The Effect of Ligamentotaxis on Clinical and Radiological Outcomes in Thoracolumbar Burst Fractures with High McCormack Grade.

The aim of this study was to investigate the effect of ligamentotaxis performed in combination with the posterior surgical approach in thoracic and lumbar burst fractures due to high-energy trauma with high McCormack scores (≥7). This observational study was conducted at the University of Health Sciences from January 2015 to December 2020. Medical records of 16 patients were retrospectively evaluated. The vertebral height measurements, local kyphosis angles, and anteroposterior spinal canal diameter were measured pre- and postoperatively. American Spinal Injury Association (ASIA), McCormack, and thoracolumbar injury classification and severity (TLICS) scores were also evaluated. All postoperative measurements showed a significant change. There was no statistical significance in the pre- and postoperative ASIA grades. No screw breakages were observed within a mean follow-up period of 35.50±11.79 months. Ligamentotaxis effectively increased the spinal canal diameter and provided vertebral height restoration and kyphosis angle correction in thoracolumbar burst fractures with a high McCormack score. However, no significant neurological improvement was observed in cases with neurological deficits, although laminectomy was performed with ligamentotaxis. Key Words: Ligamentotaxis, Lumbar vertebrae, Spine, Thoracic vertebrae, Thoracolumbar burst fractures, Trauma.

Efficacy of epidural steroid injections and evaluation of surgical and anesthetic approaches in far-lateral disc herniations.

Aim: To observe the long-term effect of epidural steroid injections (ESI) and describe surgical outcomes in patients with far-lateral lumbar disc herniations. Materials & methods: The medical records of 30 patients who underwent surgery for far-lateral lumbar disc herniations were reviewed. Results: ESI outcomes: pain scores decreased significantly after ESI (p = 0.004). The surgery was delayed for 13.78 ± 8.59 months in patients who received ESI. Surgical outcomes: the improvement in the leg pain was considerably more significant than the back pain (p < 0.001). While motor deficit improved substantially (p < 0.001), there was persistent sensory dysesthesia. Conclusion: ESI does not prevent but may delay the surgery up to 28 months. Although postoperative pain scores were significantly decreased, there was persistent back pain and sensory paresthesia.

Far-lateral lumbar disc herniation is a rare condition, and it constitutes a specific group of lumbar disc hernias regarding its anatomic location. It causes far more severe and intractable back and leg pain than the other widely known group of disc hernias. Sometimes, it can lead to sensation disorders and even functional impairment in the legs. Few can benefit from conservative treatments, including painkillers and physical therapy so surgical treatment becomes inevitable in many patients. Lumbar steroid injections to the epidural space may provide significant symptom relief and delay surgery in certain patients.

Salvage posterior atlantoaxial fixation techniques: A retrospective study / Técnicas de fijación atlantoaxial posterior de rescate: un estudio retrospectivo

Object Since the atlantoaxial region have critical neurovascular anatomy and limited bone surface for fusion, the application and choice of salvage fixation techniques are highly important. To discuss alternative posterior atlantoaxial fixation surgery techniques. Methods We retrospectively surgical records of 22 patients that posterior atlantoaxial fixation techniques were applied. Results The patients included 11 males and 11 females (mean age: 65.7 years). The fracture type that caused instability is type 2 odontoid fractures (22). In six of these patients alternative stabilization techniques were applied due to anatomical variations, huge venous bleeding and iatrogenic trauma of the screw entry points during surgery. Conclusions Owing to anatomical variations, intraoperative challenges, and/or instrumentation failures, performing alternative surgical fixation technique is an important factor that affects the success of stabilization of the atlantoaxial region. Knowledge of salvage techniques especially during the learning curve is vitally important. Surgeons should adapt to intraoperative surgical challenges as required (AU)

