Spinal tumours: recommendations of the Polish Society of Spine Surgery, the Polish Society of Oncology, the Polish Society of Neurosurgeons, the Polish Society of Oncologic Surgery, the Polish Society of Oncologic Radiotherapy, and the Polish Society of Orthopaedics and Traumatology.

PURPOSE: The purpose of these recommendations is to spread the available evidence for evaluating and managing spinal tumours among clinicians who encounter such entities. METHODS: The recommendations were developed by members of the Development Recommendations Group representing seven stakeholder scientific societies and organizations of specialists involved in various forms of care for patients with spinal tumours in Poland. The recommendations are based on data yielded from systematic reviews of the literature identified through electronic database searches. The strength of the recommendations was graded according to the North American Spine Society's grades of recommendation for summaries or reviews of studies. RESULTS: The recommendation group developed 89 level A-C recommendations and a supplementary list of institutions able to manage primary malignant spinal tumours, namely, spinal sarcomas, at the expert level. This list, further called an appendix, helps clinicians who encounter spinal tumours refer patients with suspected spinal sarcoma or chordoma for pathological diagnosis, surgery and radiosurgery. The list constitutes a basis of the network of expertise for the management of primary malignant spinal tumours and should be understood as a communication network of specialists involved in the care of primary spinal malignancies. CONCLUSION: The developed recommendations together with the national network of expertise should optimize the management of patients with spinal tumours, especially rare malignancies, and optimize their referral and allocation within the Polish national health service system.

Antibiotic prophylaxis in spine surgery: a comparison of single-dose and 72-hour protocols.

BACKGROUND: Despite the general consensus on the use of single-dose antimicrobial prophylaxis (AMP) in instrumented spine surgery, evidence supporting this approach is not robust. AIM: To compare the efficacies of single-dose and 72 h AMP protocols for the prevention of surgical site infection (SSI) in instrumented spine surgery (ISS) in a before-and-after study. METHODS: Prospective non-randomized cohort study on 5208 patients who underwent spine surgery in one neurosurgical department between 2003 and 2014. Two protocols of AMP were compared in ISS: a single-dose protocol from 2003 to 2008, and a 72 h protocol from 2009 to 2014. Patients undergoing non-instrumented spine surgery (NSS) received single-dose prophylaxis throughout both periods. The outcome measure was the incidence of SSI. FINDINGS: For ISS, the SSI incidences were 5.3% for the single-dose protocol and 2.2% for the 72 h protocol (P < 0.01). For NSS, the SSI incidence was 0.8% between 2003 and 2008 and 1.2% between 2009 and 2014 (P = 0.054). Multiple correspondence analysis showed that in surgeries with an implant a one-dose prophylaxis carries a 7.1% risk of SSI; patients who received 72 h prophylaxis had a lower (3.6%) risk of SSI. CONCLUSION: Analysis of individual categories of data suggests that 72 h prophylaxis was the most important factor for minimizing the risk of wound infection in our study group.

Relationship between the spino-pelvic parameters and the slip grade in isthmic spondylolisthesis.

PURPOSE OF THE STUDY: Analysis of changes in the spino-pelvic alignment, depending on the slip grade in patients with low and high-grade isthmic slip. MATERIALS AND METHODS: A group of 60 patients who had lumbar spine radiograms adequate to measure the spino-pelvic parameters selected from a series of 195 cases of isthmic spondylolisthesis. We analyzed the following spino-pelvic parameters: pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbosacral angle by Dubousset (LSA) and lumbar lordosis (LL). The ANOVA statistical test was used to examine whether there is a significant correlation between (1) the slip grade and the value of PI, PT, and LL, and the Pearson correlation was used to examine a correlation between (2) the size of PI and the value of other spino-pelvic parameters, (3) the value of LL and SS, (4) value of the LSA and LL, PI and PT. RESULTS: The greater the slip grade, the greater the value of PI, PT, and LL and lower LSA. Positive correlations have been found between PI and SS, PT and LL. There was also a positive correlation between LL and SS. Negative correlations were noted between LSA and LL, PI and PT. CONCLUSION: The spino-pelvic alignment changes with the grade of isthmic spondylolisthesis, and the individual spino-pelvic parameters correlate together to form a causal chain in the development of isthmic spondylolisthesis.

