Cervical kyphoscoliosis / Cifoescoliosis cervical

Cervical kyphoscoliosis is an uncommon spinal deformity. Kyphosis or outward curvature of cervical-spine (Image A) has led to a fixed flexion state resulting in suspension of patient's head in the air while lying on the imaging table. Additionally, dextroscoliosis or rightward convexity of the cervical vertebral axis has resulted in a persistent leftward head tilt (Image B). Head and neck radiation and trauma can lead to cervical kyphoscoliosis. In addition to the cosmetic deformity, patients present with myelopathic sensorimotor symptoms such as weakness and tingling of upper extremities. The Poisson effect states that flexion of the spine lengthens and stretches the spinal canal, reduces its area and narrows its lumen. This causes spinal cord impingement and myelopathy.

La cifoescoliosis cervical es una deformidad de la columna vertebral poco frecuente. La cifosis o la curvatura hacia fuera de la columna cervical (imagen A) ha dado lugar a un estado de flexión fija que provoca la suspensión de la cabeza del paciente en el aire mientras está tumbado en la mesa de diagnóstico por imagen. Además, la dextroscoliosis o convexidad hacia la derecha del eje vertebral cervical ha dado lugar a una inclinación persistente de la cabeza hacia la izquierda (Imagen B). La radiación de cabeza y cuello y los traumatismos pueden provocar cifoescoliosis cervical. Además de la deformidad estética, los pacientes presentan síntomas sensoriomotores mielopáticos como debilidad y hormigueo en las extremidades superiores. El efecto Poisson establece que la flexión de la columna vertebral alarga y estira el canal espinal, reduce su área y estrecha su lumen. Esto provoca el pinzamiento de la médula espinal y la mielopatía.

Curative effect of anterolateral spinal canal decompression combined with short segment screw fixation with posterior approach for severe thoracolumbar burst fractures with spinal cord injury / 中国骨伤

OBJECTIVE@#To explore the effect of anterolateral spinal canal decompression combined with short segment screw fixation with posterior approach for severe thoracolumbar burst fractures with spinal cord injury.@*METHODS@#From January 2016 to June 2018, 16 patients with severe thoracolumbar burst fractures (more than 50% of ratio of spinal canal encroachment, reverse fragment at the posterior edge of the vertebral body) with spinal cord injury were retrospectively analyzed, including 10 males and 6 females, ranging in age from 19 to 57 years old. Causes of injury:8 cases of fall injury, 6 cases of traffic accident injury and 2 cases of other injuries. Fracture site:T@*RESULTS@#All 16 patients were followed up, and the average follow up time was (15.9±5.4) months. The average operation time was (234±41) minutes and the average amount of bleeding was (431±93) ml. The loss of anterior height of injured vertebrae was (52.25±10.10)% before operation, (8.93± 3.61)% at 3 days after operation, and (9.25±2.88)% at the latest follow up. The results of 3 days after operation and the latest follow up were better than that before operation, and there was no significant differencesbetween results at the latest follow up and 3 days after operation (@*CONCLUSION@#For severe thoracolumbar burst fracture and spinal cord injury, with more than 50% of ratio of spinal canal encroachment and reverse fragment at the posterior edge of the vertebral body, the anterolateral spinal canal decompression combined with short segment screw fixation with posterior approach has the characteristics of accurate reduction, complete decompression and firm fixation, and the clinical effect is satisfactory.

Discectomía, artrodesis intersomática y estabilización en mielopatía espondilótica cervical. Presentación de un caso / Discectomy, artrodesis and stabilization in cervical spondylotic myelopathy. Presentation of a case

RESUMEN Las alteraciones degenerativas de la columna se engloban en el término de espondilosis cervical. La mielopatía espondilótica cervical (MEC) es la forma más común de disfunción del cordón espinal en mayores de 55 años. Se considera la intervención quirúrgica en la mayoría de los casos de mielopatía cervical espondilótica evidente desde el punto de vista clínico, dado el riesgo de deterioro neurológico. En la mayoría de los casos de mielopatía cervical, la descompresión de la médula espinal genera estabilización o mejoría de la función de los haces largos medulares. La función es mejor cuando se restablecen bien las dimensiones del conducto vertebral después de la descompresión, cuando la descompresión es más precoz y cuando no hay comorbilidad considerable.

