The Transaxillary Approach as a Direct Route in the Management of Upper Thoracic Spine Pathology: A Technical Note with Case Series.

This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.

Pelvic Incidence-Lumbar Lordosis Mismatch Is Predisposed to Adjacent Segment Degeneration After Single-Level Anterior Lumbar Interbody Fusion: A Retrospective Case-Control Study.

OBJECTIVE: Spinopelvic parameters play important roles in clinical outcomes and disability after short-segment fusion surgery for degenerative spine disease. This study aimed to investigate the relationship between preoperative or postoperative spinopelvic parameters and symptomatic adjacent segment degeneration (ASD) after single-level anterior lumbar interbody fusion (ALIF) surgery at the L4-5 segments. METHODS: All patients who underwent single-level ALIF at the L4-5 level from January 2010 to December 2013 and were followed up for 5 years were analyzed. We collected the degree of degeneration at adjacent segments and preoperative and postoperative spinopelvic parameters. We compared the preoperative and postoperative parameters between patients with and without symptomatic ASD. RESULTS: Sixty-one patients were included in our study, and 30 patients had symptomatic ASD. Degeneration at adjacent segments and preoperative spinopelvic parameters did not affect the occurrence of symptomatic ASD. Patients with symptomatic ASD had higher postoperative pelvic tilt (PT) and a mismatch between lumbar lordosis (LL) and pelvic incidence (PI) compared to those without. Postoperative PT > 15° and PI-LL mismatch > 10° were significant risk factors for symptomatic ASD. CONCLUSION: High PT and PI-LL mismatch were significant risk factors for symptomatic ASD after single-level ALIF surgery. Spine surgeons should consider achieving proper LL to insert the cage at the appropriate angle and prevent a PI-LL mismatch value > 10° after single-level fusion surgery.

Continuous wound infiltration of ropivacaine for reducing of postoperative pain after anterior lumbar fusion surgery: a clinical retrospective comparative study.

BACKGROUND: Local anesthetic infiltration at the site of a surgical wound is commonly used to control postoperative pain. In this study, we examined the effectiveness of continuous local infiltration at an abdominal surgical site in patients undergoing anterior lumbar interbody fusion (ALIF) surgery. METHODS: Sixty-one patients who underwent ALIF surgery were enrolled. For thirtyone of them, a continuous local anesthetics infiltration system was used at the abdominal site. We collected data regarding the patients' sleep quality; satisfaction with pain control after surgery; abilities to perform physical tasks and the additional application of opioids in the postoperative 48 hours. RESULTS: The On-Q system group showed reduced visual analogue scale scores for pain at the surgical site during rest and movement at 0, 12, 24, and 48 hours; and more was satisfied with pain control management at the first postoperative day (7.0 ± 1.2 vs. 6.0 ± 1.4; P = 0.003) and week (8.1 ± 1.6 vs. 7.0 ± 1.8; P = 0.010) than the control group. The number of additional patient-controlled analgesia (PCA) bolus and pethidine injections was lower in the On-Q group (PCA: 3.67 ± 1.35 vs. 4.60 ± 1.88; P = 0.049 and pethidine: 2.09 ± 1.07 vs. 2.73 ± 1.38; P = 0.032). Patients who used the On-Q system performed more diverse activity and achieved earlier ambulation than those in the control group. CONCLUSIONS: Continuous wound infiltration with ropivacaine using an On-Q system may be effective for controlling postoperative pain after ALIF surgery.

Cement Augmented Anterior Reconstruction and Decompression without Posterior Instrumentation: A Less Invasive Surgical Option for Osteoporotic Thoracolumbar Fracture with Cord Compression.

OBJECTIVE: We investigated the clinical and radiological outcomes of a cement augmented anterior reconstruction and decompression without pedicle screw fixation in patients with osteoporotic thoracolumbar vertebral fracture with myelopathy. METHODS: There were 2 male and 6 female patients with thoracolumbar fracture and myelopathy included in the study. The mean follow-up period was more than 1 years. The anterolateral decompression and cement augmented anterior reconstruction with poly(methyl methacrylate) (PMMA) was performed. Demographic data, clinical outcomes, perioperative parameters and radiologic parameter were retrospectively evaluated. RESULTS: The symptoms due to myelopathy were improved in all patients. The preoperative median visual analog scale score for lower back and leg were 8.5 that improved 4.25 and 3 at last follow up. The preoperative function state showed a median Oswestry Disability Index score 61.5 that improved 33. After surgery, preoperative encroachment of the spinal canal (5.12 mm, 37%) was disappeared. The median height of fractured vertebral body significantly increased from 7.83 to 12.63 mm. At the last follow-up point, the median height was 9.91 mm. The median kyphotic deformity was improved from 22.12° to 14.31°. At the final follow-up, the improvement was preserved (median value: 15.03). The acute complication according to PMMA such as leakage and embolization was none, but adjacent compression fracture as late complication according to cement augmentation was. One patient developed surgical site infection. CONCLUSION: On the basis of the preliminary results, we considered that anterolateral decompression and PMMA augmentation might be an optimal method for treating osteoporotic fracture with myelopathy in elderly patients or those with multiple medical comorbidities.

