Hybrid Implants in Anterior Cervical Spine Surgery: The State of the Art and New Trends for Multilevel Degenerative Disc Disease.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) still represents the first surgical option in the treatment of cervical degenerative disc disease (DDD) but is still burdened by several complications secondary to the loss of mobility at the treated segment and adjacent segment diseases (ASDs). To overcome those complications, hybrid surgery (HS) incorporating ACDF and cervical disc arthroplasty (CDA) is increasingly performed for DDD. METHODS: We retrospectively reviewed the clinical, surgical, and outcome data of 85 consecutive patients (M/F, 41/44) harboring cervical disc herniation with or without osteophytes, with radiculopathy and with or without myelopathy, who underwent the anterior approach to a cervical discectomy on two or more levels with at least one disc prosthesis, along with a cage and plate or an O Profile screwed plate. RESULTS: All the patients improved regardless of the cervical construct used. No significant relationship between different kinds of prosthesis and their surgical level; the number of cages; and the site of the cages (screwed and/or plated) was found concerning immediate stability, dynamic prosthesis effectiveness, and clinical improvement in all the patients up to the maximum follow-up time. CONCLUSIONS: Although the optimal surgical technique for cervical DDD remains controversial, HS represents a safe and effective procedure in select patients with multilevel cervical DDD, as demonstrated by biomechanical and clinical studies and the present series.

The Thoracoscopic Approach in Spinal Cord Disease.

Video-assisted thoracic surgery (VATS) has been growing in popularity over the past 2 decades as an alternative to open thoracotomy for the treatment of several spinal conditions, and in the field of minimally invasive surgery, it now acts as a keyhole to the thoracic spine. MATERIALS AND METHODS: Most VATS approaches are from the right side for pathologies involving the middle and upper thoracic spine because there is a greater working spinal surface area lateral to the azygos vein than that lateral to the aorta. Below T-9, a left-sided approach is made possible because the aorta moves away from the left posterolateral aspect of the spine to an anterior position as it passes through the diaphragm. RESULTS: VATS has been used extensively in spinal deformities such as scoliosis. The use of VATS in spine surgery includes the treatment of thoracic prolapsed disk diseases, vertebral osteomyelitis, fracture management, vertebral interbody fusion, tissue biopsy, anterior spinal release, and fusion without or with instrumentation (VAT-I) for spinal deformity correction. As the knowledge and the comfort of using such techniques have expanded, the indications have extended to corpectomy for tumor resections. DISCUSSION AND CONCLUSIONS: In the field of minimally invasive surgery, VATS now acts as a keyhole to the thoracic spine and an alternative to open thoracotomy for the treatment of several spinal conditions.Although VATS can be performed in such spine conditions, it is most beneficial in the treatment of scoliotic deformity, which requires taking a multilevel approach, from the upper to the lower thoracic spine.

Technical note-in situ laminotomy: preserving posterior tension band in surgery of pediatric multilevel spinal tumor.

BACKGROUND: Laminotomy has been introduced in surgical practice to reduce complications of laminectomy after surgery of tumors in the spinal canal. However, the posterior ligament complex, which is routinely interrupted to remove the laminoplasty segment and gain access to the spinal canal, has a tendency not to heal and can lead to progressive kyphosis and collapse. CASE PRESENTATION: A 5-month-old boy affected by a thoracolumbar extradural tumor extending along seven spinal levels was operated on. The tumor was exposed and completely resected by a one-piece laminotomy with preservation of the integrity of the posterior tension band at both extremities. After 1-year radiological examination ruled out spinal deformity. CONCLUSION: The technique herein presented, which we named in situ laminotomy, allows to fully preserve the posterior tension band without reducing the exposure of the spinal canal in multilevel tumors. Additionally, the technique makes also the reconstruction of the spine elements very easy and rapid. However, longer follow-up is necessary to prove the effectiveness of this procedure in preventing long-term deformity and instability.