ABSTRACT The degenerative alterations of the column are included in the term of cervical espondilosis. The cervical spondylotic myelopathy it is the form more common of disfuntion of the spinal cord in bigger than 55 years. It is considered the surgical intervention in most of the cases of cervical spondylotic myelopathy evident from the clinical, given point of view the risk of neurological deterioration. In most of the cases of cervical myelopathy, the decompression of the spinal marrow generates stabilization or improvement of the function of the medullary long sheaves. The function is better when they recover well the dimensions of the vertebral conduit after the decompression, when the decompression is more precocious and when there is not considerable comorbility.

Analysis of Preoperative Factors Affecting Postoperative Spinal Canal Expansion after Posterior Decompression for the Treatment of Multilevel Cervical Myelopathy / 대한척추외과학회지

STUDY DESIGN: Retrospective analysis OBJECTIVES: To evaluate preoperative factors related with spinal canal expansion after posterior decompression for the treatment of multilevel cervical myelopathy. SUMMARY OF LITERATURE REVIEW: Data about preoperative factors related with spinal canal expansion after posterior cervical decompression surgery are inconsistent. MATERIALS AND METHODS: We reviewed 67 patients with cervical myelopathy who underwent posterior laminectomy or laminoplasty. Radiologically, we evaluated the C2-7 Cobb angle and range of motion using X-rays from the preoperative assessment and final follow-up. Expansion of the spinal canal at 6 weeks postoperatively was evaluated using magnetic resonance imaging and compared with the preoperative values. The preoperative factors of age, sex, number of operated levels, operation method, and radiological parameters were investigated as factors potentially related to postoperative spinal canal expansion using multivariate regression and correlation analyses. The clinical outcome was analyzed by the Neck Disability Index (NDI) and Japanese Orthopaedic Association (JOA) scores. RESULTS: The postoperative spinal canal expansion was 4.76 mm in sagittal images and 4.31 mm in axial images, with higher values observed in males and cases of severe preoperative cord compression. A lordotic preoperative Cobb angle was related to postoperative spinal canal expansion and JOA score improvement, but without statistical significance. The clinical outcomes of NDI (18.3→14.8) and JOA scores (10.81→14.6) showed improvement, but were not significantly related with any preoperative factors. CONCLUSIONS: The amount of preoperative spinal canal stenosis was associated with postoperative spinal canal expansion after posterior decompression in multilevel cervical myelopathy. The preoperative Cobb angle was not related to postoperative spinal canal expansion or clinical improvement.

Factors Associated with the Effect of Conservative Treatment in Surgically Indicated Single-Level Lumbar Spinal Stenosis Patient / 대한척추외과학회지

STUDY DESIGN: Retrospective study of date collected prospectively.OBJECTIVES: To report analytic results about association factors related to effect of conservative treatment in surgically indicated single level lumbar spinal stenosis patient.SUMMARY OF LITERATURE REVIEW: There have been various reports about clinical outcomes and relative factors after surgical treatment of spinal stenosis. However, there are few reports about factors related to effect of conservative treatment in surgically indicated lumbar spinal stenosis patient.MATERIALS AND METHODS: We based on 40 patients who had visited our hospital from May 2010 to April 2016 who were traceable for at least three years. We analysed 20 patients who improved symptom and who didn't improved symptom then investigated association factors related to effect of conservative treatment. Clinical assessment was conducted using questionnaire and spinal canal's area and muscle amount were measured in the MRI.RESULTS: Average of the spinal canal of not-improved group is 91.29(±34.26) mm², improved group is 130.70 (±32.18) mm² and impoved group is wider (p=0.001). Muscle mass of improved group is 91.47(±9.43) cm², not-improved group is 79.26 (±14.35) cm², and improved group is wider (p=0.003). Repetitive strain and traffic accident were related in not-improved group (p=0.028). However, practiced stretching continuously were related to symptom improvement (p=0.022).CONCLUSIONS: Association factors related to effect of conservative treatment are cases of wide spinal canal, wide muscle amount, repetitive sprain, traffic accident and stretching. A small muscle amount can be considered as a key factor related to surgical conversion.

Cervical Spine CT Using Spectral Shaping: Can It Be a Solution to Overcome Artifacts in the Lower Cervical Spinal Region?

