, evidence is lacking and these medications are most often indispensable in the prevention of thromboembolic complications. Comprehensive recommendations for the correct use of AC and PAI are lacking. OBJECTIVE: The aim of this study was an analysis of the current situation with regards to the use of AC and PAI in spinal surgery and development of new recommendations. MATERIAL AND METHODS: Two independent surveys on the perioperative use of AC and PAI were obtained from centers for spinal surgery in Germany. The study obtained information on the perioperative use of AC and PAI, risk assessment of thromboembolic and hemorrhagic events as well as on the type and extent of the substance groups used. RESULTS: Almost the entire patient collective (98%) received perioperative low molecular weight heparin. In 64% the medical prophylaxis was started before surgery and in 36% after surgery. The period of prophylaxis was determined arbitrarily. Approximately 40% of interviewees employed paravertebral infiltration and 19% injected into the epidural space in patients on PAI medication. Open spinal canal surgery was performed in 30% of PAI medicated patients and closed spinal canal surgery was executed in 40%. The risk assessment of PAI differed significantly between aspirin and receptor blocker medication as well as dual administration of PAI. DISCUSSION: The use of AC and PAI in spinal surgery in Germany is very heterogeneous and large deviations from the guidelines frequently occurred. Therefore, there is a strong need for further studies to accurately assess the perioperative use of AC and PAI and to formulate precise recommendations.

A novel approach to improving the safety of patients undergoing lumbar laminectomy.

The anesthesiology field has recently embraced the use of checklists to obviate the need for long-term memory, improve safety, and achieve goals and tasks. These checklists serve to increase safety, improve consumer satisfaction, and reduce mortality and morbidity. Spinal surgery with the patient lying prone is associated with complex morbidities when there is inattention to proper positioning technique. Problems arising from malpositioning of the patient undergoing spinal surgery are attributed to body habitus and the body's contact with specialized and complex operating room table frames. Common problems associated with the prone position are brachial plexus injury, cervical spine nerve injuries, and postoperative visual loss. The purpose of this research project was to examine the use of a checklist for nurse anesthetists who provide care for patients undergoing spinal surgery. The checklist addressed specific positioning needs as a means of decreasing mortality and morbidity. It is theorized that the use of a checklist will serve as a systematic aid to memory and enable the anesthetist to adhere to proper positioning techniques in this patient population and thereby improve outcomes.

Can low-grade spondylolisthesis be effectively treated by either coflex interlaminar stabilization or laminectomy and posterior spinal fusion? Two-year clinical and radiographic results from the randomized, prospective, multicenter US investigational device exemption trial: clinical article.

OBJECT: Posterolateral spinal fusion (PSF) has long been the standard of care for degenerative spondylolisthesis, but less invasive, motion-preserving alternatives have been proposed to reduce the complications associated with fusion while still providing neural decompression and stabilization. The object of the current study is to evaluate the safety and efficacy of coflex Interlaminar Stabilization compared with PSF to treat low-grade spondylolisthesis with spinal stenosis. METHODS: This is a prospective, randomized, multicenter FDA investigational device exemption (IDE) trial comparing coflex Interlaminar Stabilization with laminectomy and PSF. A total of 322 patients from 21 sites in the US were enrolled between 2006 and 2008 for the IDE trial. The current study evaluated only the subset of patients from this overall cohort with Grade 1 spondylolisthesis (99 in the coflex group and 51 in the fusion group). Subjects were randomized 2:1 to receive decompression and coflex interlaminar stabilization or decompression and posterolateral spinal fusion with spinal instrumentation. Data collected included perioperative outcomes, Oswestry Disability Index (ODI), back and worse leg visual analog scale (VAS) scores, 12-Item Short Form Health Survey, Zurich Claudication Questionnaire (ZCQ), and radiographic outcomes at a minimum of 2 years. The FDA criteria for overall device success required the following to be met: 15-point reduction in ODI, no reoperations, no major device-related complications, and no postoperative epidural injections. RESULTS: At a minimum of 2 years, patient follow-up was 94.9% and 94.1% in the coflex and fusion control groups, respectively. There were no group differences at baseline for any demographic, clinical, or radiographic parameter. The average age was 63 years in the coflex cohort and 65 years in the fusion cohort. Coflex subjects experienced significantly shorter operative times (p < 0.0001), less estimated blood loss (p < 0.0001), and shorter length of stay (p < 0.0001) than fusion controls. Both groups experienced significant improvements from baseline at 2 years in ODI, VAS back, VAS leg, and ZCQ, with no significant group differences, with the exception of significantly greater ZCQ satisfaction with coflex at 2 years. FDA overall success was achieved in 62.8% of coflex subjects (59 of 94) and 62.5% of fusion controls (30 of 48) (p = 1.000). The reoperation rate was higher in the coflex cohort (14 [14.1%] of 99) compared with fusion (3 [5.9%] of 51, p = 0.18), although this difference was not statistically significant. Fusion was associated with significantly greater angulation and translation at the superior and inferior adjacent levels compared with baseline, while coflex showed no significant radiographic changes at the operative or index levels. CONCLUSIONS: Low-grade spondylolisthesis was effectively stabilized by coflex and led to similar clinical outcomes, with improved perioperative outcomes, compared with PSF at 2 years. Reoperation rates, however, were higher in the coflex cohort. Patients in the fusion cohort experienced significantly increased superior and inferior level angulation and translation, while those in the coflex cohort experienced no significant adjacent or index level radiographic changes from baseline. Coflex Interlaminar Stabilization is a less invasive, safe, and equally efficacious clinical solution to PSF to treat low-grade spondylolisthesis, and it appears to reduce stresses at the adjacent levels. Clinical trial registration no.: NCT00534235 (ClinicalTrials.gov).

