Technical aspects of total spondylectomy of C2.

BACKGROUND: Tumorous involvement of the second cervical vertebra is an infrequent, but severe disease. Primary tumors and solitary metastases can be addressed by a radical procedure, a complete removal of the whole compartment. The second cervical vertebra has a highly complex anatomy, and its operation requires considerable surgical skills. The aim of this retrospective study is to present technical aspects of complete resection of C2 for tumor indications, clinical and radiological evaluation of our group of patients and comparison of results of recent reports on surgery in this region in the literature. METHODS: Between 2006 and 2019 we performed 10 total resections of C2 for primary bone tumor or solitary metastasis at our department. Operation was indicated for chordoma in 4 cases and for other diagnoses (plasmacytoma, EWSA, metastases of papillary thyroid carcinoma, medullary thyroid carcinoma, lung carcinoma and sinonasal carcinoma) in one case each. The operative procedure was in all cases performed in two steps. It always started with the posterior approach. The anterior procedure was scheduled according to the patient's condition after an average interval of 16.9 days (range 7-21). RESULTS: A stable upper cervical spine was achieved in all patients. A solid bone fusion over the whole instrumentation was present in all living patients and they returned to their preoperative activity level. By the final follow-up 6 patients died: one patient died on the 5th postop day because of diffuse uncontrollable bleeding from surgical wound, three patients died of generalization of the underlying disease and two patients due to complications associated with local recurrence of the disease. In addition to regular follow-ups, the surviving patients (N.=4) were also examined upon completion of the study, i.e., on average 91 months (range 17-179 months) postoperatively. With exclusion of an early deceased patient, the average follow-up period of deceased patients was 34.6 months (range 9-55) (N.=5). The average follow-up of the whole group of patients was 59,7 months (N.=9). CONCLUSIONS: Total spondylectomy of C2 is an exceptional surgical procedure associated with risk of serious complications but offers chance for a complete recovery of the patient. Defining indications accurately, especially in solitary metastases, is very difficult even with current level of imaging and other testing. The quality of life of long-term surviving patients in our study was not significantly impacted.

Decompression alone versus decompression with instrumented fusion in the treatment of lumbar degenerative spondylolisthesis: a systematic review and meta-analysis of randomised trials.

OBJECTIVE: To determine the efficacy of adding instrumented spinal fusion to decompression to treat degenerative spondylolisthesis (DS). DESIGN: Systematic review with meta-analysis. DATA SOURCES: MEDLINE, Embase, Emcare, Cochrane Library, CINAHL, Scopus, ProQuest Dissertations & Theses Global, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform from inception to May 2022. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Randomised controlled trials (RCTs) comparing decompression with instrumented fusion to decompression alone in patients with DS. Two reviewers independently screened the studies, assessed the risk of bias and extracted data. We provide the Grading of Recommendations, Assessment, Development and Evaluation assessment of the certainty of evidence (COE). RESULTS: We identified 4514 records and included four trials with 523 participants. At a 2-year follow-up, adding fusion to decompression likely results in trivial difference in the Oswestry Disability Index (range 0-100, with higher values indicating greater impairment) with mean difference (MD) 0.86 (95% CI -4.53 to 6.26; moderate COE). Similar results were observed for back and leg pain measured on a scale of 0 to 100, with higher values indicating more severe pain. There was a slightly increased improvement in back pain (2-year follow-up) in the group without fusion shown by MD -5·92 points (95% CI -11.00 to -0.84; moderate COE). There was a trivial difference in leg pain between the groups, slightly favouring the one without fusion, with MD -1.25 points (95% CI -6.71 to 4.21; moderate COE). Our findings at 2-year follow-up suggest that omitting fusion may increase the reoperation rate slightly (OR 1.23; 0.70 to 2.17; low COE). CONCLUSIONS: Evidence suggests no benefits of adding instrumented fusion to decompression for treating DS. Isolated decompression seems sufficient for most patients. Further RCTs assessing spondylolisthesis stability are needed to determine which patients would benefit from fusion. PROSPERO REGISTRATION NUMBER: CRD42022308267.

Atlantoaxial rotatory dislocation: Surgical treatment in a pediatric patient cohort.

