Metastatic clear cell sarcoma of the pancreas: From diagnosis to treatment.

This article presents a comprehensive case report on an uncommon instance of metastatic clear cell sarcoma (CCS) originating from the pancreas. The high mortality rate of pancreatic carcinoma underscores the importance of precise diagnosis and early detection. The authors report a novel case of CCS with pancreatic metastasis, detailing successful surgical intervention through distal pancreatectomy and splenectomy, resulting in favourable outcomes. This study highlights the standard role of surgery in treating advanced CCS and emphasizes preoperative imaging and thorough patient history assessment. This article also underscores the necessity for long-term surveillance due to the potential for recurrence or metastasis. Despite the favourable recovery postsurgery, the absence of subsequent follow-up evaluation prompts consideration of the need for extended monitoring. This article raises questions about the nature of the pancreatic lesion and suggests the possibility of a primary lesion. Further evidence is crucial to establish the correlation between the features related to the development of the patient's primary and metastatic tumours. In conclusion, this study offers valuable insights into metastatic CCS of the pancreas, highlighting the importance of regular postoperative follow-up for improved outcomes through early detection and intervention.

Application of the cortical bone trajectory technique in posterior lumbar fixation.

The cortical bone trajectory (CBT) is a novel technique in lumbar fixation and fusion. The unique caudocephalad and medial-lateral screw trajectories endow it with excellent screw purchase for vertebral fixation via a minimally invasive method. The combined use of CBT screws with transforaminal or posterior lumbar interbody fusion can treat a variety of lumbar diseases, including spondylolisthesis or stenosis, and can also be used as a remedy for revision surgery when the pedicle screw fails. CBT has obvious advantages in terms of surgical trauma, postoperative recovery, prevention and treatment of adjacent vertebral disease, and the surgical treatment of obese and osteoporosis patients. However, the concept of CBT internal fixation technology appeared relatively recently; consequently, there are few relevant clinical studies, and the long-term clinical efficacy and related complications have not been reported. Therefore, large sample and prospective studies are needed to further reveal the long-term complications and fusion rate. As a supplement to the traditional pedicle trajectory fixation technique, the CBT technique is a good choice for the treatment of lumbar diseases with accurate screw placement and strict indications and is thus deserving of clinical recommendation.

Epidural gas-containing pseudocyst leading to lumbar radiculopathy: A case report.

BACKGROUND: Lumbar radiculopathy is a common symptom in the clinic and is often caused by lumbar disc herniation or osteophytes compressing the nerve root; however, it is rare for nerve roots to be compressed by epidural gas. Few symptomatic epidural gas-containing pseudocyst cases have been reported. Furthermore, the reported cases were due to a mix of gas and obvious osteophytes; therefore, it was hard to rigorously conclude that gas was the factor responsible for radiculopathy. We provide evidence that because no epidural gas accumulated before radiculopathy occurred and the symptoms were relieved after removal of the gas, the epidural gas-containing pseudocyst was the root cause of radiculopathy in this case. CASE SUMMARY: An 87-year-old man with a 3-wk history of right radiating pain was admitted to our hospital. Computed tomography (CT) and magnetic resonance imaging (MRI) examinations showed a vacuum phenomenon and huge lesions with low signal intensity located in the same area where the pain occurred. After carefully checking the images acquired in the last 3 mo, we found an abdominal CT examination performed 40 d prior because of abdominal pain. The CT images showed no gas-containing pseudocyst in the epidural space and notably, he had no leg pain at the time. To ensure a low-intensity intervention and complete decompression of the nerve, percutaneous endoscopic lumbar nerve decompression surgery was advised. A gas-containing pseudocyst was identified under endoscopy. The symptoms were relieved after surgery, and the postoperative images showed total disappearance of the vacuum phenomenon and lesions with low signal intensity on CT and MRI. Histological examination showed that the sampled gas-containing pseudocyst tissue was fibrous connective tissue. CONCLUSION: This case thoroughly illustrates that an epidural gas-containing pseudocyst can result in radiculopathic pain through a comprehensive evidence chain. Percutaneous endoscopic decompression is a minimally invasive and effective treatment method.