Objetivo Dado que la región atlantoaxial tiene una anatomía neurovascular crítica y una superficie ósea limitada para la fusión, la elección y la aplicación de las técnicas de fijación de rescate son muy importantes. El objetivo de este estudio es describir técnicas alternativas de cirugía de fijación atlantoaxial posterior. Métodos Realizamos retrospectivamente registros quirúrgicos de 22 pacientes a los que se les aplicaron técnicas de fijación atlantoaxial posterior. Resultados Entre los pacientes se incluyeron 11 varones y 11 mujeres (edad media: 65,7 años). El tipo de fractura que causó inestabilidad fue la fractura de odontoides tipo 2 (22). En seis de estos pacientes se aplicaron técnicas alternativas de estabilización debido a variaciones anatómicas, sangrado venoso considerable y trauma iatrogénico en los puntos de entrada del tornillo durante la cirugía. Conclusiones Debido a variaciones anatómicas, dificultades intraoperatorias y/o fallas de instrumentación, la realización de una técnica de fijación quirúrgica alternativa es un factor importante que afecta el éxito de la estabilización de la región atlantoaxial. Conocer las técnicas de salvamento, especialmente durante la curva de aprendizaje, es de vital importancia. Los cirujanos deben adaptarse a los desafíos quirúrgicos intraoperatorios, según sea necesario (AU)

Salvage posterior atlantoaxial fixation techniques: A retrospective study.

OBJECT: Since the atlantoaxial region have critical neurovascular anatomy and limited bone surface for fusion, the application and choice of salvage fixation techniques are highly important. To discuss alternative posterior atlantoaxial fixation surgery techniques. METHODS: We retrospectively surgical records of 22 patients that posterior atlantoaxial fixation techniques were applied. RESULTS: The patients included 11 males and 11 females (mean age: 65.7 years). The fracture type that caused instability is type 2 odontoid fractures (22). In six of these patients alternative stabilization techniques were applied due to anatomical variations, huge venous bleeding and iatrogenic trauma of the screw entry points during surgery. CONCLUSIONS: Owing to anatomical variations, intraoperative challenges, and/or instrumentation failures, performing alternative surgical fixation technique is an important factor that affects the success of stabilization of the atlantoaxial region. Knowledge of salvage techniques especially during the learning curve is vitally important. Surgeons should adapt to intraoperative surgical challenges as required.

Effects of Modified Osteoplastic Pterional Craniotomy on Temporal Muscle Volume and Frontal Muscle Nerve Function.

Introduction Pterional craniotomy is a surgical approach frequently used in aneurysm and skull base surgery. Pterional craniotomy may lead to cosmetic and functional problems, such as eyebrow drop due to facial nerve frontal branch damage, temporal muscle atrophy, and temporomandibular joint pain. The aim was to compare the postoperative effects of our modified osteoplastic craniotomy with classical pterional craniotomy in terms of any change in volume of temporal muscle and in the degree of frontal muscle nerve damage. Materials and Methods Aneurysm cases were operated with either modified osteoplastic pterional craniotomy or free bone flap pterional craniotomy according to the surgeon's preference. Outcomes were compared in terms of temporal muscle volume and frontal muscle nerve function 6 months postoperatively. Results Preoperative temporal muscle volume in the modified osteoplastic pterional and free bone flap pterional craniotomy groups were not different ( p > 0.05). However, significantly less atrophy was observed in the postoperative temporal muscle volume of the osteoplastic group compared with the classical craniotomy group ( p < 0.001). In addition, when comparing frontal muscle nerve function there was less nerve damage in the modified osteoplastic pterional craniotomy group compared with the classical craniotomy group, although this did not reach significance ( p > 0.05). Conclusion Modified osteoplastic pterional craniotomy significantly reduced atrophy of temporal muscle and caused proportionally less frontal muscle nerve damage compared with pterional craniotomy, although this latter outcome was not significant. These findings suggest that osteoplastic craniotomy may be a more advantageous intervention in cosmetic and functional terms compared with classical pterional craniotomy.

Tract pain because of cervical spondylotic myelopathy: A case series.

Spinal cord compression may lead to pain that is sometimes directed to areas far below the compression level. In certain cases, it may present as sciatica pain, knee pain or low back pain (LBP). These types of pain are called tract pain or funicular pain. Tract pain because of cervical spondylotic myelopathy (CSM) may lead to delays in the diagnosis and treatment of CSM in some cases, and sometimes unnecessary medical and surgical treatments. This study evaluated the results of four patients who presented to the outpatient clinic with complaints of LBP accompanying CSM findings. This study aims to present the improvement in low back pain as a result of anterior cervical microdiscectomy and cage procedure in four patients who presented with tract pain because of CSM, which is a rare condition.

Assessment of risk factors in de novo aneurysm development.