OBJECTIVE: To investigate the image quality, radiation dose, and intermodality agreement of cervical spine CT using spectral shaping at 140 kVp by a tin filter (Sn140-kVp) in comparison with those of conventional CT at 120 kVp. MATERIALS AND METHODS: Patients who had undergone cervical spine CT with Sn140-kVp (n = 58) and conventional 120 kVp (n = 49) were included. Qualitative image quality was analyzed using a 5-point Likert scale. Quantitative image quality was assessed by measuring the noise and attenuation within the central spinal canals at C3/4, C6/7, and C7/T1 levels. Radiation doses received by patients were estimated. The intermodality agreement for disc morphology between CT and MRI was assessed at C3/4, C5/6, C6/7, and C7/T1 levels in 75 patients who had undergone cervical spine MRI as well as CT. RESULTS: Qualitative image quality was significantly superior in Sn140-kVp scans than in the conventional scans (p < 0.001). At C7/T1 level, the noise was significantly lower and the decrease in attenuation was significantly less in Sn140-kVp scans, than in the conventional scans (p < 0.001). Radiation doses were significantly reduced in Sn140-kVp scans by 50% (effective dose: 1.0 ± 0.1 mSv vs. 2.0 ± 0.4 mSv; p < 0.001). Intermodality agreement in the lower cervical spine region tended to be better in Sn140-kVp acquisitions than in the conventional acquisitions. CONCLUSION: Cervical spine CT using Sn140-kVp improves image quality of the lower cervical region without increasing the radiation dose. Thus, this protocol can be helpful to overcome the artifacts in the lower cervical spine CT images.

Unplanned Second-Stage Decompression for Neurological Deterioration Caused by Central Canal Stenosis after Indirect Lumbar Decompression Surgery

STUDY DESIGN: Prospective cohort study. PURPOSE: This study aimed to identify risk factors for unplanned second-stage decompression for postoperative neurological deficit after indirect decompression using lateral lumbar interbody fusion (LLIF) with posterior fixation. OVERVIEW OF LITERATURE: Indirect lumbar decompression with LLIF has been used as a minimally invasive alternative to direct decompression to treat degenerative lumbar diseases requiring neural decompression. However, evidence on the prevalence of neurological deficits caused by spinal canal stenosis after indirect decompression is limited. METHODS: This study included 158 patients (mean age, 71.13±7.98 years; male/female ratio, 67/91) who underwent indirect decompression with LLIF and posterior fixation. Indirect decompression was performed at 271 levels (mean level, 1.71±0.97). Logistic regression analysis was used to identify the risk factors for postoperative neurological deficits. The variables included were age, sex, body mass index, presence of primary diseases, diabetes mellitus, preoperative motor deficit, levels operated on, preoperative severity of lumbar stenosis, and preoperative Japanese Orthopedic Association (JOA) score. RESULTS: Postoperative neurological deficit due to spinal canal stenosis occurred in three patients (1.9%). Spinal stenosis due to hemodialysis (p<0.001), ligament ossification (p<0.001), presence of preoperative motor paralysis (p<0.001), low JOA score (p=0.004), and severe canal stenosis (p=0.02) were significantly more frequent in the paralysis group. CONCLUSIONS: Severe preoperative canal stenosis and neurological deficit were identified as risk factors for postoperative neurological deterioration caused by spinal canal stenosis. Additionally, uncommon diseases, such as spinal stenosis due to hemodialysis and ligament ossification, increased the risk of postoperative neurological deficit; therefore, in such cases, indirect decompression is contraindicated.

Segmental Spinal Dysgenesis–“Redefined”

STUDY DESIGN: Retrospective single institutional observational study. PURPOSE: Segmental spinal dysgenesis (SSD), a complex spinal dysraphic state caused by notochord malformation disorders, is named after its morphological presentation where a spine segment is dysgenetic, malformed or absent. This study’s objective was to examine and reassess SSD imaging findings and correlate them with an embryological explanation. OVERVIEW OF LITERATURE: Scott and his colleagues defined SSD as segmental agenesis or dysgenesis of the lumbar or thoracolumbar vertebrae and underlying spinal cord. Tortori-Donati and his colleagues defined it as a morphologic continuum ranging from hypoplasia to an absent spinal cord segment. METHODS: Fifteen children, whose imaging findings and clinical features were consistent with SSD, were included in the study. Magnetic resonance imaging (MRI) was performed per institutional spine protocol. RESULTS: Five children (33.3%) presented with a high-ending bulbous cord with no caudal segment, six (40%) presented with a dorsal or lumbar segmental dysgenetic cord with a low-lying, bulky caudal cord but without significant spinal canal narrowing, and four (26.6%) presented with segmental caudal dysgenesis with severe kyphoscoliosis, gibbus deformity, and spinal canal narrowing with a normal distal segment (normal or low-lying). CONCLUSIONS: SSD is a complex spinal anomaly in children requiring clinical-radiological assessment followed by multidisciplinary management based on the extent and severity of the dysgenetic cord and the type of SSD. MRI plays a crucial role in both diagnosing and classifying SSD prior to surgical treatment to prevent further impairment.

