Minimally invasive discectomy versus open laminectomy and discectomy for the treatment of cauda equina syndrome: A preliminary study and case series.

Background: Cauda Equina syndrome (CES) is a potentially devastating condition and is treated usually with urgent open surgical decompression of the spinal canal. Currently, the role of minimally invasive discectomy (MID) as an alternative surgical technique for CES is unclear. Objective: The purpose of this study was to compare clinical outcomes following MID and open laminectomy and discectomy for the treatment of CES. Methods: The study cohort included patients that underwent surgery due to CES at our institute. Patients' outcomes included: surgical complications, length of hospitalization, postoperative lower extremity motor score (LEMS), Numerical Rating Scale (NRS) for leg and back pain, Oswestry disability index (ODI), and the EQ-5D health-related quality of life questionnaire. Results: Twelve patients underwent MID and 12 underwent open laminectomy and discectomy. Complications and revisions rates were comparable between the groups. Postoperative urine incontinence and saddle dysesthesia improved in 50% of patients in both groups. LEMS improved from 47.08 ± 5.4 to 49.27 ± 0.9 in the MID group and from 44.46 ± 5.9 to 49.0 ± 1.4 in the open group. Although, leg pain improved in both groups from 8.4 ± 2.4 to 3 ± 2.1 in the MID and from 8.44 ± 3.3 to 3.88 ± 3 in the open group, significant improvement in back pain was found only in the MID group. Final functional scores were similar between groups. Conclusions: Our preliminary results suggest that minimally invasive discectomy is an effective and safe procedure for the treatment of CES when compared to open laminectomy and discectomy. However, MID in these cases should only be considered by surgeons experienced in minimally invasive spine surgery. Further studies with bigger sample sizes and long-term follow-ups are needed.

Arthroscopic Repair of Humeral Avulsion of Glenohumeral Ligament Lesions: Outcomes at 2-Year Follow-up.

BACKGROUND: Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon condition but a major contributor to shoulder instability and functional decline. PURPOSE: To describe the pre- and postoperative HAGL lesion presentations of instability, pain, and functionality and the return-to-sports activities in patients managed arthroscopically for anterior and posterior HAGL lesions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data on patients with HAGL lesions treated with arthroscopic repair between 2009 and 2018 were retrospectively retrieved from medical charts, and the patients were interviewed to assess their level of postoperative functionality. The Rowe; Constant; University of California, Los Angeles; Oxford; and pain visual analog scale (VAS) scores were obtained for both pre- and postoperative status. Return-to-sports activities and level of activities after surgery were compared with the preinjury state, and complications, reoperations, and recurrent instability were recorded and evaluated. RESULTS: There were 23 study patients (12 females and 11 males; mean age, 24 years). The mean follow-up duration was 24.4 months (range, 7-99 months; median, 17 months). In 7 (30.4%) of the patients, HAGL lesions were diagnosed only intraoperatively. A significant improvement was seen in all examined postoperative functional scores and VAS. At the last follow-up visit, 2 patients (8.7%) reported residual instability with no improvement in pain levels and declined any further treatment, and 3 others (13.0%) required revision surgeries for additional shoulder pathologies (reoperations were performed 18-36 months after the index procedure). The remaining 18 patients (78.3%) were free of pain and symptoms. There was a mean of 0.65 coexisting pathologies per patient, mostly superior labral anterior-posterior, Bankart, and rotator cuff lesions. CONCLUSION: HAGL lesions are often missed during routine workup in patients with symptoms of instability, and a high level of suspicion is essential during history acquisition, clinical examination, magnetic resonance imaging arthrogram interpretation, and arthroscopic evaluation. Arthroscopic repair yields good pain and stability results; however, some high-level athletes may not return to their preinjury level of activity.

Spine deformities in patients with cerebral palsy; the role of the pelvis.