Aneurysms that occur anywhere in intracranial except where primary aneurysms develop, are called "de novo aneurysms". The risk factors and formation time of de novo aneurysms are not fully known. Congenital, environmental and hemodynamic factors can play a role in aneurysm development. The 43-year-old female patient was operated with the middle cerebral artery superior trunk aneurysm in our clinic. She came to us again after 17 months with a severe headache. In computed cranial tomography angiography, the middle cerebral artery superior trunk placement aneurysm was found to have a partial clip and "de novo aneurysm" was developed. She was re-operated for "de novo aneurysm". In this study, the risk factors in development of "de novo aneurysms" were discussed in the light of literature through this patient.

A Simple Technique for Removing Broken Pedicle Screws.

Removing a broken pedicle screw is not always easy. Different methods and tools have been developed to remove the broken screw. Preserving the pedicle is an advantage for re-instrumentation. The head of the broken screw can be modified with the aid of a high-speed drill and the screw can be removed using a fractured screw removal tool without any problems. In addition, performing this procedure under the microscope reduces the risk of injury in the surrounding dura mater and the root. We believe that this simple technique can be conveniently used while removing a broken pedicle screw.

Lateral transorbital approach: an alternative microsurgical route for supratentorial cerebral aneurysms.

OBJECTIVE: Transorbital approaches for neurosurgery have recently attracted attention and several anatomical studies have aimed to improve these techniques, but significant deficiencies in clinical practice remain, especially for aneurysm surgery. The authors present an alternative microsurgical route and the results of an analysis of patients with intracranial aneurysms who underwent a lateral transorbital approach (LTOA) using lateral orbito-zygoma-sphenotomy (LOZYGS). METHODS: The clinical and surgical results of a series of 54 consecutive patients with 1 or more aneurysms who underwent surgery via LTOA are reported. A lateral orbitotomy was performed after making a 3-cm skin incision parallel to the lateral orbital rim. A second bone flap, which included the zygoma and sphenoid bones that form the lateral orbital wall, was removed. The lesser sphenoid wing, including the anterior clinoid process, was fully drilled, except in cases of middle cerebral artery (MCA) aneurysms. Cisternal dissection was performed using the classic microsurgical technique starting from the proximal Sylvian fissure and carotid cistern. After the aneurysm was clipped following microsurgical principles, the dura mater was closed in a watertight fashion and 2-piece bone reconstruction was achieved. RESULTS: Sixty aneurysms in 54 patients were clipped using the LOZYGS route. Twenty-one aneurysms were located on the MCA, 30 on the anterior communicating artery, 8 on the internal carotid artery, and 1 at the apex of the basilar artery. The unruptured-to-ruptured aneurysm ratio was 17:43. The operative field was moved to the orbit using the LTOA to avoid interference by bone and muscle tissues. Early proximal control was achieved using a short working distance and direct exposure of the base of the cerebrum, without any requirement for retraction. Because different view angles and surgical corridors were used, no segment of the aneurysm or the parent artery remained unexposed. Therefore, the introduction of additional tools was not required. CONCLUSIONS: The LTOA allowed enhanced broad-perspective exposure of the operative field, early proximal control, and satisfactory surgical freedom. This alternative surgical approach safely exposed the target area and the operative field. The LOZYGS route is safe and effective for the LTOA and microsurgical clipping of anterior circulation aneurysms. According to the authors' surgical experience and clinical experience, the LTOA can be considered an alternative surgical route to supratentorial aneurysm surgery.

Cavernous hemangiomas of the third ventricle: Alternative surgical routes in two cases.

Cavernous Hemangiomas (CH) arise from any part of the cerebrum. Intraventricular lesions are rare and pure third ventricular localization is rare for CHs. Cavernomas of the ventricles may present with bleeding or signs associated with hydrocephalus. Radical excision is advocated for optimal management of cavernomas. In the present study, we present two cavernomas of the third ventricle which were completely excised via interhemispheric transcallosal transforaminal and Sylvian approaches. Radical excision should be the aim of the surgeon since reoperation for residual cavernomas is more commonly associated with complications and poor outcome. Total excision should be the goal of the treatment due to risk of rebleeding or regrowth.

The surgery and early postoperative radicular pain in cases with multifocal lumbar disc herniation.