[Anterior interbody fusion of cervical spine with case-plate PCB]. / Przednia stabilizacja miedzytrzonowa kregoslupa szyjnego implantem typu cage-plytka PCB--prezentacja przypadków.

Two cases with cervical discopathy and radiculopathy are presented. Discectomy and anterior interbody fusion with cage-plate PCB manufactured by French company Scient'x was performed. Authors present the shape of the implant and technical details of implantation. The paper discusses the advantages of the PCB which simplifies and shortens the operation procedure, minimizes the risk of traditional bone graft harvesting and provides immediate stabilization of the operated segment.

Immediate stiffness of the C5-C6 segment after discectomy with the Cloward technique: an in vitro biomechanical study on a human cadaveric model.

OBJECTIVE: To determine whether the Cloward technique of cervical discectomy and fusion increases immediate postoperative stiffness of single cervical motion segment after application of interbody dowel bone graft. METHODS: We measured and compared the stiffness of single-motion segments in cadaveric cervical spines before and immediately after interbody fusion with the Cloward technique. Changes in range of motion and stiffness of the C5-C6 segment were measured in a bending flexibility test (flexion, extension, lateral bending and axial rotation) before and after a Cloward procedure in 11 fresh-frozen human cadaveric specimens from the 4th through the 7th vertebrae. RESULTS: The Cloward procedure produced a statistically significant increase in stiffness of the operated segment in flexion and lateral bending when compared with the intact spine. The less stiff the segment before the operation, the greater the increase in its postoperative flexural stiffness (statistically significant). The Cloward procedure produced nonuniform changes in rotational and extensional stiffness that increased in some specimens and decreased in others. CONCLUSION: Our data demonstrate that Cloward interbody fusion increases immediate postoperative stiffness of an operated segment only in flexion and lateral bending in cadaveric specimens in an in vitro environment. Thus, Cloward fusion seems a relatively ineffective method for increasing the stiffness of a construct. This may add to discussion on the use of spinal instrumentation and postoperative management of patients after cervical discectomy, which varies from bracing in hard collars through immobilization in soft collars to no external orthosis.

[The case of severe craniocervical dislocation due to rheumatoid arthritis]. / Przypadek powaznej dyslokacji pogranicza czaszkowo-kregoslupowego na tle reumatoidalnego zapalenia stawów.

UNLABELLED: The authors describe a case of craniocervical dislocation secondary to rheumatoid arthritis producing important canal narrowing: ventrally by migrated odontoid and dorsally by posterior arch of C-1 with medullary compression. Symptoms of hyperreflexia, spasticity and left hemiparesis with Babinski sign were present. SURGICAL PROCEDURE: transoral odontoidectomy was performed followed by suboccipital approach, C-1 laminectomy and occipitocervical fixation (Olerud device and bone graft). Outcome with neurologic improvement. CONCLUSIONS: Transoral odontoidectomy combined with occipitocervical decompression and fixation is effective approach for treatment of severe craniocerebral dislocation. Its advantages: ventral and dorsal decompression combined with immediate stabilisation.

Anterior transsternal approach to the upper thoracic spine.

Cervicothoracic junction and upper thoracic spine down to T4 can be reached through anterior approach via sternotomy. Transsternal approach is the best route to gain access to lesions localized within vertebral bodies of the upper thoracic spine allowing for their resection, interbody fusion and replacement with bone cement. Consecutive modifications of transsternal approach evolved towards less extensive osteotomy from full median sternotomy, through manubriotomy with clavicle resection to partial lateral manubriotomy. Less extensive modifications provide limited lateral exposure of the spine and are more demanding technically. We present two cases of the upper thoracic spine tumours operated on through full medial sternotomy. We believe that median sternotomy has several advantages over less extensive modifications: it is technically simple to perform approach for trained thoracic surgeon, safer as it provides better exposure of the mediastinum and thus sufficient control of great vessels including subclavian ones, gives better exposure of T3, T4 and even T5 vertebral bodies, allows perpendicular sight and attack to anterior surface of the upper thoracic spine and therefore good visualizing of the posterior longitudinal ligament and dura, do not destabilize shoulder girdle nor affect function of the upper limb. Additional caudal exposure of the thoracic spine as down as T5 can be obtained by dissecting a plane between the brachiocephalic vein, vena cava superior and ascending aorta.

