The extreme lateral approach for treatment of thoracic and lumbar vertebral body metastases.

In addition to radiotherapy, the utility of surgical decompression and stabilization in patients with metastatic vertebral body tumors causing cord compression, progressive deformity and/or intractable pain has been well demonstrated. Minimally invasive approaches are an attractive alternative to traditional procedures as they may reduce the degree of disruption of normal anatomy, decrease blood loss, shorten hospital stays and reduce the risk of infection or wound dehiscence. The extreme lateral approach is a procedure that provides access to the anterior spine through a small incision along the flank utilizing a unique retractor system without disruption of posterior vertebral elements, spinal musculature and ligaments. A review of two senior surgeons' databases was performed between June 2010 and October 2014 to identify patients with metastatic vertebral body tumors who were treated surgically at the University of Miami during this period. We report the results of eight cases in which the extreme lateral approach was employed to perform a corpectomy and cage reconstruction for metastatic disease of the thoracic and lumbar vertebral bodies. Each case was supplemented by posterior percutaneous or less commonly open pedicle screw instrumentation. Postoperative imaging demonstrated excellent decompression of neural elements as well as deformity correction, and all patients maintained or improved neurologic function. There were no instances of wound dehiscence or infection. Our results indicate that the extreme lateral approach can be effectively used to excise metastatic vertebral body lesions of the thoracolumbar spine causing spinal cord and/or nerve root compression and spinal deformity.

Laser Interstitial Thermal Therapy: Lighting the Way to a New Treatment Option in Neurosurgery.

ABBREVIATIONS: LITT, laser interstitial therapyNd:YAG, neodymium-doped yttrium aluminum.

The use of modest systemic hypothermia after iatrogenic spinal cord injury during surgery.

Iatrogenic spinal cord injury (SCI) is an uncommon (0%-3%), yet devastating, complication of spine surgery. Recent evidence based on small clinical studies indicates that modest hypothermia is a feasible treatment option for severe SCI. We extended this treatment modality to patients with devastating iatrogenic SCI. We conducted a retrospective case series of five male patients (cervical trauma--1, cervical degenerative--2, thoracic trauma--1, and thoracic scoliosis--1) with an age range of 16-51 years (average age of 46 years) with intraoperative motor-evoked potential/somatosensory-evoked potential loss secondary to catastrophic events during the spinal operation associated with new SCI. Modest hypothermia was instituted immediately postsurgery for 24 hours. Four patients also received methylprednisolone. Preoperative American Spinal Injury Association (ASIA) scores were D (n=3) and E (n=2), while immediate postoperative scores were A (n=1), B (n=1), C (n=2), and D (n=1). Immediate postoperative MRI revealed new cord signal change in three patients. Two patients required subsequent surgery. ASIA scores at last follow-up were C (n=1), D (n=3), and E (n=1) with an improvement of 1-2 grades per patient. Adverse events such as pulmonary embolism, deep venous thrombosis, coagulopathy, or infection were not observed. Hypothermia is a feasible treatment option for patients with iatrogenic SCI. While hypothermia has not been proven to improve outcomes in these situations, aggressive medical management, including cooling, resulted in better-than-expected outcomes in this small cohort.

An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine.

OBJECT: Minimally invasive anterolateral approaches to the lumbar spine are options for the treatment of a number of adult degenerative spinal disorders. Nerve injuries during these surgeries, although rare, can be devastating complications. With an increasing number of spine surgeons utilizing minimal access retroperitoneal surgery to treat lumbar problems, the frequency of complications associated with this approach will likely increase. The authors sought to better understand the location of the lumbar contribution of the lumbosacral plexus relative to the disc spaces encountered when performing the minimally invasive transpsoas approach, also known as extreme lateral interbody fusion or direct lateral interbody fusion. METHODS: Three fresh cadavers were placed lateral, and a total of 3 dissections of the lumbar contribution of the lumbosacral plexus were performed. Radiopaque soldering wire was then laid along the anterior margin of the nerve fibers and the exiting femoral nerve. Markers were placed at the disc spaces and lateral fluoroscopy was used to measure the location of the lumbar plexus along each respective disc space in the lumbar spine (L1-2, L2-3, L3-4, and L4-5). RESULTS: The lumbosacral plexus was found lying within the substance of the psoas muscle between the junction of the transverse process and vertebral body and exited along the medial edge of the psoas distally. The lumbosacral plexus was most dorsally positioned at the posterior endplate of L1-2. A general trend of progressive ventral migration of the plexus on the disc space was noted at L2-3, L3-4, and L4-5. Average ratios were calculated at each level (location of the plexus from the dorsal endplate to total disc length) and were 0 (L1-2), 0.11 (L2-3), 0.18 (L3-4), and 0.28 (L4-5). CONCLUSIONS: This anatomical study suggests that positioning the dilator and/or retractor in a posterior position of the disc space may result in nerve injury to the lumbosacral plexus, especially at the L4-5 level. The risk of injuring inherent nerve branches directed to the psoas muscle as well as injury to the genitofemoral nerve do still exist.

Modification of Wright's technique for placement of bilateral crossing C2 translaminar screws: technical note.