Persistence of postoperative radicular pain after surgery for multifocal disc herniation (MFDH) is a clinical problem. This study aims to evaluate the effects of a combined treatment approach compared with unilateral stabilization on early postoperative radicular pain in patients with MFDH.Age, sex, level of operation, clinical findings, and radicular pain visual analogue scale (VAS) scores before surgery in the early postoperative period and at 3 months after surgery were retrospectively reviewed for 20 cases of multifocal lumbar disc herniation. The combined approach (translaminar and far lateral) was used for 13 cases. Seven cases underwent transforaminal lumbar interbody fusion (TLIF) and unilateral transpedicular stabilization following total facetectomy.The mean age of the sample was 49.4 ±â€Š10.1 years and the female-to-male ratio was 8:12. The mean VAS scores for radicular pain in cases treated with the combined approach were 8.2, 4.07, and 2.3 in the preoperative and early postoperative periods and 3 months after surgery, respectively. The mean score for radicular pain improved by 50.4% in the early postoperative period and by 72% in the late postoperative period. The mean VAS scores for radicular pain in cases who underwent TLIF and unilateral stabilization after facetectomy were 8.4, 2.1, and 1.4 in the preoperative and early postoperative periods and 3 months after surgery, respectively. The mean VAS score for radicular pain improved by 75% in the early postoperative period and by 83.3% in the late postoperative period.The combined approach is an effective alternative in cases with MFDH. TLIF and unilateral segmental stabilization provide substantial decompression and eliminate mechanical compression by conserving the height of the intervertebral foramen in the event that sufficient decompression is unable to obtain. We suggest that elimination of chemical mediators, particularly those causing pain in the dorsal ganglion, contributes to the absence of early radicular pain.

Traumatic Acute Subdural Hematomas: Analysis of Outcomes and Predictive Factors at a Single Center.

AIM: In the present study, we evaluated the association of the Glasgow Coma Scale (GCS) score and amount of blood loss with mortality in patients presenting with traumatic acute subdural hematoma (ASDH). MATERIAL AND METHODS: This retrospective study was performed on 99 patients who were operated for traumatic acute subdural hematoma (ASDH) without any systemic association at a single center. Epidural hematoma was reported to be the most common additional pathology. Age, sex, mechanism of trauma, time interval between onset of trauma and admission to the emergency ward, associated problems, thickness of hematoma and Glasgow Coma Scale (GCS) score at the time of admission and on discharge were all studied. RESULTS: The GCS score was inversely proportional to the thickness of hematoma and interval between onset of trauma and surgery (p < 0.05). Although the mortality rate was reported to be high in traffic accidents, the rate was low in patients with head trauma only (p < 0.05). The mortality rate was high in patients with associated pathologies (p < 0.05). Lost patients were reported to be older patients with more extensive ASDH or those who presented earlier with a low GCS (p < 0.05). CONCLUSION: ASDH is associated with high mortality. GCS score and the thickness of the ASDH are important predictors of mortality. Age, additional trauma, and interval between trauma and hospital admission are major predictive factors for mortality.

Relationship of biological factors to survival in spinal gunshot injuries.

BACKGROUND: Gunshot injuries are the third leading cause of spinal injuries, after falls from a significant height and traffic accidents. Severity of spinal damage from gunshot injury depends upon certain mechanical and biological factors. The aim of the present study was to investigate the effect of biological factors on survival in cases of spinal gunshot injury. METHODS: A total of 110 cases of spinal gunshot injury admitted multiple times to emergency services between 2012 and 2014 were included. Age, sex, region of trauma, additional organ or systemic involvement, treatment modalities (conservative, surgical), and mortality rates were analyzed. Effects of biological factors on survival were evaluated. RESULTS: Mean age of the study population was 25.51±11.74 years (min: 4; max: 55) and 95.5% of the population was male. Regions of trauma were thoracic in 50 (45.4%) subjects, cervical in 42 (38.2%), and lumbar in 18 (16.4%). Most common American Spinal Injury Association (ASIA) score was category A, as was found in 77 (70%) cases. No significant correlation was found among age, sex, ASIA score, treatment modality (conservative or surgical), and survival (p>0.05). Additional organ or systemic injury was present in 66 (60%) patients. Additional organ or systemic injury significantly affected survival, independent of the spinal region of trauma (p<0.01). CONCLUSION: Spinal gunshot injuries are complex, with unclear treatment protocol. Irrespective of the indications of spinal surgery, additional organ injuries unfavorably affect survival in cases of spinal gunshot injury. Appropriate management of all biological factors directly affects mortality rate in cases of spinal gunshot injury.

Surgical management of Juxtafacet cysts in the lumbar spine.