Endoscopically-Assisted Percutaneous Unilateral Atlantoaxial Screw-Rod Nonfusion Fixation Treatment for Type II Odontoid Fractures in Geriatric Patients: Case Series and Technical Note.

BACKGROUND: Considerable controversy exists regarding the optimal treatment for type II odontoid fractures in geriatric patients. Surgical intervention can help patients return to their prior level of function as rapidly as possible while avoiding the morbidity and mortality associated with prolonged and bedbound hospitalization. However, the optimal treatment is still a difficult choice for patients with increased risk from anesthesia. OBJECTIVES: The objective of our study was to describe an innovative method of endoscopically-assisted percutaneous unilateral C1 lateral mass screw and C2 pedicle screw-rod nonfusion fixation for type II odontoid fractures in geriatric patients. STUDY DESIGN: A case series design and technical notes. SETTING: This study took place at Second Affiliated Hospital of Chongqing Medical University. METHODS: Seven geriatric patients (> 65 years) with type II odontoid fractures and an American Society of Anesthesiologists (ASA) score of 2 or higher received endoscopically-assisted percutaneous unilateral atlantoaxial screw-rod nonfusion fixation. After surgery, all patients were required to wear a rigid collar full-time for 12 weeks. Intraoperative data, the bone union time, American Spinal Injury Association (ASIA) scale scores, Neck Disability Index (NDI) scores, and postoperative complications were collected for assessment.RESULTS The surgical goal was successfully achieved in all patients, 3 of whom had high ASA scores (>= 3) and underwent surgery under local anesthesia. The operative time ranged from 112 to 169 minutes (mean, 131.1 minutes). No neurovascular complications were observed intraoperatively or postoperatively. All patients rapidly returned to their prior level of function and were followed up for 12 to 24 months (average: 16.9 months). Bone union was achieved in all patients. LIMITATIONS: This study is limited by being a retrospective study. CONCLUSIONS: Endoscopically-assisted percutaneous unilateral atlantoaxial screw-rod nonfusion fixation is a feasible technique for type II odontoid fractures in geriatric patients. This method offers a compromise between non-operative and operative treatment and allows geriatric patients to rapidly return to their prior level of function. KEY WORDS: Endoscopically-assisted surgery; geriatric patient; percutaneous atlantoaxial fixation; type II odontoid fracture; unilateral nonfusion fixation.

Posterior Percutaneous Transpedicular Endoscopic Approach for Treating Single-Segment Cervical Myelopathy.

BACKGROUND: Standard posterior percutaneous endoscopic cervical discectomy (PECD) is considered an effective minimally invasive surgery. Although standard PECD can be used to treat radiculopathy with relatively minimal trauma, it is still a challenge to use this approach for treating myelopathy. OBJECTIVE: This report is aimed at first describing a posterior transpedicular approach under endoscopy for myelopathy and evaluating the feasibility and short-term clinical effects of this approach. METHODS: In our retrospective analysis between Feb. 2016 to Mar. 2017, 16 patients managed with PECD using the posterior transpedicular approach for symptomatic single-segment myelopathy. Surgery involved drilling 1/2 to 2/3 of the medial portion of the pedicle under endoscopy to provide sufficient space and an appropriate angle for inserting the endoscope into the spinal canal, followed by ventral decompression of the spinal cord. Computed tomography and magnetic resonance imaging were used to evaluate pedicle healing and spinal cord decompression. The primary outcomes included a visual analog scale (VAS) scores of axial neck pain and Japanese Orthopaedic Association (JOA) scores of neurological conditions. RESULTS: All patients completed a 1-year follow-up examination. The mean duration of surgery was 95.44 ± 19.44 min (52-130 min). The fluoroscopy duration was 5.88 ± 1.05 (4-7). The VAS scores of axial pain significantly improved from 6.94 ± 0.75 preoperatively to 2.88 ± 1.22 postoperatively (P < 0.05). The mean JOA scores improved from 8.50 ± 1.12 preoperatively to 14.50 ± 1.46 at the final follow-up (P < 0.05). The effects were excellent in 8 cases, good in 6 cases, and fair in 2 cases. After partial pedicle excision, the width of the remaining pedicle was 1.70 ± 0.22 mm postoperatively and significantly recovered to 3.38 ± 0.49 mm at the 1-year follow-up. There were no surgery-related complications, such as dural tearing, spinal cord injury, nerve root injury, pedicle fracture, and cervical hematocele or infection. CONCLUSIONS: The posterior transpedicular approach is an effective method for the treatment of myelopathy in select patients and is a supplement to the described surgical approach for PECD.

