Analysis of spinal canal diameter in the placement of thoracic spinal cord stimulator paddle leads.

BACKGROUND: Neurologic deficit is known as a rare complication of thoracic spinal cord stimulator (SCS) paddle lead implantation, but many believe its incidence after SCS paddle lead placement is under-reported. It is possible that imaging characteristics may be used to help predict safe paddle lead placement. OBJECTIVE: This imaging study was undertaken to determine the minimum canal diameter required for safe paddle lead placement. METHODS: Patients who underwent thoracic laminotomy for new SCS paddle lead placement from January 2018 to March 2023 were identified retrospectively. Preoperative thoracic canal diameter was measured in the sagittal plane perpendicular to the disc space from T5/6 to T11/12. These thoracic levels were chosen because they span the most common levels targeted for SCS placement. Patients with and without new neurologic deficits were compared using a Mann-Whitney U-test. RESULTS: Of 185 patients initially identified, 180 had thoracic imaging available for review. One (0.5%) and 2 (1.1%) of 185 patients complained of permanent and transient neurologic deficit after thoracic SCS placement, respectively. Patients with neurologic deficits had average canal diameters of <11 mm. The average canal diameter of patients with and without neurologic deficits was 10.2 mm (range 6.1-12.9 mm) and 13.0 mm (range 5.9-20.2), respectively (p < 0.0001). CONCLUSION: Postoperative neurologic deficit is an uncommon complication after thoracic laminotomy for SCS paddle lead placement. The authors recommend ensuring a starting thoracic canal diameter of at least 12 mm to accommodate a SCS paddle lead measuring 2 mm thick to ensure a final diameter of >10 mm. If canal diameter is <12 mm, aggressive undercutting of the lamina, a second laminotomy, or placement of smaller SCS wire leads should be considered.

Spinous Process Splitting Laminectomy for Lumbar Spinal Stenosis: 2D Operative Video.

Degenerative lumbar spinal stenosis involves an acquired reduction in the spinal canal diameter due to osteoarthritic changes on the disk, facet joints, and ligaments and may result in spinal cord or cauda equina compression.1 This process may lead to pain radiating to the legs, neurogenic claudication, and neurologic deficit. First-line treatment includes conservative care such as physical therapy, spinal injections, and lifestyle changes. If this strategy is insufficient to achieve symptom relief, surgical management is recommended.1,2 Surgery generally encompasses a decompression procedure through a posterior approach. There are several techniques to accomplish this in the context of severe bilateral stenosis including standard open laminectomy, unilateral laminectomy with bilateral decompression, and a tubular approach with bilateral decompression (e.g., "over-the-top technique").2 Among these, the spinous process splitting laminectomy has emerged as a strategy that allows decompressing the spinal canal through a familiar anatomy to the surgeon while respecting paravertebral muscles.3,4 This technique involves exposure of the laminae by cutting through the spinous process and then separating both halves and muscles attached at the sides. The main advantage is that the insertion of these paravertebral soft tissues is preserved, the required retraction is reduced and postoperative pain is decreased.4 Moreover, the learning curve to achieve a successful decompression employing the splitting laminectomy is substantially shorter than with other minimally invasive approaches, such as tubular. This video aims to show the steps to perform this technique (Video 1). We report the case of a 74-year-old male who presented with left sciatica and neurogenic claudication. The images showed multilevel degenerative lumbar spinal stenosis, with severe bilateral compression at L4-5, without signs of instability. Surgical alternatives were discussed with the patient, and it was decided to perform an L4-5 spinous process splitting laminectomy. The patient had a good evolution with an unremarkable postoperative course.

[Minimally invasive decompression techniques for spinal cord stenosis]. / Minimal-invasive Dekompressionsverfahren der Spinalkanalstenose.