INTRODUCTION: Juxtafacet cysts of the lumbar spine are extradural degenerative lesions associated with symptoms of lower back pain and radiculopathy. The aim of this study is to evaluate the efficacy of surgery and address controversial issues in the treatment of symptomatic juxta facet cysts in the Neurosurgical Department of our hospital and review of the literature. METHODS: Data from seven patients (age range 58-68 years, mean age 63 years) with low back and radicular leg pain due to a lumbar facet joint cyst were retrospectively analyzed. Demographic data, cyst level, presence of concominant local pathology, treatment and results of treatment were recorded. After surgery there was no case of a recurrent cyst during the follow-up period. The mean follow-up period of patients at the time of this study was 4 years. RESULTS: All patients had back pain, while five also experienced unilateral radicular leg pain and two had bilateral leg pain. Four patients had neurogenic claudication. MRI identified the cyst and highlighted underlying pathology in all cases. All patients underwent surgical cyst excision. Post-operatively, all patients showed a total resolution of symptoms with sustained benefit at final evaluation. CONCLUSION: Surgery is a safe and effective treatment for lumbar juxtafacet cysts.

Multilevel Noncontiguous Spinal Fractures: Surgical Approach towards Clinical Characteristics.

STUDY DESIGN: The study retrospectively investigated 15 cases with multilevel noncontiguous spinal fractures (MNSF). PURPOSE: To clarify the evaluation of true diagnosis and to plane the surgical treatment. OVERVIEW OF LITERATURE: MNSF are defined as fractures of the vertebral column at more than one level. High-energy injuries caused MNSF, with an incidence ranging from 1.6% to 16.7%. MNSF may be misdiagnosed due to lack of detailed neurological and radiological examinations. METHODS: Patients with metabolic, rheumatologic diseases and neoplasms were excluded. Despite the presence of a spinal fracture associated clearly with the clinical picture, all patients were scanned within spinal column by direct X-rays, computed tomography and magnetic resonance imaging. When there were ≥5 intact vertebrae between two fractured vertebral segments, each fracture region was managed with a separated stabilization. In cases with ≤4 intact segments between two fractured levels, both fractures were fixed with the same rod and screw system. RESULTS: There were 32 vertebra fractures in 15 patients. Eleven (73.3%) patients were male and age ranged from 20 to 64 years (35.9±13.7 years). Eleven cases were the American Spinal Injury Association (ASIA) E, 3 were ASIA A, and one was ASIA D. Ten of the 15 (66.7%) patients returned to previous social status without additional deficit or morbidity. The remaining 5 (33.3%) patients had mild or moderate improvement after surgery. CONCLUSIONS: The spinal column should always be scanned to rule out a secondary or tertiary vertebra fracture in vertebral fractures associated with high-energy trauma. In MNSF, each fracture should be separately evaluated for decision of surgery and planned approach needs particular care. In MNSF with ≤4 intact vertebra in between, stabilization of one segment should prompt the involvement of the secondary fracture into the system.

Outcomes and demostration of cranial firearm injuries: A multicenter retrospective study.

BACKGROUND: Cranial firearm injuries (CFAI) are associated with significant morbidity and mortality.This study was aimed to determine the factors affecting mortality of CFAI cases managed in our institution by a retrospective analysis of CT scans and clinical data. METHODS: This multicenter retrospective study examined two hundred and nineteen patients presenting to neurosurgery clinics after CFAI between January 2012 and November 2014. Age, sex, Glasgow Coma Score (GCS), CT findings, and mortality and morbidity rates of the patients were analyzed to determine the factors affecting mortality. RESULTS: Mean age of the study population was 24.19±12.25 years, 85.8% of them were male. The most common CT findings were fracture (100%), intracranial hemorrhage (61.2%), and an intracranially located foreign body (44.3%). A cranial operation was performed in 64.8% of the victims. Mean GCS on admission was 8±3.9, which increased in survivors (p<0.05). CONCLUSION: CFAIs are associated with increased mortality and morbidity. We determined that many factors affected morbidity and mortality rates, and patient age, presence of intracranial hemorrhage, GCS, and treatment protocols were significantly associated with mortality.

Comparison of Wiltse and classical methods in surgery of lumbar spinal stenosis and spondylolisthesis.

