Watertight Sealing Without Lumbar Drainage for Incidental Ventral Dural Defect in Transthoracic Spine Surgery: A Retrospective Review of 53 Cases.

STUDY DESIGN: A retrospective review. OBJECTIVES: To evaluate the therapeutic efficacy of the triple layer closure technique to establish watertight sealing without diversion of lumbar drainage, in preventing persistent incidental subarachnoid-pleural fistula and other neurological complications related to excessive drainage of cerebrospinal fluid (CSF) after dural defect in transthoracic ossified posterior longitudinal ligament (OPLL) surgery. SUMMARY OF BACKGROUND DATA: CSF leakage into the pleural cavity leads to unfavorable conditions for natural healing of incidental durotomy due to the negative pressure environment of the pleural space and lack of wound healing around the bony cavity near the decompressed spinal cord. This often leads to a persistent incidental subarachnoid-pleural fistula. In addition, diversion of lumbar drainage may lead to excessive CSF drainage resulting in intracranial hypotension. To avoid this, we studied the efficacy of a modified sealing method to establish a more watertight covering at the ventral dural defect without lumbar CSF drainage. METHODS: Fifty-three patients who had CSF leakage from the ventral aspect of the spinal cord during transthoracic spine surgery for thoracic OPLL between 2004 and 2013 were retrospectively reviewed. Patients were divided into 2 groups: a conventional group (group A) and a triple layer closure group (group B). In group A (n=33 patients), the dural defect was covered with fibrin glue (Beriplast P) mixed with gelfoam (Spongostan Standard) with subsequent subarachnoid lumbar drainage. In group B (n=20 patients), the dural defect was sealed using the triple layer technique with 2 layers of fibrin glue and gelatin sponge plus a third layer of synthetic hydrogel (Duraseal, Dural Sealant System) without subsequent subarachnoid lumbar drainage. Both groups had chest tubes that drained through an underwater seal. Clinical data including duration and total amount of drainage (chest tube and lumbar drainage), related complications, and duration of hospital stay were compared between the 2 groups. RESULTS: Compared with the patients in group A, group B had a significantly smaller total volume of drainage and shorter chest tube drainage time (P<0.05) during their hospital stay. In group A, complications occurred in 6 cases (18.2%), including 3 cases of intracranial hypotension combined with transient mental status alteration, postural headache, and dizziness, 1 case of regional atelectasis with pneumonia, and 2 cases of revision thoracotomy. Revision thoracotomy was performed to treat persistent subarachnoid-pleural fistula due to significant and prolonged CSF leakage. In group B, there were no complications and no revision thoracotomy was needed. The mean duration of hospital stay was shorter in group B (15.6 d) compared with group A (22.4 d). CONCLUSIONS: The established watertight closure of the dural defect using the triple layer sealing method without lumbar drainage was more effective and safe.

Symptomatic isolated lumbar interdural arachnoid cyst.

A 72-year-old man presented with an extremely rare case of symptomatic isolated lumbosacral interdural arachnoid cyst manifesting as pain and weakness in the right buttock and lower extremity that had aggravated for 2 weeks. Although the surgical strategy for the interdural cyst was not complicated, the origination of the cyst was not clearly understood. Surgery found an isolated membrane of the cyst inside double-layered dura without communication with the intact arachnoid membrane. Cerebrospinal fluid with hemorrhage accumulated within the interdural cyst indicated recent bleeding into the cyst. Our experience suggests that this cyst was congenital based on the surgical results and imaging studies.

Analysis of the incidence and clinical effect of the heterotopic ossification in a single-level cervical artificial disc replacement.