BACKGROUND CONTEXT: Several relatively new screw techniques have been described that rigidly capture the posterior elements of C2. The previously described procedures of axis fixation are technically demanding and place the vertebral artery at some risk. A novel and less technically demanding technique of obtaining C-2 translaminar screws has been recently described. Although the risk of vertebral artery injury has been essentially eliminated, the authors recognize that neurologic injury from breakthrough of the inner cortex of the lamina by the drill or screw is still a possibility. PURPOSE: Describe and illustrate a modified C2 translaminar technique and review the results of patients who have undergone the surgery. The current modification of the C2 translaminar screw technique was designed to reduce the risk of inadvertent screw placement within the spinal canal. STUDY DESIGN/SETTING: A techniques paper combined with a retrospective clinical review of patients undergoing the surgery. PATIENT SAMPLE: Patients undergoing posterior instrumented fusion surgery of the cervical spine, which incorporates C2 posterior elements using the translaminar technique. OUTCOME MEASURES: Radiographic analysis of the fusion construct incorporating the C2 translaminar screws. METHODS: We have modified the previously described technique of C-2 translaminar screw placement with the addition of "exit" cortical windows to assure bicortical, intralaminar screw placement. RESULTS: The results of the first six patients with an average follow-up of 12 months demonstrated this method to be safe and effective in fixating the axis. CONCLUSIONS: We have made a simple modification of Wright's elegant technique with the addition of "exit" windows at the facet-laminar junctions. This gives us the assurance that the C2 screw has not entered the spinal canal by directly visualizing the tip of the screw exiting the outer cortices of the lamina before leaving the operating room.

Vertically unstable type III odontoid fractures: case report.

OBJECTIVE AND IMPORTANCE: Type III odontoid fractures are generally thought of as unstable fractures that can be successfully treated with an external orthosis. However, there is a rare subtype of Type III odontoid fractures that is similar in the degree of instability to atlanto-occipital dislocation injuries. Not recognizing or not treating this injury urgently and aggressively could lead to devastating iatrogenic neurological injuries such as quadriplegia and fatal lower brainstem palsies. CLINICAL PRESENTATION: We present the case of a 73-year-old woman with a vertically distracted Type III odontoid fracture and associated quadriparesis and brainstem deficits. The patient was kept in a rigid collar, placed in a kinematic bed, and admitted to the trauma service for the management of her life-threatening systemic injuries. Traction was not applied. INTERVENTION: As soon as the patient was systemically stable, she was taken to the operating room for C1-C2 fixation with a screw-rod construct supplemented by cable and structural iliac crest bone graft. CONCLUSION: Delayed recognition of this subtype of Type III odontoid fracture could have fatal or highly morbid consequences, such as quadriparesis/-plegia, lower brainstem dysfunction, and ventilator-dependence, for the patient. It is important to keep a high level of suspicion for this unusual subtype of Type III odontoid fracture.

The role of the sternocleidomastoid muscle flap for esophageal fistula repair in anterior cervical spine surgery.

STUDY DESIGN: A retrospective study was undertaken which evaluated the medical records and imaging studies of a subset of patients managed by the spine service at Jackson Memorial Hospital who were diagnosed with an esophageal perforation in the setting of spinal surgery. OBJECTIVE: To assess the safety and efficacy of a sternocleidomastoid muscle flap in the repair of esophageal perforation in the setting of anterior cervical spine surgery. SUMMARY OF BACKGROUND DATA: The management of an esophageal fistula in the setting of spine surgery is challenging and starts with a prompt and accurate diagnosis. In addition to broad spectrum intravenous antibiotics, several methods have been described to repair the fistula, which range from enteral tube feeding, direct repair, and/or repair with a local or free muscle flap. METHODS: The review encompassed medical records, discharge summaries, operative reports, and imaging studies. Data were gathered with specific attention to demographics, primary pathology, mechanism of esophageal injury, method of spinal stabilization, method of esophageal repair, and time to initiation of oral intake. Follow-up interviews were conducted either in-person or by telephone. RESULTS: Six patients were treated over the study period. There were 3 men and 3 women. The mean age was 52.8 years. Primary pathologies were penetrating trauma, blunt trauma (2 cases), degenerative disease (2 cases), and tumor. Mechanisms of esophageal injury were penetrating trauma, acute iatrogenic, chronic iatrogenic (3 cases), and intubation trauma. The time to diagnosis ranged from immediate to 10 months. The method of spinal stabilization was anterior autograft followed by posterior instrumentation in 4 of 6 patients. The method of esophageal repair was an inferiorly based sternocleidomastoid (SCM) flap in 4 cases, primary repair in 1 case, and esophageal diversion alone in 1 case. The time to oral intake averaged 59.2 days (range, 23-113 days) in those with a SCM flap versus 153.5 days (range, 119-188 days) in those treated without a flap. CONCLUSION: The use of an SCM flap for the repair of esophageal injury, in the setting of anterior cervical spine surgery, is a safe and effective tool. An SCM flap appeared to improve the time in initiating oral intake without any significant morbidity.

Spontaneous spinal epidural hematoma during pregnancy: case report and literature review.

OBJECTIVE AND IMPORTANCE: Spinal epidural hematoma is a rare cause of spinal cord compression and acute para- or quadriplegia. Traumatic spinal epidural hematomas are usually seen in older men with a history of ankylosing spondylitis and vertebral fracture. Spontaneous spinal epidural hematomas are commonly associated with coagulopathies, tumors, or vascular malformations. There have been only five previously published case reports in the English-language literature of spontaneous spinal epidural hematomas in conjunction with pregnancy. CLINICAL PRESENTATION: We present the case of a 24-year-old woman at 20 weeks' gestation who presented to our service with a spontaneous cervicothoracic spinal epidural hematoma and complete quadriplegia. INTERVENTION: The patient was taken to the operating room for urgent surgical decompression and evacuation of the spinal epidural hematoma. CONCLUSION: The patient made a complete neurological recovery in long-term follow-up. In the meantime, she carried her pregnancy to term and gave birth to a healthy baby. Therefore, we advocate aggressive and early surgical intervention, similar to the five previously reported cases in the English-language literature, in the case of a spinal epidural hematoma causing cord compression and devastating neurological deficit in a pregnant woman.