[Screw fixation of craniocervical junction]. / Stabilizacja pogranicza czaszkowo-kregoslupowego srubami.

In recent years an increase has been observed of the use of screw techniques for the fixation of the craniocervical junction. For clinical use two techniques have been introduced: (1) transarticular screw fixation, and (2) transpedicular screw fixation. In the former the screw is inserted through the C2 lateral mass, the fissure of the C1-C2 joint, and the C1 lateral mass. (2) in the latter the screw is inserted into the C2 pedicle and anchored in C2 vertebral body. Transarticular or pedicle screws can be easily connected to longitudinal elements such as rods or plates, and combined with lateral mass screws of the remaining cervical vertebrae or occipital screws. In comparison to sublaminar wiring or interlaminar clamping the screw techniques: (a) strengthen the stiffness of the construct and speed up fusion, (b) allow fixation in the absence or deficiency of laminae as a result of trauma or laminectomy, and (c) can selectively include only the affected segments. Increased construct stiffness is due to deep anchorage of the screw in bone providing thus a solid grip on the vertebra. Both techniques require preoperative assessment of the course of the vertebral artery using imaging methods. In about 18% of cases abnormal course of the artery precludes screw use. Pedicle screw insertion requires direct control of the medial and superior walls of C2 pedicle with dissector introduced into the vertebral canal, which requires removal of the atlantoaxial ligament. Additional control can be achieved with lateral fluoroscopy. The entry point for transarticular screw is on the lateral mass of the odontoid 2-3 mm laterally to the medial margin of C2 facet and 2-3 mm above the C1/C2 articular fissure. The screw trajectory is 0-10 degrees in horizontal plane and towards the anterior C1 tuberculum in sagittal plane.

[Fixating techniques of craniocervical junction: selection criteria]. / Metody stabilizacji pogranicza czaszkowo-kregoslupowego--kryteria doboru.

Adequate choice of fixation technique at craniocervical junction depends on many factors: anatomical conditions at fusion site (e.g. anterior dislocations of the odontoid and rupture of the transverse ligament are contraindications for direct odontoid screw fixation. Sublaminar wiring and interlaminar clamps are useless in case of deficiency of posterior bony elements of C1 and C2 whether a result of laminectomy or destruction), bone quality (osteopenic bone is contraindication for screw techniques either transarticular or transpedicular). Enclosing of occipital bone into instrumentation may be difficult in wire and clamping techniques. In contrast screw techniques allow for easy grip the occipital bone. Screw techniques seem ideal in cases requiring enclosing of the occipital bone. The fusion rate at C1/C2 level seems independent of fixation techniques. When supplemented with external immobilization even biomechanically inferior wiring or interlaminar clamping provide nearly 100 rate of fusion. Screw techniques are technically demanding but they seem the method of choice when occipital bone is to be enclosed in instrumentation.

[Trans-sternal approach to the cervicothoracic junction]. / Dojscie przez mostek do pogranicza szyjno-piersiowego kregoslupa.

Cervicothoracic junction and upper thoracic spine down to T4 can be reached through anterior approach via sternotomy. Transsternal approach is the best route to gain access to lesions localized within vertebral bodies of the upper thoracic spine allowing for their resection, interbody fusion and replacement with bone cement. Consecutive modifications of transsternal approach evolved toward less extensive osteotomy from full median sternotomy, through manubriotomy with clavicle resection and partial lateral manubriotomy. Less extensive modifications provide limited lateral exposure of the spine and are more demanding technically. We present two cases of upper thoracic spine tumours operated on through full medial sternotomy. We believe that median sternotomy has several advantages over less extensive modifications: it is technically simple to perform for trained thoracic surgeon, safer as it provides better exposure of the mediastinum and thus sufficient control of great vessels including subclavian ones, gives better exposure of T3, T4 and even T5 vertebral bodies, allows perpendicular sight and attack to anterior surface of the upper thoracic spine and therefore good visualizing of the posterior longitudinal ligament and dura, do not destabilize shoulder girdle nor affect function of the upper limb. Additional caudal exposure of the thoracic spine as down as T5 can be obtained by dissecting a plane between the brachiocephalic vein, vena cava superior and ascending aorta.