Salvage Anterior Lumbar Interbody Fusion for Pseudoarthrosis After Posterior or Transforaminal Lumbar Interbody Fusion: A Review of 10 Patients.

BACKGROUND: After interbody cage implantation for posterior or transforaminal lumbar interbody fusion (PLIF or TLIF) spinal fusion surgery, pseudoarthrosis can develop. However, there are several shortcomings of the posterior approach if the interbody cage requires removal. Therefore, an anterior approach may be useful. METHODS: We reviewed salvage anterior lumbar interbody fusion (ALIF) for pseudoarthrosis after PLIF or TLIF performed from December 2006 to December 2016. A total of 10 patients met inclusion criteria for the study. All preoperative and postoperative clinical and radiologic parameters were recorded. RESULTS: Salvage ALIF resulted in improvements in clinical and radiologic outcomes in all cases. In 9 cases, the previously inserted cage was successfully removed. In 1 case, only 1 of the 2 previously inserted cages could be removed, as the previously inserted cage exhibited a high subsidence and remained in a diagonal position in the vertebral body. No serious complications occurred in all cases. Bone fusion was successful in all cases. CONCLUSIONS: ALIF is useful for salvage surgery to treat failed PLIF or TLIF. The advantages of salvage ALIF include improvements in clinical and radiologic outcomes and a low complication rate after surgery. To successfully remove a previously inserted cage, the vascular window of the anterior index level and the degree of subsidence of the cage should be well characterized through preoperative radiologic imaging.

Anterior lumbar interbody fusion with percutaneous pedicle screw fixation for multiple-level isthmic spondylolisthesis.

OBJECTIVE: Multiple-level lumbar isthmic spondylolisthesis is rarely reported. Here, we report 23 consecutive patients who underwent anterior lumbar interbody fusion (ALIF) with percutaneous pedicle screw fixation (PPF) for multiple-level isthmic spondylolisthesis. PATIENTS AND METHODS: From June 2008 through December 2014, multiple-level lumbar isthmic spondylolisthesis was diagnosed in 23 patients (6 men, 17 women) at Wooridul Spine Hospital (Busan, South Korea). Isthmic spondylolisthesis occurred at three spinal levels in 2 patients and at two levels in 21 patients. All patients underwent ALIF with PPF. We used the Oswestry Disability Index (ODI) and visual analog scale scores to evaluate the preoperative and postoperative functional outcome, low back pain, and radicular pain. We also evaluated segmental lordosis and the fusion status using radiographs and data from computed tomography. RESULTS: Isthmic spondylolisthesis occurred from L3 to S1 and mostly occurred at two consecutive spinal levels (i.e., L4-L5 and L5-S1). Significant improvements in the ODI and visual analog scale were observed in patients at final follow up (p<0.05). The mean segmental lordosis significantly increased after operation (from 22.7° to 32.7°). The mean lumbar lordosis significantly increased after operation (from 45.8 to 53.1). Radiographs of all of the patients showed solid fusion at the last follow-up. There was one case of screw fracture at the S1 level; however, in this case the last follow-up radiograph exhibited solid fusion. CONCLUSIONS: Anterior lumbar interbody fusion with PPF can be an effective treatment choice and yield good clinical outcomes in patients with multiple-level isthmic spondylolisthesis.

Abducens nerve palsy as a postoperative complication of minimally invasive thoracic spine surgery: a case report.

BACKGROUND: Thoracic disc surgeries make up only a small number of all spine surgeries performed, but they can have a considerable number of postoperative complications. Numerous approaches have been developed and studied in an attempt to reduce the morbidity associated with the procedure; however, we still encounter cases that develop serious and unexpected outcomes. CASE PRESENTATION: This case report presents a patient with abducens nerve palsy after minimally invasive surgery for thoracic disc herniation with an intraoperative spinal fluid fistula. A literature review of all cases related to this complication after spine surgery is included. Despite the uncommon nature of this type of complication, understanding the procedure itself, the principle occurrences and outcomes following the procedure, the physiopathogical features of abducens nerve palsy, and the possible adverse effects of spinal surgery, including minimally invasive procedures, can enable an early diagnosis of complications and facilitate the procedure. CONCLUSIONS: In spite of being very rare and multifactorial, uni- or bilateral abducens nerve paralysis carries significant morbidity and can occur as a postoperative complication after conventional or minimally invasive spine surgery. This condition requires an accurate diagnosis and adequate multidisciplinary follow up.