Transtubular image-guided surgery for spinal intradural lesions: techniques, results, and complications in a consecutive series of 60 patients.

OBJECTIVE: The authors previously described the image merge tailored access resection (IMTAR) technique for resection of spinal intradural lesions (SIDLs). The authors reported their updated experience with the IMTAR technique and compared surgical results between patients who underwent operations with 2D or 3D fluoroscopic guidance. METHODS: The authors reviewed 60 patients who underwent SIDL resection with transtubular techniques over a 14-year period. The earlier patients in the series underwent operations with 2D fluoroscopic image guidance. The latter patients underwent operations with the IMTAR technique based on 3D image guidance. The results of both techniques were analyzed. RESULTS: Sixty patients were included: 27 females (45%) and 33 males (55%). The median (range) age was 50.5 (19-92) years. Gross-total resection (GTR) was achieved in 52 patients (86.7%). Subtotal resection was accomplished in 5 patients (8.3%). Neurological complications occurred in 3 patients (5%), and tumor recurrence occurred in 1 patient (1.7%). The non-IMTAR and IMTAR cohorts showed similar postoperative Nurick scale scores and rates of neurological complications and GTR. The median (interquartile range) bone resection surface area at the index level was 89.5 (51-147) mm2 in the non-IMTAR cohort and 35.5 (11-71) mm2 in the IMTAR cohort, with a statistically significant difference (p = 0.0112). CONCLUSIONS: Surgery for SIDLs may be challenging, and meticulous surgical planning is crucial to optimize tumor access, maximize resection, and minimize risk of complications. Image-guided transtubular resection is an additional surgical technique for SIDLs and facilitates microsurgical tumor removal of ventrally located lesions with a posterolateral approach, without requiring potentially destabilizing bone resection.

Using Smartphones for Clinical Assessment in Cervical Spondylotic Myelopathy a Feasibility Study.

Degenerative cervical myelopathy (DCM) is characterized by a progressive deterioration in spinal cord function. Its evaluation requires subjective clinical examination with wide interobserver variability. Objective quantification of spinal cord function remains imprecise, even though validated myelopathy-grading scales have emerged and are now widely used. We created a Smartphone Application, the N-Outcome App, with the aim of quantifying accurately and reliably spinal cord dysfunction using a 5-minute Test. A patient suffering from DCM was clinically evaluated before surgery, at 3 and 6 months follow-up after surgical decompression of the cervical spinal cord. Standard scores (Nurick grade, modified Japanese Orthopedic Association (mJOA) score) were documented at these time points. A 5-minute motor and proprioceptive performance test aided by a smartphone with the N-outcome App was also performed. Motor performance in rapid alternating movements and finger tapping improved in correlation with improvements in standard grading scale scores. Clinical improvements were seen in maximum reflex acceleration and in Romberg testing which showed less closed/open eyes variation, suggesting pyramidal and proprioceptive function recovery. We demonstrate that using the N-Outcome App as an adjunct to clinical evaluation of compressive myelopathy is feasible and potentially useful. The results correlate with the results of clinical assessment obtained by standard validated myelopathy scores.

Transtubular Anterior Cervical Foraminotomy for the Treatment of Compressive Cervical Radiculopathy: Surgical Results and Complications in a Consecutive Series of Cases.

STUDY DESIGN: This was a retrospective review of patients with compressive cervical radiculopathy treated with a minimally invasive anterior cervical foraminotomy (ACF). PURPOSE: This study aimed to evaluate the results and complication rates of ACF in a consecutive series of patients and to report our clinical results of ACF as a minimally invasive technique in a series of 45 consecutive patients treated for compressive cervical radiculopathy. OVERVIEW OF LITERATURE: ACF is a motion-sparing procedure and an alternative to anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy for direct nerve root decompression in patients with compressive cervical radiculopathy. METHODS: The chart review recorded clinical and radiological features preoperatively and postoperatively and at follow-up (FU). The effect of prognostic factors was analyzed in relation to the clinical outcome. RESULTS: Between January 2004 and October 2019, 45 patients (15 females and 30 males) with a mean age of 55.9 years (range, 28-78 years) underwent ACF for unilateral cervical radiculopathy. The global clinical outcome according to the MacNab scale was evaluated as excellent in 64.5% of patients (n=29), good in 28.9% (n=13), fair in 4.4% (n=2), and poor in 2.2% (n=1). The radiological FU was available for 73.3% (n=33). The statistical analysis revealed no influence of age, sex, operated level, and side on the clinical outcome. Only one patient (2.2%) exhibited spontaneous bone fusion at the operated level on FU after a right-sided C6-7 ACF with no clinical consequences. No patient presented with signs of delayed segmental instability. The overall reoperation rate of this series was 4.4%. CONCLUSIONS: ACF is a feasible and low-cost alternative to ACDF in selected patients with cervical radiculopathy. The use of tubular retractors in ACF may confer an added advantage that creates a safe corridor for direct cervical root decompression yet minimizing surrounding soft tissue retraction and avoiding unnecessary bone removal.