A comprehensive review of the sinuvertebral nerve with clinical applications / 대한해부학회지

The anatomy and clinical significance of the sinuvertebral nerve is a topic of considerable interest among anatomists and clinicians, particularly its role in discogenic pain. It has required decades of research to appreciate its role, but not until recently could these studies be compiled to establish a more complete description of its clinical significance. The sinuvertebral nerve is a recurrent nerve that originates from the ventral ramus, re-entering the spinal canal via the intervertebral foramina to innervate multiple meningeal and non-meningeal structures. Its complex anatomy and relationship to discogenic pain have warranted great interest among clinical anatomists owing to its sympathetic contribution to the lumbar spine. Knowledge of the nerve has been used to design a variety of diagnostic and treatment procedures for chronic discogenic pain. This paper reviews the anatomy and clinical aspects of the sinuvertebral nerve.

Intramuscular Hematoma on the Psoas Muscle / 대한신경손상학회지

Intramuscular hematomas on the psoas muscle are rare and usually occur as a result of trauma, iatrogenic etiology during lumbar surgery, rupture of the aortic aneurysm, and hematologic diseases. The incidence of spontaneous psoas muscle hematomas has slowly increased as a result of using anticoagulation and antiplatelet agents. Magnetic resonance (MR) imaging is a more sensitive option compared to computed tomography (CT) when diagnosing a hematoma. Coronal T2-weighted images are more useful. CT imaging is also useful to establish the rapid diagnosis of hematoma. When a prolonged prothrombin time and international normalized ratio and decrease platelet count are noted, psoas muscle hematomas should be considered, if there was no lesion in the spinal canal. Most hematomas resolve spontaneously without clinical complications if the hematoma is not large or it is not compressing the surrounding important structures, irrespective of cause.

Efficacy of Biportal Endoscopic Spine Surgery for Lumbar Spinal Stenosis

BACKGROUND: Biportal endoscopic spine surgery (BESS) is a recent addition to minimally invasive spine surgery treatments. It boasts excellent magnification and fine discrimination of neural structures. Selective decompression with preservation of facet joints for structural stability is also feasible owing to access to the spinal canal and foramen deeper inside. This study has a purpose to investigate clinical benefits of BESS for spinal stenosis in comparison to the other common surgical treatments such as microscopic decompression-only (DO) and fusion and instrumentation (FI). METHODS: From December 2013 to March 2015, 30 cases of DO, 48 cases of FI, and 66 consecutive cases of BESS for lumbar spinal stenosis (LSS) were enrolled to evaluate the relative clinical efficacy of BESS. Visual analog scale (VAS) for back pain and leg pain, postoperative hemoglobin, C-reactive protein (CRP) changes, transfusion, and postoperative complications were examined. RESULTS: All the patients were followed up until 6 months, and 98 patients (86.7%) for 2 years. At the 6-month follow-up, VAS for back pain improved from 6.8 to 2.8, 6.8 to 3.2, and 6.8 to 2.8 (p = 0.078) for BESS, DO, and FI, respectively; VAS for leg pain improved from 6.3 to 2.2, 7.0 to 2.5, and 7.2 to 2.5 (p = 0.291), respectively. Two cases in the BESS group underwent additional foraminal decompression, but no fusion surgery was performed. Postoperative hemoglobin changes for BESS, DO, and FI were −2.5, −2.4, and −1.3 mL, respectively. The BESS group had no transfusion cases, whereas 10 cases (33.3%) in DO and 41 cases (85.4%) in FI had transfusion (p = 0.000). CRP changes for BESS, DO, and FI were 0.32, 6.53, and 6.00, respectively, at day 2 postoperatively (p = 0.000); the complication rate for each group was 8.6% (two dural tears and one root injury), 6.7% (two dural tears), and 8.3% (two dural tears and two wound infections), respectively. CONCLUSIONS: BESS for LSS showed clinical results not inferior to those of the other open surgery methods in the short-term. Stable hemodynamic changes with no need for blood transfusion and minimal changes in CRP were thought to cause less injury to the back muscles with minimal bleeding. Foraminal stenosis decompression should be simultaneously conducted with central decompression to avoid an additional surgery.

