Buckling of the Ligamentum Flavum as a Rare Complication of Anterior Cervical Corpectomy and Fusion: A Case Report

Introduction and Importance Neurological deterioration due to buckling of the ligamentum flavum (LF) is an uncommon complication after anterior cervical corpectomy or discectomy with fusion. Case Presentation In this report, we present the case of a 66-year-old male who underwent anterior cervical partial corpectomy of C5 and discectomy of prolapsed C5- C6 with fusion. Postsurgery, the patient displayed signs of neurological deterioration. Upon immediate cervical magnetic resonance imaging (MRI), posterior canal stenosis and severe compression with cord signal due to LF buckling were detected. A posterior laminectomy procedure and canal decompression at the C5-C6 level with bone fusion were performed. Clinical Discussion Patient presented with walking difficulty, then walking disability, followed by bilateral upper and lower limb paresthesia with burning sensation. Examination showed ⅘ muscle strength in both handgrips. Further investigation showed brisk deep tendon reflexes, positive Hoffman sign unilaterally, equivocal Babinski sign, and progressive quadriparesis. Magnetic resonance imaging showed mild and diffuse building of some cervical discs, with spinal cord progression. We performed an anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF); a titanium mesh with plates and screws was used for fusion, with removal of a calcified and herniated subligamentous disc. Postoperatively, upper and lower limb strength deteriorated; immediate cervical and thoracic MRI showed LF buckling, which caused canal stenosis and severe compression. Urgent posterior laminectomy and canal decompression with bone fusion was scheduled on the same day. The patient underwent physiotherapy and regained upper and lower limb strength and his ability to walk. Conclusion This indicates the possibility of neurological deterioration as a result of LF buckling, whichmay be a result of LF thickening accompanied by hyperextension in the cervical region. In this regard, immediate imaging following signs of neurological complications after anterior cervical corpectomy or discectomy warrants early detection, which results in a better prognosis.

Analysis of postoperative outcomes of degenerative diseases of the lumbosacral junction / Análise dos resultados pós-operatórios do degenerador da junção lombossacral / Análisis de los resultados postoperatorios de las enfermedades degenerativas de la unión lumbosacra

ABSTRACT Objective: The article presents an analysis of the clinical efficacy and causes of unsatisfactory outcomes of surgical treatment in patients with degenerative diseases of the lumbosacral junction of the spine. Methods: Patients were allocated to one of three groups, depending on the method of surgical intervention on the lumbosacral junction: 1) (n=352) - operated by the method of microsurgical discectomy; 2) (n=83) - operated with the use of artificial IVD prostheses; 3) (n = 183) - operated with the use of interbody fusion and posterior rigid stabilization. To investigate the causes of unsatisfactory outcomes, a correlation analysis was conducted of long-term clinical outcomes with preoperative instrumental parameters in the operated segment, surgical tactics used, and the development of complications. Results: It is determined that long-term "good" clinical outcomes are associated with individual preoperative parameters of the lumbosacral junction of the spine - linear displacement, sagittal angulation, height of the interbody space, degree of IVD degeneration by ADC. Conclusion: In degenerative diseases of the lumbosacral junction of the spine, the detailed analysis of long-term clinical outcomes enable the identification of the causes that affect the development of unsatisfactory outcomes, which are individual morphostructural changes in the lower lumbar segment: the amplitude of the segmental angle, the angle of the lumbar lordosis, the degree of linear displacement of the vertebrae, the height of the interbody space, and ADC. Complex clinical and instrumental analysis enabled us to determine possible surgical tactics. Level of Evidence II; Prognostic Studies— Investigating the Effect of a Patient Characteristic on the Disease Outcome.

RESUMO Objetivo: O artigo apresenta a análise da eficácia clínica e as causas dos resultados insatisfatórios no tratamento cirúrgico de pacientes com doenças degenerativas da articulação lombossacral da coluna vertebral. Métodos: Dependendo do método da intervenção cirúrgica na junção lombossacral, três grupos de pacientes foram alocados: 1) (n = 352) - operado pelo método de discectomia microcirúrgica; 2) (n = 83) - operado com a utilização de próteses artificiais IVD; 3) (n = 183) - operado com a utilização de fusão intercorporal e estabilização rígida posterior. Para investigar as causas de resultados insatisfatórios, foi realizada uma análise de correlação do desfecho clínico a longo prazo com parâmetros instrumentais pré-operatórios no segmento operado, táticas cirúrgicas e desenvolvimento de complicações. Resultados: Determinou-se que o resultado clínico "bom" a longo prazo está associado a parâmetros pré-operatórios individuais da junção lombossacral da coluna - deslocamento linear, angulação sagital, altura do espaço inter-corpo, grau de degeneração IVD por ADC. Conclusão: Nas doenças degenerativas da junção lombossacral da coluna vertebral, a análise detalhada do curso clínico a longo prazo, que é uma alteração morfoestrutural individual no segmento lombar inferior - a amplitude do ângulo segmentar, o ângulo de lordose lombar, o grau de deslocamento linear das vértebras, a altura do espaço de corpo intermédio, ADC, análise clínica e instrumental complexo - permitiu determinar possíveis táticas cirúrgicas. Nível de Evidência II; Estudos prognósticos - Investigação do efeito de característica de um paciente sobre o desfecho da doença.