A Novel Posterior Trench Approach Involving Percutaneous Endoscopic Cervical Discectomy for Central Cervical Intervertebral Disc Herniation.

OBJECTIVE: This report describes a novel posterior trench approach involving percutaneous endoscopic cervical discectomy (PECD) for central cervical intervertebral disc herniation (CIVDH) and an evaluation of the feasibility, safety, and short-term clinical effect of this approach. BACKGROUND CONTEXT: Central CIVDH is considered the contraindication for posterior PECD. MATERIALS AND METHODS: A single-center retrospective observational study was performed with 30 patients managed with posterior PECD using the trench approach for symptomatic single-level central CIVDH. Primary outcomes included the measures of bodily pain and physical function based on the SF-36 and modified MacNab criteria. Radiographical follow-up included the static and dynamic cervical plain radiographs, computed tomographic scans, and magnetic resonance images. RESULTS: A positive clinical response for symptom relief was achieved in all patients. The postoperative MRI showed total removal of the herniated disc. CONCLUSIONS: As a supplement to the described surgical techniques of PECD, this trench approach provides novel access for the treatment of CIVDH, especially for the central type. The advantages of this technique include the provision of access to decompress the ventral region of the thecal sac and the ability to avoid damage to the facet joint. The steep learning curve might be a major disadvantage, and the sample volume is a limitation of the study; the effectiveness and reliability of the trench approach should be further verified in a comparative cohort study with a large volume of patients.

Anterior Transcorporeal Approach to Percutaneous Endoscopic Cervical Diskectomy for Single-Level Cervical Intervertebral Disk Herniation: Case Series with 2-Year Follow-Up.

OBJECTIVE: To examine the effects of anterior transcorporeal percutaneous endoscopic cervical diskectomy (ATPECD) for the treatment of single-level cervical intervertebral disk herniation (CIDH) with a focus on its safety, feasibility, clinical efficacy, and specific possible complications. METHODS: A series of 35 patients with symptomatic single-level CIDH were enrolled to be treated with ATPECD. Neck and arm pain was measured using the visual analog scale. Quality of life was measured using the bodily pain and physical function on the SF-36. The average disk height and vertical vertebral body height were recorded. Bone healing was evaluated on the basis of postoperative computed tomography. RESULTS: Successful removal of the herniated disk was confirmed in all 35 cases. At 2 years, the patients showed a significant treatment effect in the visual analog scale and body pain and physical function portions of the SF-36 (1.14 ± 0.60 vs. 7.62 ± 0.61, 63.92 ± 6.74 vs. 32.55 ± 6.80, and 82.14 ± 6.22 vs. 34.43 ± 4.50, respectively, P < 0.01). Mean preoperative disk height was 6.79 ± 0.37 mm, which decreased to 6.34 ± 0.46 mm 2 years post operation (6.6% decrease). Preoperative surgical vertebral body height also decreased from preoperation (15.79 ± 0.52 mm) to 2 years post operation (15.12 ± 0.38 mm) (4.2% decrease). Three surgery-related complications were observed (8.6%). CONCLUSIONS: Preliminary clinical experience with ATPECD shows that it is safe, effective, feasible, and minimally invasive. Although it has some disadvantages, such as the need for repeated fluoroscopy, some minor complications, and nonsymptomatic disk height decreases, ATPECD can supplement minimally invasive surgeries in selected cases of CIDH.

Biomechanical Study of Novel Unilateral Fixation Combining Unilateral Pedicle and Contralateral Translaminar Screws in the Subaxial Cervical Spine.