INTRODUCTION: Progressive neuromuscular spinal deformities with pelvic obliquity and loss of sitting balance are typical features of severely affected patients with cerebral palsy. The pelvis represents the key bone between the spine and the lower extremity when it comes to deciding whether and when to operate and if spine or hip surgery first is beneficial. The pelvis can be looked at as the lowest vertebra and as the rooftop of the lower extremities. BIOMECHANICAL CONSIDERATIONS: To allow for a normal spinal shape, the pelvis needs to be horizontal in the frontal plane and mildly anterior tilted in the sagittal plane, less for sitting and more for standing. Any abnormal pelvic position requires spinal compensation and challenges the equilibrium control of the individual. Both anatomical neighbourhoods - the spine and the hip joints - have to be considered when spinal deformities, hip instability and contractures evolve, in conservative therapy (bracing, physiotherapy, seating in the wheelchair) and when surgical interventions are weighed out against each other. SURGICAL CONSIDERATIONS: Multiple anatomical factors such as sagittal profile and pelvic orientiation, pelvic transverse plane asymmetries and lumbosacral malformations have to be considered in case the pelvis is instrumented with sacral and iliac screws. Rotational deformities and asymmetries of the pelvic bones make the safe insertion of long screws challenging. Advantages of primary pelvic fixation include correction of pelvic obliquity, especially considering the lever arm of the whole spinal construct. The risk of revision surgery due to progression of distal curves is also reduced. Disadvantages of pelvic fixation include the complexity of the additional intervention, which may result in longer operating times, increased risk of blood loss, infection and hardware malpositioning.

Acute Presentation of Cervical Myelopathy Following Manipulation Therapy.

BACKGROUND: Spinal manipulation therapy (SMT) is commonly used as an effective therapeutic modality for a range of cervical symptoms. However, in rare cases, cervical manipulation may be associated with complications. In this review we present a series of cases with cervical spine injury and myelopathy following therapeutic manipulation of the neck, and examine their clinical course and neurological outcome. We conducted a search for patients who developed neurological symptoms due to cervical spinal cord injury following neck SMT in the database of a spinal unit in a tertiary hospital between the years 2008 and 2018. Patients were assessed for the clinical course and deterioration, type of manipulation used and subsequent management. A total of four patients were identified, two men and two women, aged 32-66 years. In three patients neurological deterioration appeared after chiropractic adjustment and in one patient after tuina therapy. Three patients were managed with anterior cervical discectomy and fusion while one patient declined surgical treatment. Assessment for subjective and objective evidence of cervical myelopathy should be performed prior to cervical manipulation, and suspected myelopathic patients should be sent for further workup by a specialist familiar with cervical myelopathy (such as a neurologist, a neurosurgeon or orthopedic surgeon who specializes in spinal surgery). Nevertheless, manipulation therapy remains an important and generally safe treatment modality for a variety of cervical complaints. This review does not intend to discard the role of SMT as a significant part in the management of patients with neck related symptoms, rather it is meant to draw attention to the need for careful clinical and imaging investigation before treatment.

Metal-on-Metal Hip Replacement: MRI Signal Intensities of Different Body Tissues and Their Relations to Blood Metal Ion Levels.

BACKGROUND: Metal-on-metal total hip prostheses (MoM-THR) have been shown to produce hypersensitivity reactions and fluid collection (pseudotumor) by the hip as well as high blood metal ions levels (BMILs). OBJECTIVES: To evaluate the magnetic resonance imaging (MRI) signal-to-noise ratio (S/N) in selected body tissues around the hip of patients who underwent MoM hip replacement and to correlate to BMILs. METHODS: Sixty-one MRI hip examinations in 54 post-MoM-THR patients (18 males, 36 females, mean age 65 years) were retrospectively evaluated independently by two readers. The mean S/N ratio in a region of interest was calculated for periprosthetic pseudotumor collection (PPC), the bladder, fat, and muscle on axial T1w, FSE-T2w, and short tau inversion recovery (STIR) sequences on the same location. BMILs were retrieved from patient files. RESULTS: PPC was detected in 32 patients (52%) with an average volume of 82.48 mm3. BMIL did not correlate with the presence of PPCs but positively correlated with the PPC's volume. A trend for positive correlation was found between BMILs and S/N levels of STIR images for muscle and bladder as well as for PPC and cobalt levels. A trend for correlation was also seen between BMIL with PPC's T1 w S/N. CONCLUSIONS: Alteration of MRI S/N for different hip tissues showed a tendency for correlation with BMILs, possibly suggesting that metal deposition occurs in the PPC as well as in the surrounding tissues and bladder.

Surgical Technique: Arthroscopic Osteoplasty of Anterior Inferior Iliac Spine for Femoroacetabular Impingement.