•Surgical correction of AARD is an appropriate method of treatment after failed non-operative therapy.•The technique of surgical reduction and C1-C2 fixation using Harms/Goel technique provides excellent clinical outcomes.•In case of traumatic AARD we recommend to consider temporary fixation.

High-grade high-dysplastic lumbosacral spondylolisthesis in children treated with complete reduction and single-level circumferential fusion: A prospective case series.

Introduction: Surgical treatment of high-grade developmental spondylolisthesis remains controversial with paucity of data reporting complete reduction of the deformity, especially in pediatric patients. Research question: To assess efficacy and safety of complete reduction and circumferential L5-S1 fusion in children with high-grade high-dysplastic spondylolisthesis. Emphasis was placed on fusion rates, correction of lumbosacral deformity and long-term clinical outcomes by means of patient-reported outcome measures (PROMs). Material and methods: Consecutive series of 18 pediatric patients referred to surgery over an 11-years period. Several radiographic variables and PROMs were collected pre- and post-surgery with minimum follow-up of 2-years. Results: The mean age of cohort was 12.9 years with a mean follow-up of 7.8 years. Postoperatively, the mean slip was reduced from 64.4±9.8% to 4.5±5.9% with no loss of correction during follow-up. PROMs significantly improved following the index procedure (p<0.0001). Lumbo-pelvic parameters improved after surgery, including SS, but not PT. Development of adjacent level spondylolisthesis was noted in eight subjects (44%), two of these patients required additional surgery. Posterolateral and anterior fusion was obtained in 100% and 78% of cases, respectively. One patient developed a transient right-sided L5 nerve paresis after surgery that gradually resolved within one year post-surgery. Preoperatively, we recorded three patients with L5 nerve root motor deficit, which resolved completely in two cases and in one patient remained unchanged. Discussion and conclusion: Complete reduction can safely be accomplished without an increased risk of nerve root injury. Coupled with single-level circumferential fusion, it provides high fusion rates with satisfactory spino-pelvic alignment.

Cervical spondylotic myelopathy: the prediction of outcome following surgical intervention in 93 patients using T1- and T2-weighted MRI scans.

INTRODUCTION: Cervical spondylotic myelopathy (CSM) can lead to significant disability through a spectrum of clinical manifestations ranging from dexterity loss to more profound weakness, incontinence and paralysis. AIM: To determine the outcome of surgical decompression for CSM and investigate pre-operative predictors of outcome. METHODS: Prospectively collected data on all patients who underwent decompressive surgery for CSM and completed 12-month follow-up were reviewed. Data on age, MRI T1 and T2 signal changes pre-operatively, surgical approach and the Nurick's Myelopathy Grade (NMG) was analysed pre-operatively and 1 year post-surgery. RESULTS: Data on 93 consecutive patients who underwent surgery for CSM were reviewed. Median age was 62 (23-94) years and 59% were male. The median follow-up was 37 (17-88) months. The approach was anterior in 38 (42%) patients, posterior in 55 (58%); improvement was not significantly different when the two groups were compared. The number of levels decompressed increased with age (p value <0.0001). The group with a pre-operatively high signal on T1-weighted MRI images [n = 28 (30%)] was associated with less neurological recovery post-operatively compared to the patients with a normal T1 cord signal. None of the patients deteriorated neurologically post-operatively, while 66% improved by at least one NMG. CONCLUSION: Surgical decompressions for CSM stop the progress of symptoms at 12 months post-surgery and may result in a significant improvement of NMG in two-thirds of the patients. Changes in the T1-weighted MRI images predict worse outcomes following surgery.

Incidence of vascular complications arising from anterior spinal surgery in the thoraco-lumbar spine.