Minimally invasive anterior foraminotomy for cervical radiculopathy: how I do it.

BACKGROUND: The standard treatment for cervical radiculopathy is anterior discectomy and fusion. The authors describe a minimally invasive anterior cervical foraminotomy as a surgical option for direct nerve root decompression in cervical radiculopathy. METHOD: Through a modified Smith-Robinson approach, the prevertebral fascia is mobilized laterally, displacing the sympathetic chain with it. A thumbnail size portion of the longus colli muscle is removed. A tubular retractor is placed, centered over the index uncovertebral joint. The lateral part of the joint is progressively drilled towards the foramen. After exposure of the intervertebral foramen, the perivascular ligamentous tissue is opened. Removal of disc fragments and osteophytes allows direct visualization and direct decompression of the nerve root. CONCLUSION: Anterior cervical foraminotomy is a safe "motion preserving" procedure for direct nerve decompression in selected patients with cervical radiculopathy that does not require cervical fusion.

Multilevel Pedicular Osteotomies for En Bloc Resection of a Primary Ewing Sarcoma of the Subaxial Cervical Spine with Pedicle Screw Reconstruction.

BACKGROUND: Primary Ewing sarcoma of the mobile spine is a rare disease. Its management requires careful surgical planning, because radical, margin-free excision is directly correlated with prognosis. Extensive bone removal in the cervical spine can lead to instability and cause postoperative iatrogenic cervical deformity. Thus, spinal instrumentation plays an important role in restoring postresection spinal stability and improving quality of life. METHODS: We present a novel technique that allows successful removal of a large Ewing sarcoma of the subaxial cervical spine, infiltrating and traversing the posterior bone elements, and extending into the paraspinal muscles. This technique involves radical en bloc resection of posteriorly located cervical tumors via multilevel pediculotomy, with terminal vertebrae pedicle screw reconstruction. RESULTS: Terminal vertebrae cervical pedicle screw reconstruction allowed wide surgical excision with satisfactory oncologic and mechanical results. CONCLUSIONS: This technique enables 1-stage total tumor resection and stabilization and may be a viable alternative to radical en bloc resection of posteriorly located epidural malignant lesions of the cervical spine in selected cases.

Surgical planning for cervical deformity based on a 3D model.

The treatment of fixed cervical deformity is complex, but the principles guiding its correction remain the same as in deformity of other spinal regions, with the goal of deformity correction that results in a solid fusion with adequate decompression of the neural elements. In these challenging cases, osteotomies are necessary to mobilize the rigid spine and to obtain the desired correction, but they can be associated with increased risk of complications. Therefore, careful preoperative planning and a complete understanding of the anatomic variations allow patient-tailored approaches with and case specific techniques for the optimal and safe treatment of a variety of complex cervical deformities. We present a case report with a complex spinal deformity where a 3D model was used for surgical strategy that allowed us to "simulate" the osteotomies and get a better correction of the cervical deformity.

Image Merge Tailored Access Resection (IMTAR) of Spinal Intradural Tumors. Technical Report of 13 Cases.

OBJECTIVE: Standard translaminar approaches for intradural extramedullary (IDEM) tumors require extensive soft tissue dissection and partial facet removal. Ventral lesions may necessitate wider bone resection with subsequent possible spinal instability. Any manipulation of an already compromised spinal cord may lead to neurological injury. We describe an image-guided minimal access technique for IDEM tumor resection. METHODS: Retrospective chart review of 13 consecutive patients after institutional ethics committee approval. We superimpose preoperative magnetic resonance imaging data with intraoperative 3-dimensional fluoroscopic images, allowing to simultaneously visualize osseous anatomy and the soft tissue lesion using appropriate windowing. We then plan optimal angle of trajectory to the tumor, which defines the skin incision and the transmuscular trajectory. A tubular retractor is placed to span the tumor. Microsurgical tumor resection is then carried out using this angle of approach. RESULTS: Thirteen patients (mean age. 57 years; male-to-female ratio, 10:3) were operated on during 28 months. Gross total resection was achieved in all patients. Neurological improvement occurred in 12 of the 13 patients. There was no neurological deficit outside of the expected sensory loss due to intentional nerve root sacrifice. No mechanical pain nor tumor recurrence were noted during the follow-up (mean, 16 months; range, 2-30 months). CONCLUSIONS: Image merge tailored access resection appears to be at least equivalent in terms of tumor resection, blood loss, and complications to other tubular techniques. It may reduce risks of neurological deficit and spine instability. Image merge tailored access resection is a novel application of merging intraoperative fluoroscopic images with preoperative magnetic resonance images for tailored IDEM resection.