Can we define success criteria for lumbar disc surgery? : estimates for a substantial amount of improvement in core outcome measures.

BACKGROUND AND PURPOSE: A successful outcome after lumbar discectomy indicates a substantial improvement. To use the cutoffs for minimal clinically important difference (MCID) as success criteria has a large potential bias, simply because it is difficult to classify patients who report that they are "moderately improved". We propose that the criteria for success should be defined by those who report that they are "completely recovered" or "much better". METHODS: A cohort of 692 patients were operated for lumbar disc herniation and followed for one year in the Norwegian Registry for Spine Surgery. The global perceived scale of change was used as an external criterion, and success was defined as those who reported that they were "completely recovered" or "much better". Criteria for success for each of (1) the Oswestry disability index (ODI; score range 0-100 where 0 = no disability), (2) the numerical pain scale (NRS; range 0-10 where 0 = no pain) for back and leg pain, and (3) the Euroqol (EQ-5D; -0.6 to 1 where 1 = perfect health) were estimated by defining the optimal cutoff point on receiver operating characteristic curves. RESULTS: The cutoff values for success for the mean change scores were 20 (ODI), 2.5 (NRS back), 3.5 (NRS leg), and 0.30 (EQ-5D). According to the cutoff estimates, the proportions of successful outcomes were 66% for the ODI and 67% for the NRS leg pain scale. INTERPRETATION: The sensitivity/specificity values for the ODI and leg pain were acceptable, whereas they were very low for the EQ-5D. The cutoffs for success can be used as benchmarks when comparing data from different surgical units.

Evaluation of tenoxicam on prevention of arachnoiditis in rat laminectomy model.

Post laminectomy arachnoiditis has been shown by experiments with rats and post operative radiological imaging in humans. The purpose of this experimental study was to determine the efficacy of tenoxicam in preventing arachnoiditis in rats. Twenty-four Wistar rats were divided into two groups, and L3 laminectomy was performed. In the tenoxicam group, 0.5 mg/kg tenoxicam was applied intraperitoneally. Normal saline was applied intraperitoneally in the control group. Later, the rats were killed at weeks 3 and 6, and the laminectomy sites were evaluated pathologically for arachnoiditis. The results showed that 6 weeks after surgery, the tenoxicam group showed lowest arachnoiditis grades. However, statistically significant difference was not found in arachnoiditis between the control group and the tenoxicam group. Based on these findings it is concluded that application of the tenoxicam after lumbar laminectomy did not effectively reduce arachnoiditis. Performing the most effective surgical technique without damage around tissue in a small surgical wound and having meticulous hemostasis in surgery seem to be the key for preventing arachnoiditis effectively.

Laminectomy in patients with achondroplasia: the impact of time to surgery on long-term function.

STUDY DESIGN: Retrospective analysis, survey. OBJECTIVE: To describe a cohort of individuals with achondroplasia undergoing thoracolumbar laminectomy and to examine if shorter time to surgery was related to improvement in long-term functional outcome. SUMMARY OF BACKGROUND DATA: Data on the long-term benefits of laminectomy are mixed for such patients. Earlier intervention may be associated with greater likelihood of long-term benefit, but quantified data are lacking. METHODS: We retrospectively studied 49 patients with achondroplasia who underwent primary laminectomy for spinal stenosis. Patients completed a questionnaire to assess symptoms, walking distance, and independence (per Modified Rankin Scale), before surgery and currently. Responses were analyzed for the likelihood of improved walking distance or Rankin level. RESULTS: Our patients had the following mean values: age, 37.7 ± 10.6 years; body mass index, 31.8 ± 5.5; symptom duration, 74.0 ± 100.1 months; preoperative symptom severity score, 2.7 ± 1.0 points; mean changes in blocks walked, +0.39 ± 2.0; and Rankin level, +0.08 ± 1.47. Patients with a time-to-surgery interval of <6 months were 7.13 times (95% confidence interval [CI], 1.39-36.66) more likely to experience improvement in walking distance and 4.00 times (95% CI, 1.05-15.21) more likely to experience Rankin level improvement than patients whose interval was >6 months. Intervals of up to 12 and 24 months were associated with increased likelihoods of 4.95 (95% CI, 1.41-17.41) and 3.43 (95% CI, 1.05-11.22), respectively, of improved walking distance compared with those with longer time-to surgery intervals, but those Rankin level improvements were not statistically significant. CONCLUSION: Time from symptom onset to surgery in patients with achondroplasia is an important predictor of long-term functional outcome. For sustained long-term postsurgical improvement, the window of opportunity might be relatively narrow. Patients with achondroplasia should seek medical advice for spinal stenotic symptoms as soon as possible.