STUDY DESIGN: Modern biomaterials and instrumentation have popularised surgery of the thoraco-lumbar spine through an anterior route. The advantage of anterior surgery is that it allows for a direct decompression of the compromised spinal canal. However, the potential for devastating long-term sequelae as a result of complications is high. PURPOSE: The aim of this study was to give a general overview and identify the incidence of vascular complications. OVERVIEW OF LITERATURE: There is limited literature describing the overall incidence and complications of anterior spinal surgery. METHODS: A retrospective review of a prospective database of 1,262 consecutive patients with anterior surgery over a twelve-year period. RESULTS: In our study, 1.58% (n=20) of patients suffered complications. Injury to a major vessel was encountered in 14 (1.11%) cases, of which nine involved an injury to the common iliac vein. In six cases, the original procedure was abandoned due to a life-threatening vascular injury (n=3) and unfavourable anatomy (n=3). CONCLUSIONS: The incidence of vascular and other complications in our study was relatively low. Nevertheless, the potential for devastating long-term sequelae as a result of complications remains high. A thorough knowledge and awareness of normal and abnormal anatomy should be gained before attempting such a procedure, and a vascular surgical assistance especially should be readily accessible. We believe use of access surgeons is mandatory in cases with difficult or aberrant anatomy.

Cement augmentation for vertebral fractures in patients with multiple myeloma.

Objective of our study was to assess the outcome of cement augmentation in patients with multiple myeloma. We reviewed 12 patients with 48 vertebral fractures. Mean age was 62.5 years. Average length of follow-up was 27.5 months. Expected survival was less than 12 months in 2 patients and more than 12 months in the remaining patients. After surgery mean survival was 32.5 months. Mean correction in vertebral angle was 3.6°. Karnofsky score was more than 70 in 5 patients, 50-70 in 6 and less than 50 in 1 patient preoperatively, while it was more than 70 in all patients postoperatively. Preoperative mean ODI was 72%. After surgery it was 46% at 6 weeks and 14% at 12 months. All patients reported improvement in their pain status after surgery. Cement augmentation is a safe and effective way of treating symptoms of multiple myeloma, which occur due to vertebral metastases. It results in excellent pain control and improvement in quality of life.

Role of intraoperative red cell salvage and autologus transfusion in metastatic spine surgery: a pilot study and review of literature.

STUDY DESIGN: Prospective cohort study. PURPOSE: There has been no research examining the use of intraoperative cell salvage during metastatic spinal surgery. The present work is a pilot study investigating the role of cell salvage during metastatic spine surgery. OVERVIEW OF LITERATURE: There is no spinal literature about role of cell salvage and autologus transfusion in metastatic spinal cancer. METHODS: Sixteen spinal metastases patients who received red cell salvage using a leucocyte depletion filter were enrolled. Of these, ten patients who received salvaged blood transfusion were included in the final analysis. Data collection involved looking at the case notes, operating room records and the prospectively updated metastatic spinal cancer database maintained in the spinal department. Cell salvage data was recovered from the central cell salvage database maintained in the anesthetic department. RESULTS: Amount of salvaged blood ranged from 120 to 600 mL (average, 318 mL). The average drop in hemoglobin was 1.65 units (range, 0.4-2.7 units). Three patients (30%) required postoperative allogenic blood transfusion. The average follow up was 9.5 months (range, 6-6 months). One patient developed new lung metastasis, at seven months. No patient developed new liver metastases. Preoperatively, six patients had diffuse skeletal metastases. Of this subgroup, three developed new skeletal metastases. No cases showed any wound related problems in the postoperative period. CONCLUSIONS: In our study transfusion of intraoperatively salvaged blood did not result in disseminated metastatic cancer. We would suggest that red cell salvage might have a role during metastatic spine surgery.

Spinal subdural hematoma as a complication of spinal surgery: can it happen without dural tear?

Post spinal surgery subdural hematoma is a rare entity. This is a report of a case of acute post-operative spinal subdural hematoma, without any dural injury. The case was managed expectantly and went on to complete resolution of the hematoma and full clinical recovery.

A study investigating the validity of modified Tokuhashi score to decide surgical intervention in patients with metastatic spinal cancer.