INTRODUCTION: In several situations, the stability of the subaxial cervical spine is damaged and involves the lateral mass of 1 side; in these cases, a pedicle screw (PS) or lateral mass screw (LMS) may not be suitable for placement on the affected side. Therefore, salvage short-segment fixation with satisfactory stability is needed when bilateral fixation is not feasible. METHODS: Seven fresh-frozen human cervical spine specimens were used to test the 3-plane range of motion (ROM) of the C4-C5 segment. Quasistatic 2-Nm flexibility testing was performed in the following sequence: 1) intact; 2) destabilization (using 3-column injury models) treated with bilateral mass screws (BMSs); 3) destabilization treated with a unilateral PS combined with a contralateral translaminar screw (UPS+CTLS); and 4) destabilization treated with bilateral PSs (BPSs). Then, a pullout strength test was performed for the PSs, LMSs, and translaminar screws (TLSs) using 7 isolated C4 and C5 vertebrae. RESULTS: The UPS+CTLS group showed no significant difference from the BMS group in the 3-plane ROM or from the BPS group in the axial rotation or flexion-extension ROM but showed a significantly greater lateral bending ROM than did the BPS group. The pullout strength test showed that both C4 and C5 TLSs had strength similar to that of LMSs but poorer than that of PSs. CONCLUSIONS: Fixation with the hybrid UPS+CTLS construct performed as well as BMS fixation in our biomechanical tests and may play a clinical role when BPS or BMS placement is not feasible for short-segment fixation.

Modified K-Hole Percutaneous Endoscopic Surgery for Cervical Foraminal Stenosis: Partial Pediculectomy Approach.

BACKGROUND: Percutaneous endoscopic cervical discectomy has evolved as an efficient, minimally invasive spine surgery for radiculopathy caused by soft and/or osseous foraminal stenosis. Although interlaminar access can be used to resect lateral herniated lesions or osteophytes located in the foramina, with limited operative space, nerve retraction may be unavoidable. This procedure may injure the nerve root and cause postoperative arm pain, numbness, and muscle weakness, especially when the herniation is located in the ventral nerve root or when there is a massive osteophyte in the foramina. However, posterior partial cervical pediculectomy under endoscopy provides a new approach to effectively reduce or even avoid nerve retraction and reduce the potential risk of nerve injury. OBJECTIVES: This report presents a partial pediculectomy approach and compares the clinical outcomes of different surgical methods, including posterior percutaneous endoscopic cervical discectomy (P-PECD) and P-PECD combined with partial pediculectomySTUDY DESIGN: This study used a retrospective comparative study design. SETTING: This study took place at the Second Affiliated Hospital of Chongqing Medical University. METHODS: From February 2015 to March 2017, 84 patients with single-level and unilateral soft and/or osseous cervical foraminal stenosis were recruited. Patients were treated with P-PECD (40 patients) and P-PECD combined with partial pediculectomy (44 patients). Postoperative clinical outcomes were assessed using the modified MacNab grading criteria and the Visual Analog Scale (VAS) at different times after surgery. The surgery duration, dosage of postoperative analgesic medication, duration of hospital stay, and postoperative complications were recorded. RESULTS: The mean duration of the conventional P-PECD surgery was 74.48 ± 7.08 minutes, which was significantly longer (P = 0.002) than that observed for the P-PECD with partial pediculectomy (66.00 ± 9.62 minutes). The analgesic dosage in the conventional P-PECD group was significantly higher than that in the partial pediculectomy group (9.14 ± 3.07 units vs. 5.71 ± 3.41 units; P = 0.001). The hospital stay in the conventional P-PECD group was significantly longer than that in the partial pediculectomy group (3.86 ± 0.85 days vs. 3.24 ± 0.83 days; P = 0.022). The VAS scores at 1 day, 3 days, and 7 days after surgery in the conventional P-PECD group were significantly higher than those in the partial pediculectomy group (all P < 0.001). The modified MacNab grading criteria showed no significant difference at each follow-up (P = 1). The incidence of complications in the P-PECD with partial pediculectomy group (2/44, 4.55%) was significantly lower than that in the conventional P-PECD group (4/40, 10.0%), including complications of increased pain, increased numbness, and worsening of muscle weakness. LIMITATIONS: This study is limited by being a retrospective study, and by having a small sample size and a short follow-up period. CONCLUSIONS: As an alternative to the P-PECD surgical technique, P-PECD with partial pediculectomy effectively reduced the postoperative complications and may be preferable when considering the surgery duration, postoperative hospital stay, analgesic dosage, and postoperative VAS score. KEY WORDS: Cervical disc herniation, foraminal stenosis, percutaneous endoscopic cervical discectomy, PECD, P-PECD, partial pediculectomy.