[Lumbar interbody fusion. Biomechanical significance for the spine]. / Spondylodeza miedzytrzonowa kregoslupa ledzwiowego. Znaczenie dla biomechaniki kregoslupa.

The authors discuss the significance of interbody fusion for early and long term stability of the lumbar spine. They stress that the aim of the modern spinal instrumentation is to promote bone healing and not to replace fusion. Without fusion every stabilization device will fail in fatigue. The biomechanics of different types of spinal fusion and biomechanical conditions at fusion site are discussed. A history of lumbar interbody fusion including threaded implants (cages) is presented. Interbody cages combine positive properties of tricortical bone graft: the strength of cortical to the bone with improved incorporation properties of cancellous bone. In contrast bone graft their biomechanical performance is far better: they increase strength and stability of osteosynthesis, do not go collapse and resorption, prevent from decrease in disc space height and kyphotic angulation of the fused motion segment, require less bone to achieve fusion. They can be used solely without support of any stabilization system. Preliminary experience in fusion with interbody threaded implants suggest significant efficacy of this method.

[Embolization of AVM's of thoracic spinal cord with histoacryl glue]. / Embolizacja naczyniaków odcinka piersiowego rdzenia kregowego za pomoca kleju histoakrylowego.

The authors present two cases of inoperable AVM's of thoracic spinal cord successfully treated by embolization with histoacryl glue (B. Brown Melsungen AG). The glue used for embolization is characterized by instant polymerization when comes in contact with blood. A mass of polymer is visible on X-ray thanks to contrast medium Lipiodol and metallic powder Tungsten that are added to glue and injected together with the latter. In the first case, a female who presented with paraparesis and walked only with assistance embolization performed in one session resulted in neurological improvement enabling independent walking at follow-up 2 yrs later. In the second case of a young male not walking for severe paraparesis embolization performed in three sessions resulted in significant neurological recovery. 10 days after the first session the patient became ambulatory. 6 months after treatment he presented with mild paraparesis and was still ambulatory and leading independent life. In each case embolization was performed after balloon occlusion test during which the function of spinal cord was monitored by somatosensory evoked potentials and neurological assessment.

[Somatosensory evoked potentials in the assessment of preserved function of long spinal cord pathways versus decisions of operation]. / Somatosensoryczne potencjaly wywolane w ocenie zachowania czynnosci dlugich dróg rdzeniowych a decyzja operacyjna.

In the light of several presented clinical cases the authors point out the usefulness of somatosensory evoked potentials for the objective determination of the continuity of long pathways in the spinal cord, which in correlation with the clinical findings and results of imaging methods helps in making the decision of surgical intervention. The non-invasiveness of this method makes possible repeated safe control examinations for assessment of the dynamic of lesions in the cord and objective assessment of the neurological condition after operations on the cord.

[A case of complete Th7-Th8 fracture-dislocation treated by one-stage posterior and transthoracic approach]. / Przypadek calkowitego podwichniecia Th7-Th8 bez uszkodzenia rdzenia kregowego operowany z jednoczasowego dojscia tylnego i przez klatke piersiowa.

The authors present a case of severe traumatic fracture-dislocation of Th8 with total anterior slippage of Th7 on Th8 without spinal cord injury. The patient underwent one-stage anterior and posterior decompression. Posterior surgery included Th4 to Th9 laminectomy and Th7-Th8 facetectomy and posterior bone graft. Anterior procedure included Th8 vertebrectomy, anterior interbody bone graft and anterior plating with usage of "Zespol" plate and screws anchored in Th6, Th7, Th8 and Th9 vertebral bodies. Postoperative period was uneventful and the patient remained neurologically intact. He was placed in a plaster jacket and mobilized of fifth day after surgery.

[Thoracic outlet syndrome: results of surgical treatment]. / Zespól górnego otworu klatki piersiowej--wyniki leczenia chirurgicznego.