BACKGROUND CONTEXT: Heterotopic ossification (HO) is a well-known phenomenon occurring after joint arthroplasty. However, its incidence and clinical effects have not yet been clearly identified with cervical disc replacement. PURPOSE: The first aim of this study was to evaluate the incidence of HO in single-level cervical disc replacement. The second aim was to identify the relationship of HO with clinical outcomes and radiological findings. STUDY DESIGN: A retrospective study of 48 patients who underwent single-level artificial disc replacement in one of our clinics. PATIENT SAMPLE: Between November 2004 and December 2008, 48 consecutive patients underwent single-level cervical artificial disc replacement in Seoul Wooridul Hospital, Seoul, Korea. OUTCOMES MEASURES: Clinical outcomes were graded using visual analog scale (VAS) scores (score range, 0-10, with 0 reflecting no pain). Functional outcomes were measured using Oswestry Disability Index (ODI) scores. Radiological outcomes were evaluated with follow-up dynamic X-ray. METHODS: Occurrence of HO was investigated with the McAfee classification on the follow-up cervical dynamic X-ray. We also measured cervical range of motion (ROM) to identify HO's biomechanical effects. For the clinical effects, the VAS and the ODI were evaluated in correlation with the occurrence of HO. RESULTS: In 48 treated patients, a total of 13 HOs were detectable. Grade 1 and 2 HO occurred in 11 patients and Grade 3 HO in two patients. Mean occurrence of HO was observed on the 11th month after the surgery. HO that led to the restriction of the ROM was not present in any patients. The clinical outcome was not significantly correlated with the occurrence of HO. CONCLUSIONS: The overall incidence of HO after cervical artificial disc replacement was relatively high. However, Grade 3 and 4 HO that limit the ROM rarely occurred. Moreover, the occurrence of HO did not affect the clinical symptoms and biomechanical dynamics. A longer follow-up with a larger group of patients should be undertaken, which may demonstrate a higher rate of HO and long-term effects on the ROM.

Transcorporeal approach for disc herniation at the C2-C3 level: a technical case report.

The authors describe a less invasive approach for a disc herniation at the high cervical region. A 68-year-old female patient presented with posterior neck and shoulder pain, and tingling sensation and numbness in the left hand after she fell down stairs 2 months before presentation. On neurologic examination, the power of flexion and extension of the left elbow and grasping of the left hand was decreased. Hoffmann sign was positive in both hands. Magnetic resonance imaging showed a huge herniation of the C2-C3 disc compressing the left paramedian area of the spinal cord. After a routine surgical exposure for discectomy of the C3-C4 disc, a drill hole of about 5 mm diameter was made at the middle of the C3 vertebral body. The hole was extended cranioposteriorly to the superoposterior border of the C3 endplate. The posterior disc at the midline of the C2-C3 was removed first then the herniated disc completely removed. Postoperatively, the patient showed improvement of the neck and shoulder pain and numbness of the hand. At 7-month follow-up, she completely recovered from her neurologic symptoms. Compared with the other approaches to high cervical lesion, the current approach was straightforward and less invasive. If there is no need to stabilize the spinal motion segment, this transcorporeal approach can be a useful surgical option as it decreases the extent of tissue dissection of the submandibular retropharyngeal area that might increase the risk of neurovascular injury.

Single-level instrumented mini-open transforaminal lumbar interbody fusion in elderly patients.

OBJECT: The purpose of this study was to analyze the surgical outcomes in cases involving elderly patients who underwent single-level instrumented mini-open transforaminal lumbar interbody fusion (TLIF). METHODS: The authors performed a retrospective review of 27 consecutive cases involving elderly patients (> or = 65 years of age) who underwent single-level instrumented mini-open TLIF and were followed up for at least 3 years. Degenerative spondylolisthesis was diagnosed in 16 patients, stenosis with instability in 8, and lytic spondylolisthesis in 3. All cases were Grade I or II based on the American Society of Anesthesiologists' classification system. Clinical outcomes were assessed using a visual analog scale, the Oswestry Disability Index, and patients' subjective satisfaction. Sagittal balance, bone union, and adjacent segment degeneration (ASD) were assessed using plain radiography and 3D CT. RESULTS: The mean age of patients at the time of surgery was 69.3 years (range 65-80 years). Minor complications occurred in 2 patients (7.4%) in the perioperative period. At a mean follow-up duration of 38.6 months (range 36-42 months), clinical success was achieved in 88.9% of cases. The mean segmental lordosis and sacral tilt significantly increased after surgery (from 11.9 and 33.5 degrees to 13.9 and 37.2 degrees , p = 0.024 and p = 0.001, respectively). Solid fusion was achieved in 77.8% of the patients. Adjacent segment deterioration was found in 44.4% of the patients. No patients underwent revision surgery due to nonunion or ASD. The development of ASD was significantly related to postoperative sacral tilt (p = 0.006). CONCLUSIONS: Single-level instrumented mini-open TLIF yielded good clinical and radiological outcomes with a low complication rate in elderly patients.