Treatment of Single-Level Thoracic Tuberculosis by Percutaneous Endoscopic Débridement and Allograft via the Transforaminal Approach Combined with Percutaneous Pedicle Screw Fixation: A Multicenter Study with a Median Follow-Up of 36 Months.

OBJECTIVE: To examine effects of percutaneous endoscopic débridement and allograft via the transforaminal approach combined with percutaneous pedicle screw fixation as treatment for single-level thoracic tuberculosis. METHODS: This multicenter retrospective analysis included 75 patients with single-level thoracic tuberculosis who underwent percutaneous endoscopic débridement and allograft via the transforaminal approach combined with percutaneous pedicle screw fixation and were followed for >36 months between January 2012 and December 2014. RESULTS: Follow-up was 36-48 months (average 41.1 ± 2.2 months). Intraoperative blood loss was low (average 30.5 ± 7.9 mL), and bed rest time was short (average 1.5 ± 0.3 days). No recurrence was observed in all 75 patients. Except for 3 patients, almost all patients (96%) achieved grade I or II fusion in interbody bone grafting. Segmental Cobb angle was 13.5° ± 4.1° before surgery, 10.5° ± 3.7° immediately after surgery, and 11.7° ± 3.9° at 36 months of follow-up. All patients achieved complete recovery of neurologic function (American Spinal Injury Association grade E), including 15 patients with spinal cord injury (American Spinal Injury Association grade D) before surgery. The visual analog scale and 36-Item Short-Form Health Survey scores significantly improved at 1, 3, 12, and 36 months of follow-up. No complications related to internal fixation occurred within the follow-up period; complication rate was 9.0%. CONCLUSIONS: Median follow-up clinical experience with percutaneous endoscopic débridement and allograft via the transforaminal approach combined with percutaneous pedicle screw fixation indicates that the technique is safe, effective, feasible, and minimally invasive.

Usage of Bone Wax to Facilitate Percutaneous Endoscopic Cervical Discectomy Via Anterior Transcorporeal Approach for Cervical Intervertebral Disc Herniation.

BACKGROUND: Currently, anterior transdiscal access and posterior interlaminar approach are the main approaches for percutaneous endoscopic cervical discectomy (PECD). To overcome access shortcomings, we previously described a novel anterior endoscopic transcorporeal approach on a migrated cervical disc. We innovatively introduced bone wax into endoscopic surgery to aid hemostasis and facilitate the process of drilling an intracorporeal tunnel. METHODS: Five patients with cervical intervertebral disc herniation (CIDH) were treated by PECD via the anterior transcorporeal approach. During the operation, we marked the punctured tunnel with bone wax containing indigo carmine as a guide and smeared bone wax on the endoscopic burr to aid hemostasis. RESULTS: A satisfactory clinical outcome was observed in all 5 patients postoperatively; pain and neurologic condition were dramatically improved. Surgery-related complications, such as esophageal injury, vascular rupture, hematoma, intervertebral disc infection, or postoperative headache, were not encountered. A computed tomography scan was used to observe the process of bone healing. At 3-month postoperative follow-up, the bone defect within the drilling tunnel had partially shrank and was completely healed at 6 months postoperatively. CONCLUSIONS: The anterior endoscopic transcorporeal approach for PECD is a novel, valuable alternative for the treatment of CIDH. Bone wax could indeed facilitate the operation by guiding the drilling process and instantly controlling the bleeding without obvious interference with bone healing. Long-term follow-up is warranted in further clinical studies.