Anatomic Considerations of Anterior Transarticular Screw Fixation for Atlantoaxial Instability

STUDY DESIGN: Cadaveric, observational study.PURPOSE: Atlantoaxial instability (AAI) is characterized by excessive movement at the C1–C2 junction between the atlas and axis. An anterior surgical approach to expose the upper cervical spine for internal fixation and bone grafting has been developed to fix AAI. Currently, no anatomic information exists on the anterior transarticular atlantoaxial screw or screw and plate fixation between C1 and C2 in the Indian population. The objective of this study is to assess the anatomic landmarks of C1–C2 vertebrae: entry point, trajectory, screw length, and safety of the procedure.OVERVIEW OF LITERATURE: Methods outlined by Magerl and Harms are the optimal approaches among the dorsal techniques. Contraindications for these techniques include aberrant location of vertebral arteries, fractures of C1–C2 posterior structures. In these cases, anterior transarticular fixation is an alternative. Several available screw insertion trajectories have been reported. Biomechanical studies have demonstrated that adequate rigidity of this fixation is comparable with posterior fusion techniques.METHODS: Direct measurements using Vernier calipers and a goniometer were recorded from 30 embalmed human cadavers. The primary parameters measured were the minimum and maximum lateral and posterior angulations of the screw in the sagittal and coronal planes, respectively, and optimum screw length, if it was placed accurately.RESULTS: The posterior and lateral angles of screw placement in the coronal and sagittal planes ranged from 16° to 30° (mean±standard deviation [SD], 23.93°±3.93°) and 8° to 17° (mean±SD, 13.3°±2.26°), respectively. The optimum screw length was 25–38 mm (mean±SD, 28.76±3.69 mm).CONCLUSIONS: If the screw was inserted without lateral angulation, the spinal canal or cord could be violated. If a longer screw was inserted with greater posterior angulation, the vertebral artery at the posterior or posterolateral aspect of the C1 superior facet could be violated. Thus, 26° and 30° of lateral and posterior angulations, respectively, are the maximum angles permissible to avoid injury of the vertebral artery and violations of the spinal canal or atlanto-occipital joint.

Vertebral hydatidosis: bibliographical review and clinical case report / Hidatidose vertebral: revisão bibliográfica e relato de caso clínico / Hidatidosis vertebral: revisión bibliográfica y reporte de caso clínico

ABSTRACT We will present a literature review of the vertebral location of hydatidosis. It is a rare, locally aggressive condition with a high recurrence rate that requires clinical treatment (antihelminthic drugs) and surgery, with decompression of the spinal canal. We report a case with more than 11 years of follow-up, which required surgical treatment on 4 occasions. Level of Evidence V; Therapeutic-investigational study of treatment results.

RESUMO Estaremos apresentando uma revisão bibliográfica da localização vertebral da hidatidose, patologia de baixa frequência, localmente agressiva, com alta taxa de recorrência, que requer tratamento médico (antihelmíntico) e cirúrgico com a descompressão do canal espinhal. Nós reportamos um caso com seguimentos de mais de 11 anos, que exigiu tratamento cirúrgico em 4 oportunidades. Nível de Evidência V; Estudo terapêutico - investigação dos resultados do tratamento.

RESUMEN Presentaremos una revisión bibliográfica de la localización vertebral de la hidatidosis. Es una patología poco frecuente, agresiva localmente, con alta tasa de recurrencia y que requiere tratamiento clínico (medicaciones antihelmínticas) y quirúrgico, con descompresión del canal vertebral. Mostramos un caso clínico con seguimiento de más de 11 años, el que requirió tratamiento quirúrgico en 4 oportunidades. Nivel de Evidencia V; Estudio terapéutico-investigación de los resultados del tratamiento.