AIM: Minimally invasive approaches to posterior lumbar surgery are available today that can enhance patient comfort by greatly reducing tissue damage and offer better clinical results. However, such methods have not yet gained widespread popularity despite their significant advantages. This study compares the Wiltse method and the classical method of lumbar surgery based a cohort, clinical study of 57 patients. The patients all had degenerative lumbar spinal stenosis and/or spondylolisthesis and had developed multifidus muscular atrophy. MATERIALS AND METHODS: We enrolled 57 patients admitted to our clinic between April 2012 and September 2013 with a diagnosis of degenerative lumbar spinal stenosis and/or spondylolisthesis. These were treated with the classic posterior approach (n=26) or the Wiltse method (n=31). FINDINGS: In the classical method group, the ratio of female to male patients was 20/6 and the mean age was 58.19±10.17 years. A comparison of preoperative and postoperative multifidus muscle cross-sectional measurements (average of right and left) revealed a 36.09% atrophy level in the classical method group and a 26.34% atrophy level in the Wiltse group (p<0.01). However, atrophy development was 18.82% higher in the classical method group (p<0.05) relative to the Wiltse group. CONCLUSION: The Wiltse method is less invasive and causes less tissue damage. It reduces the change of hemorrhage and multifidus muscles and offers a shorter duration of hospitalization with less pain.

General versus epidural anesthesia for lumbar microdiscectomy.

This study was a retrospective analysis of 850 lumbar microdiscectomy (LMD) under epidural anesthesia (EA; n=573) or general anesthesia (GA; n=277) performed by the same surgeon and paid by invoice to the Social Security Institution of the Turkish Republic between April 2003 and May 2013. Although GA is the most frequently used method of anesthesia during LMD, the choice of regional anesthetia (epidural, spinal or a combination of these) differs between surgeons and anesthetists. Studies have reported that EA in surgery for lumbar disc herniation may be more reliable than GA, as it enables the surgeon to communicate with the patient during surgery, but few studies have compared the costs of these two anesthetic methods in LMD. We found that EA patient costs were significantly lower than GA patient costs (p<0.01) and there was a statistically significant difference between the two groups in terms of the time spent in the operating room (p<0.01). There was no difference in the duration of surgery (p>0.05). The anesthetic method used during LMD affected the complication rate, cost and efficiency of operating room use. We suggest that EA is an anesthetic method that can contribute to health care cost savings and enable LMD to be completed with less nerve root manipulation and more comfort, efficacy, reliability and cost efficiency without affecting the success rate of the surgical procedure.

Removal of large hydatid cysts with balloon-assisted modification of Dowling's method: technical report.

BACKGROUND: Delivery of hydatid cysts, especially large ones, without rupture is very important and there is still no 100% successful method. METHODS: After the hydatid cyst was reached, starting near the surface working around the cyst toward the base, a Foley probe was advanced and, in the region of desired dissection, the balloon of the Foley probe was inflated, and adhesion bands were freed to allow dissection. CONCLUSIONS: We believe our balloon-aided dissection technique is a method that increases the chances of delivering hydatid cysts, with no calcification and secondary infection, without rupture.

Minimally invasive mini open split-muscular percutaneous pedicle screw fixation of the thoracolumbar spine.

We prospectively assessed the feasibility and safety of a new percutaneous pedicle screw (PPS) fixation technique for instrumentation of the thoracic and lumbar spine in this study. All patients were operated in the prone position under general anesthesia. A 6 to 8 cm midline skin incision was made and wide subcutaneous dissection was performed. The paravertebral muscles were first dissected subperiosteally into the midline incision of the fascia for lumbar microdiscectomy with transforaminal lumbar interbody fusion cage implantation. After the secondary paramedian incisions on the fascia, the PPSs were inserted via cleavage of the multifidus muscles directly into the pedicles under fluoroscopy visualization. A total of 35 patients underwent surgery with this new surgical technique. The control group for operative time, blood loss and analgesic usage consisted of 35 randomly selected cases from our department. The control group underwent surgery via conventional pedicle screw instrumentation with paramedian fusion. All patients in the minimal invasive surgery series were ambulatory with minimal pain on the first postoperative day. The operation time and blood loss and the postoperative analgesic consumption were significantly less with this new technique. In conclusion, the minimal invasive mini open split-muscular percutaneous pedicle screw fixation technique is safe and feasible. It can be performed via a short midline skin incision and can also be combined with interbody fusion, causing minimal pain without severe muscle damage.