PURPOSE: Predicted survival of a patient is the most important parameter that helps to guide the treatment of a patient with metastatic spinal cancer. We aimed to investigate the reliability of modified Tokuhashi score in the decision-making process in patients with metastatic spinal cancer. METHODS: We performed a review of our prospectively collected Metastatic Cancer Database over a period of 4 years (2007-2010). Ninety consecutive patients who were treated for metastatic spinal cancer were enrolled. Data review included demographic details, source of primary cancer, duration of symptoms, location of metastases, calculated Karnofsky's performance status, and calculated survival based on modified Tokuhashi score. We divided the patients into 3 groups. Group A included patients with expected survival less than 6 months. Group B included patients with expected survival between 6 and 12 months. Group C included patients whose expected survival was more than 12 months. We compared the calculated expected survival to the actual survival in all three groups with all patients following up to a minimum of 1 year or until death. Statistical analysis was done by Chi-square test and the Fisher Exact test. RESULTS: The survival prediction in group C was significantly accurate in 80.9 % patients (P = 0.027). However, in groups A and B, only 36.1 and 9.1 % patients survived, respectively, as per predicted. (P > 0.05). CONCLUSIONS: We can conclude from this study that, when used alone, modified Tokuhashi score may not be a reliable tool to predict survival in all patient groups.

Social implications of balloon kyphoplasty: prospective study from a single UK centre.

PURPOSE: The incidence of osteoporotic fractures is increasing with an ageing population. This has potential consequences for health services, patients and their families. Treatment of osteoporotic vertebral compression fractures (OVCFs) has been limited to non-surgical measures so far. The social and functional consequences of balloon kyphoplasty, a recent development for the treatment of VCF, were assessed in this cohort study. METHODS: Data collected prospectively from 53 patients undergoing balloon kyphoplasty for symptomatic OVCF in our hospital's spinal unit were compared with data from an historical age-matched group of 51 consecutive patients treated conservatively for symptomatic OVCF. Social functionality was recorded prior to the injury, and at 6-month and 1-year follow-up; mortality was recorded at 6 months and 1 year. RESULTS: The mortality rate in the balloon kyphoplasty group was 11 % (6/53) at 1 year post-OVCF, versus 22 % (11/51) in the conservatively treated controls. A drift to a lower level of social functionality (defined by a lower level of independence) was observed at 1 year in 21 % of patients in the balloon kyphoplasty group versus 53 % of patients in the conservatively treated group. A drift to a lower level of independence was noted in 67 % of the conservatively treated patients who started at a lower level of functionality versus 20 % drift in a similar group who were treated with balloon kyphoplasty. CONCLUSIONS: The reduction in mortality and drift in social functionality at 1 year following treatment with balloon kyphoplasty suggests that it is a viable option for the management of OVCFs.

Early results after vertebral body stenting for fractures of the anterior column of the thoracolumbar spine.

INTRODUCTION: Vertebroplasty and balloon kyphoplasty have shown to improve pain and functional outcome in cases with symptomatic vertebral fractures. Although restoration of the vertebral body height and kyphosis seemed to be easier with balloon kyphoplasty, it became clear that some of the correction achieved by the balloon is lost once it was deflated. Vertebral body stent was developed to eliminate this phenomenon. To our knowledge this is the first study in describing this technique in clinical settings. MATERIALS AND METHODS: Seventeen patients with 20 fractured vertebral bodies were included. All fractures were Type A1.3 or A3.1 (incomplete burst). Information about pain (visual analogue scale-VAS) and function (Oswestry disability index-ODI) and vertebral body deformity (vertebral angle-VA) was recorded in a prospective way at regular intervals. Patients were classified into osteoporotic group (7 patients) and traumatic groups (10 patients, younger than 60 years). RESULTS: There were 6 male and 11 female patients with mean age of 58.1 years (31-88 years). Mean follow up was 12 months. The preoperative pain level showed a mean VAS score of 8.9 in osteoporotic group and 9.7 in traumatic group. Postoperatively, in osteoporotic group, mean VAS was 4.8 at 6 weeks, 4.0 at 6 months and 2.5 at 12 months compared with traumatic fracture group where it was 2.7 at 6 weeks, 2.2 at 6 months and 1.6 at 12 months. Mean ODI in osteoporotic group was 41.7% (14-58%) and in traumatic group it was 20.4% (6-33%). Mean vertebral body angle prior to surgery in osteoporotic group was 9.7 whilst postoperatively it was 5.2°; so the mean correction achieved was 4.5°. In traumatic group preoperative VA was 13° whilst postoperatively it was 5.7°; therefore the mean correction achieved was 7.3°. None of the patients lost reduction at their last follow up. CONCLUSION: Vertebral body stenting leads to satisfactory improvement in pain, function and kyphosis correction in the treatment of osteoporotic and traumatic fractures. Anterior spinal column, especially the fragmented superior endplate is nicely reconstructed by the stent provided it is inserted accurately. With addition of posterior transpedicular instrumentation, indications for this technique may be wider covering some Type B and C fractures with similar vertebral body damage.