Síndrome de Cola de Caballo asociado a tratamiento quiropráctico: Reporte de 3 casos y revisión de la literatura / Horsetail syndrome associated with chiropractic treatment: Report of 3 cases and review of the literature

El síndrome de cola de caballo (SCC) es una urgencia quirúrgica poco frecuente con una incidencia estimada de hasta 1,8 casos por millón de habitantes, producida por la compresión de las raíces nerviosas en el extremo inferior del canal espinal. La manipulación espinal puede desempeñar un papel etiogénico, provocando la movilización y extrusión del disco. El diagnóstico temprano y el tratamiento oportuno son cruciales, ya que el pronóstico suele ser desfavorable si el tratamiento quirúrgico se retrasa produciendo un daño neurológico permanente. El objetivo de este trabajo es identificar los potenciales factores de riesgo para la manipulación espinal y optimizar esta práctica, evitando así posibles complicaciones derivadas del tratamiento quiropráctico. Presentamos 3 casos de SCC, observados y tratados en nuestro centro, en los que se sugiere una estrecha relación entre la manipulación espinal quiropráctica y la aparición de dicho síndrome. Tras realizarles una RM en la que se observó una hernia discal L5-S1 causante del SCC, los 3 pacientes fueron tratados quirúrgicamente de forma urgente. Los casos presentados demostraron la existencia de una asociación patogénica entre la manipulación espinal y el desarrollo del SCC, al producirse dicho síndrome en las horas siguientes a la manipulación debida a la protusión abrupta de un disco demostrado por RM.

Introduction: Cauda equine syndrome (CES) is a rare surgical emergency with an estimated incidence of up to 1.8 cases per million. It is caused by compression of the nerve roots at the lowest point of the spinal canal. Spinal manipulation can play a pathogenic role, resulting in mobilization and extrusion of the disc. Early diagnosis and timely treatment are crucial, since the prognosis is usually unfavorable and permanent neurological damage likely if surgical treatment is delayed. Objective: The aim of this study was to identify potential risk factors associated with spinal manipulation and, thereby, optimize this practice to reduce the risk of complications from chiropractic treatment. Methods: We present three cases of CES, observed and treated at our center, in which a close relationship between chiropractic spinal manipulation and the appearance of CES was apparent. Results: After magnetic resonance imaging (MRI) revealed an L5-S1 herniated disc causing the SCC, all three patients underwent urgent surgical treatment. Conclusion: The three presented cases demonstrate a strong pathogenic relationship between spinal manipulation and the development of CES, when this syndrome occurs within hours of spinal manipulation, secondary to MRI-documented acute disc protrusion.

Cierre dural primario utilizando un nudo extracorpóreo / Primary dural closure using an extracorporeal knot

Objetivo: Las cirugías espinales mínimamente invasivas (MISS) son actualmente utilizadas para una gran variedad de patologías espinales intradurales. Aunque las técnicas MISS han demostrado estar asociadas a grandes beneficios, el cierre dural primario puede constituir un desafío debido al estrecho corredor que ofrecen los sistemas retractores tubulares. El objetivo es describir una técnica de cierre dural primario en cirugías MISS. Métodos: Describimos la utilización de nudos extracorpóreos en el cierre primario de duramadre en cirugías espinales MISS con la utilización de instrumental estándar y presentamos un video demostrativo. Resultados: Se logró un cierre dural hermético con puntos separados, facilitados por la utilización de nudos extracorpóreos y sin la utilización de instrumental especializado. Conclusión: La utilización de nudos extracorpóreos facilita el cierre dural primario en cirugías MISS.

Objective: Minimally-invasive spinal surgery (MISS) is currently used for a wide variety of intradural spinal pathologies. Although MISS techniques have proven to be of great benefit, primary dural closure might be a challenge, due to the narrow corridor of tubular retractor systems. Methods: We describe employing an extracorporeal knot for primary dural closure during MISS, using standard instrumentation. We also illustrate this technique with a demonstration video. Results: Watertight dural closure with separated extracorporeal knots was performed, all without specialized instruments. Conclusion: The use of extracorporeal knots facilitates primary dural closure after MISS.

Factors Associated with Conversion from Conservative to Surgical Treatment in Single-Level Lumbar Spinal Stenosis Patients / 대한척추외과학회지