Hybrid implants in anterior cervical decompressive surgery for degenerative disease.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) still represent the mainstream surgical approach in the treatment of degenerative cervical Degenerative Disc Disease (DDD), being a loss of mobility at the treated segment and adjacent segment diseases well-known complications. To overcome those complications, hybrid surgery (HS) incorporating ACDF and cervical disk arthroplasty is increasingly performed for DDD. METHODS: We retrospectively reviewed the clinical, surgical, and outcome data of 62 consecutive patients (male/female, 29/37) harboring cervical disk herniation with or without osteophytes, with radiculopathy with or without myelopathy, who underwent a cervical discectomy on two or more levels with the anterior approach with at least one disk prosthesis along with cage and plate or O Profile screwed plate. RESULTS: All the patients improved regardless of the cervical construct used. No significant relationship between different kind of prostheses as well as their surgical level, the number and the site of the cages (screwed and/or plated) was found out concerning immediate stability, dynamic prosthesis effectiveness, and clinical improvement in all the patients up to the maximum follow-up. CONCLUSIONS: Although the optimal surgical technique for cervical DDD remains controversial, HS represents a safe and effective procedure in selected patients with multilevel cervical DDD, as demonstrated by biomechanical and clinical studies and the present series. Some technical aspects should be considered when dealing with this procedure, like the drilling of the endplate, and some radiological findings have to be detected because potentially predictive of future misplacement.

Long-standing Overt Ventriculomegaly in Adults and Endoscopic Third Ventriculostomy, the Perfect Treatment for the Proper Diagnosis.

OBJECTIVE: Long-standing overt ventriculomegaly in adults (LOVA) is form of hydrocephalus that develops during childhood, manifesting its symptoms during adulthood. Only a small number of LOVA case series have been published, and controversies regarding optimal management still exist. The authors collected a series of symptomatic LOVA patients treated successfully using endoscopic third ventriculostomy (ETV), aiming to strengthen what has been reported in the literature on ETV's role in both neurologic and neurocognitive outcomes. METHODS: Between 2002 and 2020, we collected 40 case studies of patients treated using an ETV. Associated pathologies were documented in 14 cases. All patients underwent magnetic resonance scans preoperatively and postoperatively while only 29 patients were submitted during follow-up to neurocognitive assessment. RESULT: At a mean follow-up of 6 years, 36 patients (90%) reported either an improvement or a stabilization of their presenting symptoms. Headache improved subjectively in 11 patients (27.5%), balance and gait disturbances improved in all patients, urinary incontinence improved in 24 patients (60%), memory disturbances subjectively improved in 21 patients (52.5%), and visual deficits improved in 5 patients (12.5%). Four patients (10%) had symptom progression, which occurred 6 to 24 months after surgery with radiologic evidence of ETV failure. CONCLUSIONS: LOVA is a form of hydrocephalus that must be correctly identified. A correct magnetic resonance study and comprehensive neuropsychologic assessment are crucial to identify it in order to define proper management. From our analysis, ETV represents the gold standard treatment granting rewarding results that are maintained in a long-term follow-up.

Descemetic and predescemetic DALK in keratoconus patients: a clinical and confocal perspective study.

PURPOSE: To evaluate the clinical outcomes and in vivo confocal microscopy (IVCM) features of keratoconus patients who underwent deep anterior lamellar keratoplasty (DALK). METHODS: DALK was performed using the big bubble technique in all the patients. If the bubble was not successful to bare the descemet membrane, a manual dissection layer-by layer was performed to expose a deep stromal plane close to the DM. The patients were divided in two groups depending on the intraoperative baring of the descemet membrane: predescemetic DALK (PD-DALK) and descemetic DALK (D-DALK) group. RESULTS: One month after surgery the D-DALK patients show an increase of mean BCVA. In the PD-DALK group mean BCVA did not show significant improvement as compared to preoperative values. At 6 months after surgery mean BCVA was found to be similar in both groups. At 1 month IVCM the peak of reflectivity of the interface was lower in D-DALK group compared to PD-DALK. At 6 months the values of reflectivity were comparable. CONCLUSIONS: At 1 month D-DALK seems to lead to a minor interface reflectivity and to a better BCVA; these differences disappear after 6 months and the values of interface reflectivity and BCVA are comparable between D-DALK and PD-DALK.