21 patients with thoracic outlet syndrome (t.o.s.) were operated on in the Department of Neurosurgery of MMA in Lódz between 1982-1991. Early and long-term results of treatment were analyzed in the group of 13 cases. In early postoperative period 5 patients were free of pain and neurologic or vascular disturbances in the upper limb. In other 6 cases pain disappeared partially and mild neurological or vascular syndromes persisted. Altogether satisfactory results of treatment were obtained in 8 patients (85%). There was some improvement in 2 patients but pain and neurological or vascular disorders were still significant after surgery. Long-term results were assessed at least 1 year after operative treatment. Recurrent pain with or without mild neurological (vascular) syndromes appeared in 6 patients (46%). Recurrent t.o.s. occurred mainly in cases of young women with low position of shoulder girdle and poorly developed musculature of this region. Only 2 patients still remained free of preoperative syndromes. Altogether only 8 patients (61%) had acceptable results of surgical treatment at long-term follow-up. The remaining 5 patients (39%) had unsatisfactory long-term results.

[Diagnosis of the upper thoracic outlet syndrome]. / Diagnostyka zespolu górnego otworu klatki piersiowej.

Basing on a review of literature and own experience the authors present the aetiology and various diagnostic methods of thoracic outlet syndrome (t.o.s.), especially electrodiagnostic and Doppler studies. Provocative tests like Wright, Adson or hyperabduction manouvers are discussed and their role in modern diagnosis of t.o.s. is presented.

[The importance of computerized tomography and magnetic resonance imaging in the diagnosis of slowly growing cerebral gliomas]. / Znaczenie tomografii komputerowej i rezonansu magnetycznego w rozpoznawaniu wolno rosnacych glejaków mózgu.

The authors present diagnostic problem in slowly growing brain gliomas. Two illustrative cases are presented. Both were characterized by scant clinical manifestations and long-term course of the illness before the operation. CT examinations repeated in both patients several times in the preoperative period of a few years disclosed unchanging hypodense areas in cerebral hemispheres. No progress in clinical status of the patients and CT imaging of the lesions were observed throughout years of observation (2 and 5 years, respectively). Rapid deterioration of neurological condition in both patients associated with enlargement of the lesions in CT allowed to establish strong suspicion of brain tumour which was confirmed by examination in each case. Histopathological examination revealed malignant gliomas in both cases. The cases confirmed once again the necessity of early MRI examination in patients with hypodense lesions of the brain found in CT. The authors believe that every hypodense area of the brain should be verified by MRI as soon as possible, regardless their size, progress and neurological status of the patient. Such as approach to the diagnosis of hypodense areas in the CT of the brain may prevent a delay in proper treatment as well as malignant transformation of primarily benign lesion.

[A case of intrasellar teratoma]. / Przypadek wewnatrzsiodlowego potworniaka.

The authors present a case of teratoma adultum of unusual intrasellar localisation. The tumour was surgically treated with excellent result. It was confined to sella turcica and partially invaded the suprasellar region. It produced headache, mild bitemporal hemianopsia and did not cause clinically evident hormonal disturbances.

[An internal fixator for posterior application to short segments of thoracic, lumbar and lumbosacral spine. Design and testing]. / Wstepne doswiadczenia wlasne w usztywnianiu kregoslupa stabilizatorem wewnetrznym Socon firmy Aesculap.

The authors present preliminary experiences in spinal instrumentation with internal fixator Socon (Aesculap). The device was introduced into the routine clinical practice in the Department in 1992. Basing on personal experience they confirm the advantages of usage of internal fixators in spinal surgery especially good stabilisation of the spine and possibility of early mobilisation of patients. Analysis of the series of 6 cases operated on in the Department with the longest follow-up of 10 months revealed no neurological or vascular complication related to pedicle screw insertion, no wound infection and no instability of instrumented segment of the spine. The report includes 3 illustrative cases operated on in the Department.

[Internal fixation of thoracolumbar, lumbar and lumbosacral spine with internal fixators]. / Usztywnianie wewnetrzne kregoslupa stabilizatorami wewnetrznymi.

The report is a review of the literature on fully implantable transpedicular fixation device known under the general name internal fixator, and designed for short (one to three segments) internal fixation of the spine in various pathologies. The implants are found in a routine clinical use throughout many European countries and have become more familiar to spine surgeons in the U.S. The authors present a general description of the fixators, indications and contraindications to their implantation, the implantation technique and possibilities of intraoperative reposition of the spine. The advantages of usage of the fixators and the history of their development are presented.