RESUMEN Objetivo: El artículo presenta el análisis de la eficacia clínica y causas de los resultados insatisfactorios de tratamiento quirúrgico de los pacientes con enfermedades degenerativas de la unión lumbosacra de la columna vertebral. Métodos: Dependiendo del método de la intervención quirúrgica sobre la unión lumbosacra, se asignaron tres grupos de pacientes: 1) (n = 352) - operado por el método de la discectomía microquirúrgica; 2) (n = 83) - operado con el uso de prótesis IVD artificiales; 3) (n = 183) - operado con el uso de fusión intersomática y estabilización rígida posterior. Para investigar las causas de los resultados insatisfactorios, un análisis de correlación de los resultados clínicos a largo plazo con parámetros instrumentales preoperatorios en el segmento operado, tácticas y complicaciones quirúrgicas se llevó a cabo. Resultados: Se determina que a largo plazo "buenos" resultados clínicos están asociados con parámetros individuales preoperatorios de la unión lumbosacra de la columna vertebral - desplazamiento lineal, angulación sagital, altura del espacio intersomático, grado de degeneración IVD por ADC. Conclusión: En enfermedades degenerativas de la unión lumbosacra de la columna vertebral, el análisis detallado de los resultados clínicos a largo plazo hace posible la identificación de las causas que afectan al desarrollo de los resultados insatisfactorios, que son cambios individuales morfoestructurales en el segmento lumbar inferior - la amplitud del ángulo segmentario, el ángulo de la lordosis lumbar, el grado del desplazamiento lineal de las vértebras, la altura del espacio intersomático y ADC. El complejo análisis clínico e instrumental nos permitió determinar posibles tácticas quirúrgicas. Nivel de Evidencia II; Estudios pronósticos - Investigación del efecto de características de un paciente sobre el desenlace de la enfermedad.

Evolución de las cajas de polyetheretherketone (PEEK). Estudio clínico y radiológico / Évolution des cages en polyétheréthercétone (PEEK). Étude clinique et radiologique / Evolution of polyetheretherketone (PEEK) boxes. Clinical and radiological study

Introducción: las cajas cervicales son implantes desarrollados como una alternativa a la utilización del injerto óseo estructural para la fusión cervical anterior. El objetivo de este estudio fue analizar la clínica y los resultados radiológicos en una serie de pacientes sometidos a disectomía y descompresión cervical anterior, a los que se les implantó una caja PEEK. Método: estudio retrospectivo, descriptivo, longitudinal de una serie de 78 pacientes incluidos en el estudio desde el año 2007 al 2013. El control radiológico incluyó radiografía anteroposterior y lateral. El seguimiento clínico y radiológico de los pacientes se llevó a cabo desde los 3 meses hasta los 12 meses. Resultados: 65 pacientes tuvieron una evolución clínica favorable (83,3 por ciento) y la evolución radiológica confirmó que 66 pacientes (84,6 por ciento) tenían una buena colocación del injerto, sin lesiones en espacios adyacentes con una fusión correcta. Conclusiones: hasta la fecha hay pocos estudios descriptivos sobre el implante de las cajas PEEK, los resultados mostrados en este trabajo están acordes a los publicados con anterioridad en este mismo campo, lo que da validez al trabajo presentado. Este estudio confirma los buenos resultados clínicos y radiológicos de pacientes a los que se les implantó una caja PEEK; se muestra su eficacia en la discectomía cervical anterior y artrodesis(AU)

Introduction: Cervical cases are implants developed as an alternative to the use of structural bone graft for anterior cervical fusion. The objective of this study was to analyze the clinical and radiological results in a series of patients submitted to anterior cervical dissectomy and decompression, to whom a PEEK box was implanted. Method: A retrospective, descriptive, longitudinal study was conducted in a series of 78 patients included in the study from 2007 to 2013. Radiological control included anteroposterior and lateral radiographies. Clinical and radiological follow-up of these patients was carried out from 3 months to 12 months. Results: 65 patients had a favorable clinical course (83.3 percent) and the radiological evolution confirmed that 66 patients (84.6 percent) had a good placement of the graft without lesions in adjacent spaces with a correct fusion. Conclusions: To date there are few descriptive studies on the implantation of PEEK boxes. This paper results are in line with those published previously in this same field, which legitimate the presented work. This study confirms the good clinical and radiological results in patients who were implanted with a PEEK box; its effectiveness in anterior cervical discectomy and arthrodesis is shown(AU)