Total spondylectomy of C2: report of three cases and review of the literature.

STUDY DESIGN: A report on 3 patients undergoing total spondylectomy of the C2 vertebra for tumor and the technique for C1-3 reconstruction. OBJECTIVE: To illustrate the feasibility of complete resection of the C2 vertebra with preservation of the vertebral arteries and cervical nerve roots. BACKGROUND: Total spondylectomy provides improved progression free survival in many patients with locally aggressive spinal tumors. However, the perceived technical demands of effectively preserving both vertebral arteries, maintaining cervical nerve roots, and biomechanical reconstruction of the cranial-cervical junction often dissuades surgeons from carrying out total spondylectomy of the C2 vertebra. METHODS: A review of 3 patients undergoing total C2 spondylectomy for tumor (thyroid adenocarcinoma, chordoma, and solitary plasmocytoma) was done. The surgical procedure that was undertaken and the technique used are described. RESULTS: Postoperatively, all 3 patients had uneventful postoperative recovery with gradual improvement in their neurologic functions. CONCLUSION: Preservation of bilateral vertebral arteries and all cervical nerve roots is feasible when carrying out intralesional total spondylectomy in patients with C2 vertebral body tumors and should be considered in patients thought to benefit from total C2 vertebra excision. In an attempt to augment construct stability and provide anterior column load sharing, we have used mesh cage and iliac crest graft between C1 and C3 held in place with a short cervical plate without complications.

Lamina-guided lateral mass screw placement in the sub-axial cervical spine.

Lateral mass (LM) screws are commonly used in posterior instrumentation of the cervical spine because of their perceived safety over pedicle screws. A possible complication of cervical LM screw placement is vertebral artery injury or impingement. Several screw trajectories have been described to overcome the risks of neurovascular injury; however, each of these techniques relies on the surgeon's visual estimation of the trajectory angle. As the reliability hereof is poorly investigated, alignment with a constant anatomical reference plane, such as the cervical lamina, may be advantageous. The aim of this investigation was to determine whether alignment of the LM screw trajectory parallel to the ipsilateral cervical lamina reliably avoids vertebral artery violation in the sub-axial cervical spine. 80 digital cervical spine CT were analysed (40 female, 40 male). Exclusion criteria were severe degeneration, malformations, tumour, vertebral body fractures and an age of less than 18 or greater than 80 years. Mean age of all subjects was 39.5 years (range 18-78); 399 subaxial cervical vertebrae (C3-C7) were included in the study. Measurements were performed on the axial CT view of C3-C7. A virtual screw trajectory with parallel alignment to the ipsilateral lamina was placed through the LM. Potential violation of the transverse foramen was assessed and the LM width available for screw purchase measured. There was no virtual violation of the vertebral artery of C3-C7 with lamina-guided LM screw placement. LM width available for screw purchase using this technique ranged from 5.2 to 7.4 mm. The sub-axial cervical lamina is a safe reference plane for LM screw placement. LM screws placed parallel to the ipsilateral lamina find sufficient LM width and are highly unlikely to injure the vertebral artery, even in bi-cortical placement. Placing LM screws parallel to the lamina appears favourable over conventional techniques.

Increased level of cytokines and matrix metalloproteinases in osteoarthritic subchondral bone.