STUDY DESIGN: Retrospective study of prospectively-collected data. OBJECTIVES: To determine the factors associated with conversion from conservative to surgical treatment in single-level lumbar spinal stenosis patients. SUMMARY OF LITERATURE REVIEW: Various reports have presented clinical outcomes after the surgical and nonsurgical treatment of spinal stenosis. However, few reports have investigated factors predicting conversion to surgery during the course of conservative treatment. MATERIALS AND METHODS: We analyzed 40 patients who visited our hospital from May 2010 to May 2015 and were traceable for at least 3 years after being advised to undergo surgery following 3 months of conservative treatment. Of these patients, 20 underwent surgery and 20 did not. We then investigated the factors associated with conversion to surgical treatment. Clinical assessments were conducted using a questionnaire, and the overall area of the spinal canal and the muscle area within the spinal canal were measured using magnetic resonance imaging. RESULTS: The average area of the spinal canal was 81.40±53.61 mm2 in the surgical group, compared to 127.75±82.55 mm2 in the nonsurgical group (p=0.042). The muscle area in the spinal canal was 5.17±1.30 cm2 in the surgical group, whereas it was 6.40±1.56 cm2 in the nonsurgical group (p=0.010). The patients in the surgical group were more likely to have experienced repetitive strain and to have frequently visited health clubs (p=0.047, p=0.037, respectively). However, regular stretching was more common in the nonsurgical group (p=0.028). CONCLUSIONS: The factors associated with conversion to surgical treatment were a narrow spinal canal, a small muscle area within the spinal canal, visiting health clubs, repetitive sprain, and not stretching. A small muscle area within the spinal canal can be considered as a key factor related to surgical conversion.

Posterior spinal canal decompression with screw fixation and reconstruction of three vertebral column for thoracolumbar burst fractures complicated with nerve injury / 中国骨伤

<p><b>OBJECTIVE</b>To explore the feasibility and clinical effect of posterior spinal canal decompression with pedicle screw fixation and reconstruction of anterior and middle vertebral column for thoracolumbar burst fractures complicated with nerve injury.</p><p><b>METHODS</b>A total of 36 patients with thoracolumbar burst fractures treated from March 2011 to April 2016 were enrolled in the retrospective study. There were 20 males and 16 females, aged from 21 to 52 years old with an average of 37.6 years. All the fractures were located on a single segment, 8 cases of T11₁₁, 10 cases of T₁₂, 12 cases of L₁, 6 cases of L₂. According to thoracolumbar injury classification and severity score(TLICS) system, the score was 7 to 9 points, with an average of 7.4 points. According to the America Spine Injury Association(ASIA) grade, 4 cases were type A, 10 cases were type B, 14 cases were type C, 8 cases were type D. All the patients underwent posterior spinal canal decompression with pedicle screw fixation and reconstruction of anterior and middle vertebral column. The recovery of nerve function was evaluated by ASIA grading. The correction of kyphosis(Cobb angle), the volume change of injuried spinal canal, the change of anterior border height of injury vertebra which can be observed by X-rays;the internal fixation loosening and breakage and all the information of bone fusion were recorded.</p><p><b>RESULTS</b>All the operations were successful, the mean operative time and intraoperative blood loss were(2.8±0.3) h (2.1 to 3.5 h) and (880±120) ml(550 to 1 350 ml), respectively. All the incisions got primary healing. All the patients were followed up for 12 to 28 months with an average of 18.4 months. All the patients obtained satisfactory bone fusion. No pseudoarticulation formation was found, and there was no loosening, breakage of pedicle screws or displacement of titanium mesh. Neurological function was improved in different degree, except in one patient with grade A and another one with grade B. According to the ASIA grade, there were 1 case of type A, 1 case of type B, 7 cases of type C, 10 cases of type D and 17 cases of type E, postoperatively. At 3 days after operative, the anterior border height of injury vertebra, Cobb angle and the volume changes of injury spinal canal were obviously improved(<0.05), and there was no significant difference between postoperative at 3 days and final follow-up(>0.05).</p><p><b>CONCLUSIONS</b>Spinal canal decompression with screw fixation and reconstruction of anterior and middle vertebral column through posterior midline approach is a safe and effective method in the treatment of thoracolumbar burst fractures with nerve injury, it is worthy to be popularized. It can complete the spinal canal decompression of 360 degree, reduction of fractures and reconstruction of vertebral three-column at the same time through a single posterior approach. The advantages includes less trauma, perfect decompression, good stability and etc.</p>

Intradural Extramedullary Cysticercosis Involving the Thoracolumbar Spinal Canal in a Patient with Cerebral Cysticercosis / 대한정형외과학회잡지

Neurocysticercosis (NCC) by Taenia solium is the most common parasitic infection of the central nervous system involving the cerebrum. However, spinal involvement of NCC is rare. Spinal NCC can cause radiculopathy, myelopathy, cauda equina syndrome, and even paraparesis, depending on its location and size. Spinal NCC may require surgical treatment as a first-line treatment because medical therapy can further aggravate the inflammation due to dead cysts, resulting in clinical deterioration. The current standard therapy for spinal NCC is surgical decompression followed by medical therapy. We experienced a case of widespread thoracolumbar intradural extramedullary cysticercosis involving the spinal canal with cerebral cysticercosis. We report this rare case with literature review.