The anterior inferior iliac spine (AIIS) has variable morphology that correlates with hip range of motion. Subspinal impingement is an extracapsular cause for femoroacetabular impingement (FAI) and is clinically significant because it results in decreased range of motion and groin pain with flexion-based activity. In symptomatic patients with AIIS extension to or below the acetabular rim, AIIS decompression is considered part of an FAI corrective procedure. A consistent exposed bony area on the anterior and inferomedial aspect of the AIIS serves as a "safe zone" of resection allowing for decompression with preservation of the origin of the rectus femoris tendon. This surgical note describes a technique for AIIS decompression. The goal for low AIIS osteoplasty is to resect the AIIS to 2 burr widths (using a 5.5-mm burr) above the acetabular rim, achieving an 11-mm clearance, creating a type I AIIS. The resultant flat anterior acetabular surface between the most anteroinferior prominent point of the AIIS and the acetabular rim allows for free movement of the hip joint without impingement. Careful execution of AIIS decompression can alleviate clinical symptoms of FAI and restore function to the hip joint.

Bilateral total hip replacement: periprosthetic pseudotumor collections are more prevalent in metal-on-metal implants compared to non-metal-on-metal ones.

BACKGROUND: Metal-on-metal (MoM) hip prostheses were shown to have high failure rates including the formation of periprosthetic cystic masses called periprosthetic pseudotumor collections (PPCs). PURPOSE: To compare MRI prevalence and size of PPCs in patients after bilateral total-hip-replacement (THR) in which at least one hip was replaced by a MoM prosthesis. MATERIAL AND METHODS: All sequential MRI examinations of patients with bilateral THR in which at least one is MoM (2010-2013) were retrospectively evaluated. MRIs were analyzed separately by two readers for the presence and size of PPCs. These were compared between MoM and non-MoM implants and between patients with unilateral or bilateral-MoM prostheses. Blood metal ion levels were also compared. RESULTS: Seventy hips of 35 patients (male:female ratio, 9:26; mean age, 64 years; age range, 35-82 years) were assessed. Sixteen patients (45%) underwent bilateral MoM-THRs and 19 (55%) had one MoM and the other non-MoM, yielding 51 MoM THRs and 19 non-MoM THRs. Twenty-eight PPCs were detected in 19 patients (54%): 26 in MoM THRs (51%) and two in non-MoM THRs (10.5%, P = 0.00009). The mean PPC volume in the MoM implants (107 mm(3)) was higher than that of the non-MoM implants (18 mm(3), P = 0.49). Cobalt/chromium blood levels were 78 µg/L/25 µg/L for bilateral MoM THRs and 21 µg/L/10 µg/L for unilateral MoM implants (P = 0.1 and 0.16, respectively). CONCLUSION: PPCs are more prevalent in MoM THRs compared to non-MoM THRs. Larger PPC volumes and higher blood metal ion levels were detected in patients with bilateral MoM THRs compared to unilateral MoM THRs (P > 0.05).

Gait characteristics and quality of life perception of patients following tibial plateau fracture.

INTRODUCTION: The purpose of the current study was to evaluate the long-term functional outcome as measured by gait patterns and quality of life assessment of patients with high-energy tibial plateau fracture compared to matched controls. MATERIALS AND METHODS: Thirty-eight patients were evaluated in a case-controlled comparison. Twenty-two patients with tibial plateau fracture were evaluated after 3.1 (1.63) years (sd) from injury. Patients underwent a computerized spatiotemporal gait test and completed the SF-12 health survey. 16 healthy subjects, matched for age and gender served as a control group. The main outcome measures for this study were spatiotemporal gait characteristics, physical quality of life and mental quality of life. RESULTS: Significant differences were found in all gait parameters between patients with tibial plateau fracture and healthy controls. Patients with tibial plateau fracture walked slower by 18% compared to the control group (p < 0.001), had slower cadence by 8% compared (p = 0.002) to the control group and had shorter step length in the involved leg by 11% and in the uninvolved leg by 12% compared to the control group (p = 0.006 and p = 0.003, respectively). Patients with tibial plateau fracture also showed shorter single limb support (SLS) in the involved leg by 12% compared to the uninvolved leg and 5% in the uninvolved leg compared to the control group (p < 0.001 and p = 0.017, respectively). Significant differences were found in the Short Form (SF)-12 scores. Physical Health Score of patients with tibial plateau fracture was 65% lower compared to healthy controls (p < 0.001), and Mental Health Score of the patients was 40% lower compared to healthy controls (p < 0.001). Finally, significant correlations were found between SF-12 and gait patterns. CONCLUSION: Long-term deviations in gait and quality of life exist in patients following tibial plateau fracture. Patients following tibial plateau fracture present altered spatiotemporal gait patterns compared to healthy controls, as well as self-reported quality of life.