OBJECTIVE: The aim of this study was to investigate the expression of several cytokines, matrix metalloproteinases (MMPs), and tissue inhibitor of matrix metalloproteinases (TIMP)-1 in osteoarthritis (OA) and control sera and different joint tissues. METHODS: Serum, synovial fluid, cartilage, synovial and subchondral bone tissues were examined in OA and control subjects. The protein level of tumor necrosis factor (TNF)-alpha, interleukin (IL)-1alpha, IL-8, IL-10 and MMP-2, MMP-3, MMP-9, and TIMP-1 were measured by immunoanalysis. RESULTS: Serum levels of TNF-alpha, MMP-3 and -9 were significantly higher in OA patients than in controls. Conversely, serum IL-10 was decreased in OA patients. CRP was elevated when compared to healthy controls and decreased significantly 6 months after the surgery. In contrast to control samples, OA cartilage and synovium revealed significantly higher MMP-2, -3, -9 and IL-10. IL-1alpha was significantly higher in OA cartilage and IL-8 in OA synovium. Interestingly, MMP-3, -9, TIMP-1 and all tested cytokines were up-regulated in OA subchondral bone. DISCUSSION: This study demonstrates pro-inflammatory condition of OA pathology and supports the idea that vascularized subchondral region may increase the synthesis of cytokines and MMPs leading to degradation of adjacent cartilage.

Harms titanium mesh cage fracture.

Interbody fusion has become a mainstay of surgical management for lumbar fractures, tumors, spondylosis, spondylolisthesis and deformities. Over the years, it has undergone a number of metamorphoses, as novel instrumentation and approaches have arisen to reduce complications and enhance outcomes. Interbody fusion procedures are common and successful, complications are rare and most often do not involve the interbody device itself. We present here a patient who underwent an anterior L4 corpectomy with Harms cage placement and who later developed a fracture of the lumbar titanium mesh cage (TMC). This report details the presentation and management of this rare complication, as well as discusses the biomechanics underlying this rare instrumentation failure.

Application of a calibration method provides more realistic results for a finite element model of a lumbar spinal segment.

BACKGROUND: An important step in finite element modeling is the process of validation to derive clinical relevant data. It can be assumed that defect states of a finite element model, which have not been validated before, may predict wrong results. The purpose of this study was to show the differences in accuracy between a calibrated and a non-calibrated finite element model of a lumbar spinal segment for different clinical defects. METHODS: For this study, two geometrically identical finite element models were used. An in vitro experiment was designed, deriving data for the calibration. Frequently used material properties were obtained from the literature and transferred into the non-calibrated model. Both models were validated on three clinical defects: bilateral hemifacetectomy, nucleotomy and interspinous defects, whereas in vitro range of motion data served as control points. Predictability and accuracy of the calibrated and non-calibrated finite element model were evaluated and compared. FINDINGS: Both finite element models could mimic the intact situation with a good agreement. In the defects, the calibrated model predicted motion behavior with excellent agreement, whereas the non-calibrated model diverged greatly. INTERPRETATION: Investigating the biomechanical performance of implants and load distribution of different spinal structures by numerical analysis requires not only good agreement with the intact segment, but also with the defect states, which are initiated prior to implant insertion. Because of more realistic results the calibration method may be recommended, however, it is more time consuming.

Stepwise reduction of functional spinal structures increase range of motion and change lordosis angle.

Many investigators have performed studies on specific defect situations or determined the contribution on isolated structures. Investigating the contribution of functional structures requires obtaining the kinematic response directly on spinal segments. The purpose of this study was to quantify the function of anatomical components on lumbar segments for different loading magnitudes. Eight spinal segments (L4-5) with a median age of 52 years (ranging from 38 to 59 years) and a low degree of disc degeneration were utilized for the in vitro testing. Specimens were mounted in a custom-built spine tester and loaded with pure moments (1-10 N m) to move within three anatomical planes at a loading rate of 1.0 degrees /s. Anatomy was successively reduced by: ligaments, facet capsules, joints and nucleus. Data were evaluated for range of motion, neutral zone and lordosis angle. Transection of posterior ligaments predominantly increased specimen flexion for all bending moments applied. Supraspinous ligament also indicated to resist in extension slightly, whereas the facet capsules did not. Facet joints contributed to axial rotation, but not in lateral bending. The anterior longitudinal ligament was found to slightly resist in axial rotation, but strongly in extension. Nucleotomy caused largest increase of all movements. The unloaded posture of the specimens changed after ligament dissection, indicating ligament pretension. The region of lumbar spine is interesting for finite element (FE) simulation due to the high evidence of disc degeneration and injuries. This study may help to understand the function of specific anatomical structures and assists in FE model calibration. We suggest to start a calibration procedure for such models with the smallest functional structure (annulus) and to cumulatively add further structures.