Introduction: Les cages cervicales sont des implants développés comme alternative de la greffe osseuse structurelle pour la fusion cervicale antérieure. Le but de cette étude est d'analyser la technique et les résultats radiologiques dans une série de patients traités par discectomie et décompression cervicale antérieure, et implantation d'une cage PEEK. Méthodes: Étude rétrospective, descriptive et longitudinale d'une série de 78 patients inclus dans une étude depuis l'année 2007 jusqu'à l'année 2013. L'étude radiologique a compris des clichés en position antéro-postérieure et latérale. Le suivi clinique et radiologique des patients a pris de 3 à 12 mois. Résultats: L'évolution clinique a été satisfaisante chez 65 patients (83,3 pourcent), tandis que l'étude radiologique a confirmé que le greffon était bien placé, il n'y avait pas de lésions dans les espaces adjacentes, et la fusion était correcte chez 66 patients (84,6 pourcent). Conclusions: Jusqu'à maintenant, il y a peu d'études descriptives abordant l'implantation des cages PEEK. Le présent travail est validé, car ses résultats sont en concordance avec les travaux publiés auparavant dans ce domaine. Cette étude confirme les bons résultats obtenus chez les patients ayant subi l'implantation d'une cage PEEK ; son efficacité est démontrée dans la discectomie cervicale antérieure et l'arthrodèse(AU)

Espondilolistesis lumbar degenerativa de un solo segmento tratada con espaciador interespinoso / Single-segment degenerative lumbar spondylolisthesis treated with an interspinous spacer

Antecedentes: El término de espondilolistesis degenerativa acuñado por Newman en 1963, es el deslizamiento hacia adelante de una vértebra inmediatamente inferior sin lisis ístmica. Se observa predominantemente en personas mayores de 40 años, con un predominio de 4:1 del sexo femenino, teniendo una prevalencia de 7.5% en hombres y 28% en mujeres, respectivamente en pacientes con lumbalgia mayores a 50 años. Material y métodos: Evaluar a un año el resultado del uso de espaciadores dinámicos en listesis grado 1 de Meyerding utilizando la escala de incapacidad de Oswestry. Se revisa el historial electrónico y radiográfico de los pacientes según los criterios en el período de Enero 2008 a Diciembre 2010 con el propósito de realizar un estudio de cohortes, retrospectivo, longitudinal y observacional. Resultados: El Oswestry prequirúrgico fue de 3.4% leve, 55.2% moderado y 41.4% severo; mientras que el postquirúrgico fue de 79.3% leve y 20.7% moderado. La cirugía más comúnmente realizada fue exploración y liberación con 72.4%, presentando discectomía únicamente en 27.6%. Los pacientes presentaron dolor irradiado a miembro pélvico derecho en 37.9%, miembro pélvico izquierdo en 44.8% y a ambos miembros pélvicos en 17.2%. Se presentó dolor postquirúrgico irradiado a miembro pélvico únicamente en 2.4%, siendo que en 100% de los casos presentaron algún tipo de dolor irradiado. Se utilizó espaciador DIAM en 79.3% y Wallis en 20.7%. Conclusiones: El tratamiento con espaciador interespinoso presenta un bajo índice de reintervención y, por lo menos a un año, presenta mejoría significativa en el índice de incapacidad.

Background: The term degenerative spondylolisthesis, coined by Newman in 1963, refers to the forward slippage of an immediately inferior vertebra without isthmic lysis. It occurs predominantly in individuals over 40 years of age and affects mainly women, with a female:male ratio of 4:1. Prevalence is 7.5% in males and 28% in females among patients over 50 years of age with low back pain. Material and methods: Assess the one-year results of the use of dynamic spacers for Meyerding grade 1 listhesis with the Oswestry disability scale. The patient's electronic and radiographic records from January 2008 to December 2010 were reviewed according to different criteria to conduct a retrospective, longitudinal and observational cohort study. Results: The preoperative Oswestry score was 3.4% mild, 55.2% moderate, and 42.4% severe; the postoperative score was 79.3% mild and 20.7% moderate. The most common surgical procedure was exploration and release in 72.4% of patients; only 27.6% underwent diskectomy. Pain irradiating to the right pelvic limb occurred in 37.9% of patients, to the left pelvic limb in 44.8%, and to both pelvic limbs in 17.2%. Only 2.4% of patients experienced postoperative pain that irradiated to the pelvic limb, as 100% of cases had some type of irradiating pain. A DIAM spacer was used in 79.3% and a Wallis device in 20.7%. Conclusions: Treatment with an interspinous spacer results in a low reoperation rate and, at least one year later, it resulted in a significant improvement in the disability rate.