Percutaneous Endoscopic Retrieval of Intraspinal Cement Leakage: Technical Note.

OBJECTIVE: We sought to preliminarily explore the efficacy and safety of percutaneous endoscopic spinal surgery for epidural cement leakage. We report a case series of patients who underwent percutaneous retrieval of leaked epidural cement and achieved spinal decompression under endoscopy. METHODS: Five patients with neurologic impairment due to epidural cement leakage after percutaneous vertebroplasty were treated with percutaneous endoscopic spinal decompression. Computed tomography reconstruction and 3-dimensional imaging were used to evaluate the extruded material. During follow-up at 3, 6, and 12 months postoperatively, all patients were advised to undergo plain radiograph and computed tomography examinations. RESULTS: The leaked epidural cement was successfully removed in all patients under percutaneous endoscopy through a unilateral or bilateral approach. At the 12-month follow-up, the visual analog scale score of all patients improved. In addition, the neurologic function of each patient improved to at least 1 grade level, as evaluated using the American Spinal Injury Association. According to the modified MacNab criteria, 2 patients had excellent recovery, whereas the other 3 patients had good recovery. CONCLUSIONS: We described a novel and minimally invasive procedure to ameliorate intractable epidural cement extrusion. As an alternative to conventional laminectomy, percutaneous endoscopic retrieval achieved the targeted decompression without damaging the posterior lamina. Moreover, the whole operation was performed under regional anesthesia accompanied with dexmedetomidine sedation, allowed real-time neural function evaluation, and had lower risks of anesthesia-related complications, compared with general anesthesia.

Foraminoplasty at the Tip or Base of the Superior Articular Process for Lateral Recess Stenosis in Percutaneous Endoscopic Lumbar Discectomy: A Multicenter, Retrospective, Controlled Study with 2-Year Follow-Up.

OBJECTIVE: To compare the clinical efficacy and complications which obtained foraminoplasty at the tip or base of the superior articular process (SAP) for the patients with lateral recess stenosis treated by percutaneous endoscopic lumbar discectomy (PELD). METHODS: Between January 2015 and January 2016, 156 patients of lumbar disc herniation accompanying with lateral recess stenosis were treated with PELD in five tertiary hospitals and fulfilled the 2-year follow-up. Among them, 78 patients obtained a foraminoplasty at the tip of SAP (group A), and foraminoplasty at the base of SAP was performed in the other 78 cases (group B). Clinical efficacy was evaluated using the visual analog scale (VAS) score for back and leg pain, Oswestry Disability Index (ODI), and 36-item Short-Form Health Survey (SF-36) score. The intervals of follow-up were scheduled at 1 month, 3 months, 6 months, 1 year, and 2 years after surgery. RESULTS: Mean operative duration is shorter in group B (55 versus 61 min, P = 0.047). Only one case belonged to group A could not tolerate the neural irritation and required conversion to an open procedure. During the surgery, no dura tears, cauda equina syndrome, or infections were observed. 5 patients experienced transient dysesthesia located at the exiting nerve in group A, while no cases complained dysesthesia in group B. 2 cases who suffered temporary motor weakness all belonged to group A. A total of 5 cases obtained a revision surgery after recurrence in the follow-up, in which 3 patients belonged to group A. Compared to the preoperative data, significant improvements in VAS scores of low back pain and sciatica, ODI, and SF-36 PCS and MC were observed in the follow-up, respectively (P < 0.05, respectively). However, no statistical difference was observed at all time-points after surgery between these two groups (P > 0.05, respectively). CONCLUSIONS: For the patients of LDH accompanying with lateral recess stenosis, compared with the routine foraminoplasty at the tip of SAP, our modified foraminoplastic technique does not only change place of foraminoplasty to the base of SAP but also simplified puncture process in transforaminal PELD. Although there was no significant difference in symptom relief, the modified foraminoplasty showed the advantages in decreasing the incidence of postoperative neural dysfunction and reducing operation time.