BACKGROUND: Lumbar spinal canal stenosis is frequently found among elderly patients and significantly limits their quality of life. Non-surgical therapy is an initial treatment option; however, it does not eliminate the underlying pathology. Surgical decompression of the spinal canal has now become the treatment of choice. OBJECTIVE: Minimalization of surgical approach strategies with maintaining sufficient decompression of the spinal canal and avoiding disadvantages of macrosurgical techniques, monolateral paravertebral approach with bilateral intraspinal decompression, specific surgical techniques. MATERIALS AND METHODS: Minimally invasive decompression techniques using a microscope or an endoscope are presented and different surgical strategies depending on both the extent (mono-, bi-, and multisegmental) and the location of the stenosis (intraspinal central, lateral recess, foraminal) are described. RESULTS: Minimally invasive microscopic or endoscopic decompression procedures enable sufficient widening of the spinal canal. Disadvantages of macrosurgical procedures (e. g., postoperative instability) can be avoided. The complication spectrum overlaps partially with that of macrosurgical interventions, albeit with significantly less marked severity. Subjective patient outcome is clearly improved. CONCLUSIONS: Referring to modern minimally invasive decompression procedures, surgery of lumbar spinal canal stenosis represents a rational and logical treatment alternative, since causal treatment of the pathology is only possible with surgery.

Transforaminal endoscopic decompression for thoracic spinal stenosis under local anesthesia.

BACKGROUND: Thoracic spinal stenosis is a common vertebral degenerative disease, and treatment remains challenging. In recent years, transforaminal endoscopic decompression has been widely used for treating lumbar degenerative diseases. However, the efficacy of this procedure for thoracic spinal stenosis has yet to be established. Herein, we report a case of thoracic spinal stenosis treated with transforaminal endoscopic decompression under local anesthesia. CASE REPORT: An 88-year-old man presented with a 1-month history of progressive paralysis and dysesthesia in the bilateral lower extremities. A diagnosis of thoracic spinal stenosis was made, based on physical examination. A two-step percutaneous transforaminal endoscopic thoracic decompression was performed for spinal canal decompression. Over a follow-up of 1 year, a favorable outcome was noted. CONCLUSION: Transforaminal endoscopic decompression is a safe and an effective surgical approach for the treatment of thoracic spinal stenosis. For patients with thoracic spinal stenosis, accurate diagnosis and elaborate surgical planning should be highlighted, and the surgical outcome can be favorable.

Fluoroscopically guided transforaminal epidural dry needling for lumbar spinal stenosis using a specially designed needle.

BACKGROUND: This report describes the methodological approach and clinical application of a minimally invasive intervention to treat lumbar spinal stenosis (LSS). METHODS: Thirty-four patients with LSS underwent fluoroscopically guided transforaminal epidural dry needling using a specially designed flexed Round Needle. The needle was inserted 8-12 cm lateral to the midline at the level of the stenosis and advanced to a position between the anterior side of the facet joint and pedicle up to the outer-third of the pedicle. The needle was advanced medially and backed laterally within a few millimetres along the canal side of the inferior articular process between the facet joint and pedicle. The procedure was completed when a marked reduction in resistance was felt at the tip of the needle. The procedure was performed bilaterally at the level of the stenosis. RESULTS: The average follow-up period was 12.9 +/- 1.1 months. The visual analogue scale (VAS) pain score was reduced from 7.3 +/- 2.0 to 4.6 +/- 2.5 points, the Oswestry Disability Index (ODI) score decreased from 41.4 +/- 17.2 to 25.5 +/- 12.6% and the average self-rated improvement was 52.6 +/- 33.1%. The VAS scores indicated that 14 (41.2%) patients reported a "good" to "excellent" treatment response, while 11 (32.4%) had a "good" to "excellent" treatment response on the ODI and 22 (64.7%) had a "good" to "excellent" treatment response on the self-rated improvement scale. CONCLUSIONS: These results suggest that fluoroscopically guided transforaminal epidural dry needling is effective for managing LSS.

Intrathecal morphine for spinal fusion in children.

Intrathecal morphine (0.025 mg/kg) was administered preoperatively to 20 children undergoing major surgery of the rachis, ie, either posterior (16 cases) or anterior (4 cases) spinal fusions. During the surgical procedure, hemodynamic control was easily maintained. Blood loss was slightly less than 50% of blood volume and the mean infusion rate of blood was 6.3 +/- 4.5 ml/kg/hour for the duration of surgery. The technique did not significantly interfere with wake-up tests, and memory of awakening was only observed in one case. The postoperative course was also positively affected. The children could be extubated within the 30 minutes following completion of surgery, and they could perform effective breathing exercises early on. High degree and long duration (36 to 72 hours) of pain relief were obtained in every case. No major adverse effect was observed. Thus, the administration of intrathecal morphine prior to spinal fusion appears to be safe, easy, and reliable. We think it should be recommended for major surgery of the rachis.