Cut-off Value for Body Mass Index in Predicting Surgical Success in Patients with Lumbar Spinal Canal Stenosis

STUDY DESIGN: Case-control. PURPOSE: To determine optimal cut-off value for body mass index (BMI) in predicting surgical success in patients with lumbar spinal canal stenosis (LSCS). OVERVIEW OF LITERATURE: BMI is an essential variable in the assessment of patients with LSCS. METHODS: We conducted a prospective study with obese and non-obese LSCS surgical patients and analyzed data on age, sex, duration of symptoms, walking distance, morphologic grade of stenosis, BMI, postoperative complications, and functional disability. Obesity was defined as BMI of ≥30 kg/m². Patients completed the Oswestry Disability Index (ODI) questionnaire before surgery and 2 years after surgery. Surgical success was defined as ≥30% improvement from the baseline ODI score. Receiver operating characteristic (ROC) analysis was used to estimate the optimal cut-off values of BMI to predict surgical success. In addition, correlation was assessed between BMI and stenosis grade based on morphology as defined by Schizas and colleague in total, 189 patients were eligible to enter the study. RESULTS: Mean age of patients was 61.5±9.6 years. Mean follow-up was 36±12 months. Most patients (88.4%) were classified with grades C (severe stenosis) and D (extreme stenosis). Post-surgical success was 85.7% at the 2-year follow-up. A weak correlation was observed between morphologic grade of stenosis and BMI. Rates of postoperative complications were similar between patients who were obese and those who were non-obese. Both cohorts had similar degree of improvement in the ODI at the 2-year follow-up. However, patients who were non-obese presented significantly higher surgical success than those who were obese. In ROC curve analysis, a cut-off value of ≤29.1 kg/m² for BMI in patients with LSCS was suggestive of surgical success, with 81.1% sensitivity and 82.2% specificity (area under the curve, 0.857; 95% confidence interval, 0.788–0.927). CONCLUSION: This study showed that the BMI can be considered a parameter for predicting surgical success in patients with LSCS and can be useful in clinical practice.

Comparison of Clinical and Radiologic Results of Mini-Open Transforaminal Lumbar Interbody Fusion and Extreme Lateral Interbody Fusion Indirect Decompression for Degenerative Lumbar Spondylolisthesis

STUDY DESIGN: Retrospective study. PURPOSE: In this study, we compared the postoperative outcomes of extreme lateral interbody fusion (XLIF) indirect decompression with that of mini-open transforaminal lumbar interbody fusion (TLIF) in patients with lumbar degenerative spondylolisthesis. OVERVIEW OF LITERATURE: There are very few reports examining postoperative results of XLIF and minimally invasive TLIF for degenerative lumbar spondylolisthesis, and no reports comparing XLIF and mini-open TLIF. METHODS: Forty patients who underwent 1-level spinal fusion, either by XLIF indirect decompression (X group, 20 patients) or by mini-open TLIF (T group, 20 patients), for treatment of lumbar degenerative spondylolisthesis were included in this study. Invasiveness of surgery was evaluated on the basis of surgery time, blood loss, hospitalization period, and perioperative complications. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ), disc angle (DA), disc height (DH), and slipping length (SL) were evaluated before surgery, immediately after surgery, and at 12 months after surgery. Cross-sectional spinal canal area (CSA) was also measured before surgery and at 1 month after surgery. RESULTS: There was no significant difference between the groups in terms of surgery time or hospitalization period; however, X group showed a significant decrease in blood loss (p < 0.001). Serious complications were not observed in either group. In clinical assessment, no significant differences were observed between the groups with regard to the JOABPEQ results. The change in DH at 12 months after surgery increased significantly in the X group (p < 0.05), and the changes in DA and SL were not significantly different between the two groups. The change in CSA was significantly greater in the T group (p < 0.001). CONCLUSIONS: Postoperative clinical results were equally favorable for both procedures; however, in comparison with mini-open TLIF, less blood loss and greater correction of DH were observed in XLIF.