Duplicated filum terminale in non-split cord malformations: An underrecognized cause for treatment failure in tethered cord syndrome.

CONTEXT: Anatomical variations of the filum terminale (FT) have been described in association with split cord malformations (SCM) but they appear to be a rare finding in its absence. We report the first case in literature of a duplicated FT in a patient presenting with tethered cord syndrome (TCS) without any radiological evidence of SCM. FINDINGS: A 47-year-old man presented with invalidating back pain radiating to both legs. Magnetic resonance imaging revealed an intradural dorsal lipoma in a low-lying conus. Intraoperatively two distinct fibrous bands were anatomically and electrophysiologically identified as the FT and both were sectioned. The diagnosis of FT was confirmed for both specimens by histology. CONCLUSION: In absence of SCM, a duplicated FT has not been previously described as a cause of TCS. It may be a cause of treatment failure for TCS if unrecognized on preoperative imaging and during surgery if one filum remains intact. We highlight the importance of a meticulous cauda equina dissection supported by intraoperative nerve stimulation to identify this rare anomaly. We hypothesize that this entity may represent a variant of SCM involving the caudal neural tube but which requires further validation at an embryological level.

Single stage transforaminal retrojugular tumor resection: The spinal keyhole for dumbbell tumors in the cervical spine.

BACKGROUND: Dumbbell tumors are defined as having an intradural and extradural component with an intermediate component within an expanded neural foramen. Complete resection of these lesions in the subaxial cervical spine is a challenge, and it has been achieved through a combined posterior/anterior or anterolateral approach. This study describes a single stage transforaminal retrojugular (TFR) approach for dumbbell tumors resection in the cervical spine. METHODS: This is a retrospective review of a series of 17 patients treated for cervical benign tumors, 4 of which were "true" cervical dumbbell tumors operated by a simplified retrojugular approach. The TFR approach allows a single stage gross total resection of both the extraspinal and intraspinal/intradural components of the tumor, taking advantage of the expanded neural foramen. All patients were followed clinically and radiologically with magnetic resonance imaging (MRI). RESULTS: Gross total resection was confirmed in all four patients by postoperative MRI. Minimal to no bone resection was performed. No fusion procedure was performed and no delayed instability was seen. At follow up, one patient had a persistent mild hand weakness and Horners syndrome following resection of a hemangioblastoma of the C8 nerve root. The other three patients were neurologically normal. CONCLUSIONS: The TFR approach appears to be a feasible surgical option for single stage resection in selective cases of dumbbell tumors of the cervical spine.

Delayed presentation of deep penetrating trauma to the subaxial cervical spine.

PURPOSE: To present a rare case of deep penetrating neck trauma in which a retained foreign body in the cervical spine (a broken knife blade) resulted in delayed radicular injury. We describe the surgical management using a retrojugular approach. CASE REPORT: Our patient sustained a stab wound to the supraclavicular triangle from a small pocketknife. He was initially managed in a local hospital by simple primary wound closure without any radiological examinations, and was discharged home. The patient re-consulted in a delayed fashion with mild local persistent neck pain. Subsequent radiological investigations revealed a foreign body (the broken blade of a pocket knife) embedded in the left neural foramen between the C6 and C7 vertebrae penetrating the disc space. The blade was lying between the left C7 nerve root and the ipsilateral vertebral artery (VA) at the transition of V1 and V2 segments. Initial neurological evaluation was normal. Some days later, the patient developed a delayed left C7 radicular deficit. We undertook urgent exploration along the wound corridor through a retrojugular, transforaminal approach with successful removal of the blade. DISCUSSION: To our knowledge, this is a unique case where a retained foreign body penetrated the soft tissues of the neck, embedding deep in the vertebral column without vascular, aerodigestive or significant primary neurological injury, while causing delayed neck pain and delayed onset radicular injury. We describe our surgical management for removal of the retained blade. The retrojugular approach gives excellent access to all of the important anatomical structures of the neck from an anterolateral approach.

[Inter-hospital CHUV-HUG medical consensus of back pain management. Its application in care pathways within CHUV of Lausanne]. / Consensus interdisciplinaire CHUV-HUG sur la prise en charge des douleurs du dos. Son application lausannoise dans la filière du dos.

Back pain is a considerable economical burden in industrialised countries. Its management varies widely across countries, including Switzerland. Thus, the University Hospital and University of Lausanne (CHUV) recently improved intern processes of back pain care. In an already existing collaborative context, the two university hospitals in French-speaking Switzerland (CHUV, University Hospital of Geneva), felt the need of a medical consensus, based on a common concept. This inter-hospital consensus produced three decisional algorithms that bear on recent concepts of back pain found in literature. Eventually, a fast track was created at CHUV, to which extern physicians will have an organised and rapid access. This fast track aims to reduce chronic back pain conditions and provides specialised education for general practitioners-in-training.