Espaciador interespinoso tipo DIAM: experiencia en Puerto Montt / DIAM interspinous spacer type: experience in Puerto Montt

El lumbago crónico constituye un problema de salud pública por su frecuencia y afección a población joven, económicamente activa. Se presenta en el presente artículo, un análisis de la biomecánica de la columna lumbar, y la importancia de los vectores de carga en la génesis del dolor, y las posibilidades de intervenir sobre ellos con la instalación de dispositivos interespinosos. Se exponen las distintas alternativas de espaciadores interespinosos y se presenta la experiencia con el DIAM. Se analizan los resultados de 17 pacientes sometidos a cirugía por lumbago crónico por fracaso a tratamiento médico quinésico, con la instalación de 26 dispositivos, destacando la buena evolución de la mayoría de ellos, con reducción significativa del dolor (EVA pre y postoperatorio) y análisis de capacidad funcional por escala de Oswestry luego de la cirugía. Todos los pacientes fueron intervenidos por el autor.

Chronic low back pain constitutes a public health problem by its frequency and affection in young population, economically active. This article presents an analysis of the biomechanics of the lumbar spine, and the importance of load vectors in pain genesis, and the possibilities to act on them with interspinous device installation. Here are exposed interspinous spacers alternatives and presents experience with the DIAM. We analyze the results of 17 patients undergoing surgery for chronic low back pain by failure of kinesics medical treatment, with the installation of 26 devices, highlighting the good performance of most of them with significant reduction in pain (VAS pre-and postoperative) and functional capacity analysis Oswestry scale after surgery. All patients were operated on by the author.

Evaluation of arthrodesis and cervical alignment in the surgical results of cervical discectomy using polymethylmetacrylate / Avaliação da artrodese e do alinhamento cervical após discectomia cervical com interposição de polimetilmetacrilato

BACKGROUND AND OBJECTIVES: Surgical treatment of cervical radiculopathy with or without myelopathy is a controversy issue, although anterior discectomy is the most common form of treatment. METHOD: We present the evaluation of the arthrodesis' rate and cervical alignment in 48 patients with cervical degenerative disease (CDD) submitted to anterior cervical discectomy with interposition of polymethylmetacrylate (PMMA). Odom and Nürick scales were used to evaluation of functional status before and after surgery. Cervical spine X-rays were used to access arthrodesis and alignment, at least 2 years after the procedure. RESULTS: Excellent and good results (Odom I and II) were obtained in 91 percent of the patients with radiculopathy and in 69 percent of those with myelopathy. Using the chi square test of independence (1 percent of significance), there was no association between excellent and good clinical results with the presence of arthrodesis verified in cervical X-rays. The presence of cervical alignment had association with good results, whereas the misalignment was associated with unfavorable outcomes. Two patients died: one cervical hematoma and other from graft migration with cord compression. CONCLUSIONS: Cervical alignment was more important than fusion to achieve good surgical results in CDD.

TEMA E OBJETIVO: O tratamento cirúrgico da radiculopatia cervical com ou sem mielopatia é um tema controverso, embora a discectomia por via anterior seja uma das formas mais comuns de tratamento. MÉTODO: Apresentamos a avaliação da artrodese cervical e do alinhamento pós operatório em 48 pacientes com doença degenerativa cervical (DDC) submetidos a discectomia por via anterior seguida da interposição de polimetilmetacrilato (PMMA). As escalas de Odom e de Nurick foram utilizadas para avaliar o status funcional dos pacientes antes e após a cirurgia. Radiografias da coluna cervical foram utilizadas para avaliar a artrodese e o alinhamento cervical, pelo menos 2 anos após o procedimento. RESULTADOS: Excelentes e bons resultados (Odom I e II) foram obtidos em 91 por cento dos casos com radiculopatia e em 69 por cento dos pacientes com mielopatia. Usando o teste do qui-quadrado de independência (1 por cento de significância), não houve associação entre os resultados excelentes e bons e a presença de artrodese. A presença de alinhamento cervical, ao contrário, correlacionou-se com bons resultados. Dois pacientes faleceram devido a hematoma cervical e migração do enxerto. CONCLUSÃO: O alinhamento cervical correlacionou-se com bons resultados cirúrgicos em nossos pacientes, enquanto que a taxa de artrodese não teve relação com o resultado clínico dos pacientes.