Metastases to the craniovertebral junction.

OBJECTIVE: This study reviews the relevant literature regarding the management of craniovertebral junction (CVJ) metastases. These rare tumors present significant diagnostic and treatment challenges. METHODS: A PubMed search of cervical spine, cervical spine metastasis, craniovertebral junction, atlantoaxial spine, and metastasis radiation was conducted to define the epidemiology, imaging, and treatment protocols in the management of metastatic CVJ tumors. RESULTS: CVJ tumors represent less than 1% of spinal metastases, and the literature is limited to small case series. CVJ tumors present with flexion, extension, and rotational pain, often associated with occipital neuralgia. Magnetic resonance imaging is the most sensitive imaging modality for the detection of spinal metastases, but plain x-rays, computed tomography, and [18F]2-fluoro-2-deoxy-D-glucose play a role in diagnosis and management. Conventional external beam radiation therapy or stereotactic radiosurgery effectively treat the majority of patients with normal spinal alignment or minimal fracture subluxations. Surgery should be considered in patients with fracture subluxations greater than 5 mm, or 3.5 mm subluxation with 11-degree angulation. The palliative goals for surgery favor posterior approaches only including laminectomy for decompression, without the need for anterior approaches with the associated morbidity. Occipitocervical instrumentation using screw-rod systems are effective for irreducible subluxations, but posterior strategies using C1-C2 or C1-C3 can be used for patients with reducible subluxations. CONCLUSION: Effective management of CVJ tumors using radiation and/or surgery results in significant pain and functional improvement in properly selected patients. Advanced surgical techniques and stereotactic radiation may improve outcomes with less morbidity.

Spinal cord compression caused by idiopathic intradural arachnoid cysts of the spine: review of the literature and illustrated case.

Intradural spinal arachnoid cysts with cord compression are rare. When becoming symptomatic they cause variable symptoms involving gait disturbance, paraparesis or tetraparesis and neuropathic pain, decreasing significantly the patients' life quality. The extension of such cysts averages 3.7 vertebral bodies. The diagnosis is clinical and radiological with the use of MRI, CT myelography or a combination of both. The best treatment option is complete removal of the cyst. However, even when paresis is regressing there is no good recovery from neuropathic pain. Laminectomy approach can cause postoperative complications especially when the cyst(s) expand(s) in more than one level. Alternatively, a cyst fenestration can be performed, including the levels of the maximal spinal cord compression. The clinical outcome is as good as after the cyst resection enabling the patient to walk again. The neuropathic pain may persist and require medication. A clinical case is presented, and the literature is reviewed. In the present case we report a patient with intradural arachnoid cysts extending from T6 to L2 and causing severe gait ataxia as well as neuropathic pain and hypaesthesia. The spinal-cord was compressed at T8 and T12. Surgical treatment with partial cyst resection in the compressed levels with an interlaminar approach brought similar results as complete resection. The patient was able to walk without help which was not possible before surgery. The cysts' extension is impressive as well as the minimal operative procedure.

Is it necessary to operate all split cord malformations before corrective surgery for patients with congenital spinal deformities?

STUDY DESIGN: Retrospective case series. OBJECTIVES: To evaluate the necessity of neurosurgical interventions for split cord malformations (SCMs) before correction and instrumentation for patients with congenital spinal deformity(CSD)s. SUMMARY OF BACKGROUND DATA: SCMs are commonly associated with CSD. As pathology of SCMs understood well, the common belief of all SCM must be operated before any orthopedic intervention is needed to be revised. MATERIALS AND METHODS: Sixty-one consecutive patients with CSD and spinal dysraphism treated by correction and posterior instrumentation between 1994 and 2005 were retrospectively evaluated. Inclusion criteria were patients with CSD and SCM, who were treated with long segment instrumentation (more than 6 functional units) with at least 2 years of follow-up. Thirty-two patients (8 male and 24 female) with an age average of 11 years +8 months (4-18 years) fulfilled the criteria. While all patients with Type I SCM were managed with neurosurgical intervention (spur excision and dural reconstruction) before corrective surgery, Type II SCM cases were treated by instrumented fusion without neurologic intervention. RESULTS: There were 18 patients with Type I and 14 patients with Type II SCM. The average follow-up was 52 (24-144) months. The correction rate of deformity was 44% in type I and 47% in Type II SCM. Two patients with Type II SCM had transient neurologic deterioration while there were no neurologic events in patients with Type II SCM. CONCLUSION: Due to high incidence of SCMs, all patients with CSDs must be evaluated with MRI, before surgery. Neurosurgical interventions are recommended even for neurologically asymptomatic Type I SCM before spinal deformity surgery; however, patients with Type II SCM can be treated safely without a need of neurosurgical intervention.