Category: Spine

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Removal of giant extraforaminal dumbbell tumors of cervical spine

The Spine Journal 9 (2009) 822–829. doi:10.1016/j.spinee.2009.06.023

Removal of cervical dumbbell tumors can be particularly challenging because of unique exposure requirements and proximity of the vertebral artery (VA). There are no reports describing the treatment of giant cervical spine dumbbell tumors (CSDTs).

PURPOSE: To introduce an extensive posterolateral approach to CSDTs involving total lateral mass resection and laminectomy.

STUDY DESIGN: Prospective study of all the patients with multilevel CSDTs treated by  this new procedure between December 2002 and March 2006.

PATIENT SAMPLE: Sixteen patients (3 men and 13 women) with CSDTs underwent the procedure we describe. The follow-up periods ranged from 9 to 51 months (average 9 months). Average age at surgery was 45 years (range 23–68 years).

OUTCOME MEASURES: Axial symptoms and Japanese Orthopedic Association scores were recorded. Pre- and postoperative ranges of neck motion were measured on lateral flexion and extension radiographs.

METHODS: After making a midline incision, we preferred exposing the extraforaminal component of the tumor before performing a semilaminectomy and lateral mass resection. Any lateral extensión of a tumor can be attained by detachment of the adjacent three or more segments of the lateral mass muscle insertion. The most lateral portion can be separated beneath the tumor’s superficial muscle flap, and then when the tumor is retracted medially, the whole portion of the lateral component can be totally exposed. We then performed total lateral mass resection and laminectomy to expose the tumor at the foramina and cervical canal.

RESULTS: We were able to completely resect the tumors in every patient. The average duration of surgery was 150 minutes. Blood loss was minimal (average 400 mL). All patients were monitores for a minimum of 9 months (range 9–51 months; mean 28 months). The follow-up period was uneventful, and no patients developed spinal instability.

CONCLUSIONS: Extensive posterolateral exposure enables surgeons to reach the lateralmost portion of CSDTs and also facilitates septation of the VA and resection of vertebral body encroachment of the tumor.


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Radiologically documented adjacent-segment degeneration after cervical arthroplasty

Surgical Neurology 72 (2009) 325–329. doi:10.1016/j.surneu.2009.02.013

Background: The authors retrospectively studied the incidence and characteristics of radiologically documented adjacent-segment degeneration after single-level diskectomy and subsequent cervical arthroplasty using the Bryan (Medtronic Sofamor Danek; Memphis, TN) disk prosthesis.

Methods: Seventy-two patients with single-level arthroplasty using the Bryan cervical disk prosthesis were evaluated. Radiological evidence of adjacent-disk disease included new formation or enlargement of anterior osteophyte, new or increasing ALL calcification, or narrowing of disk space documented on serial plain radiographs. We reported the characteristics of adjacent-segment degeneration and reviewed all of the cases.

Results: Among the 72 patients, 9 patients (12.5%) showed radiological evidence of adjacentsegment degeneration. The mean age was 43.3 years old, with a male-female ratio 1:3. The mean follow-up period was 24.2 (12.1-35.9) months. The mean period of onset was 16.3 months. Uppersegment degeneration was documented in 4 cases (3 new osteophyte, 1 enlargement of osteophyte), whereas lower-segment degeneration was noted in 5 cases (1 new osteophyte, 3 enlargement of osteophyte, 1 decreased disk height). Among the degenerated cases, 4 cases (44.4%) also showed various degrees of HO.

Conclusions: The rate of adjacent-segment degeneration was higher than that observed in previous studies. Adjacent-segment degeneration documented a tendency toward HO. A longer follow-up period is necessary to investigate and document the different types of degeneration seen at levels adjacent to artificial Bryan cervical disk prostheses.

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Outcome After Anterior Cervical Discectomy and Arthrodesis A Clinical Study of 368 Patients

Neurosurg Q 2009;19:164–170

Aim: To define the predictors for the clinical outcome after anterior cervical discectomy and arthrodesis for patients with degenerative diseases of the cervical spine. Does the subsidence of the intervertebral spacer in the adjacent vertebral have a negative influence on the outcome?
Materials and Methods: In a prospective clinical study, 368 patients underwent anterior cervical discectomy and arthrodesis with degenerative disease of the cervical spine. The patients were treated between September 1997 and January 2005. All patients were followed up 1 year after surgery.
Results: Young age of the patient, mono-segmental anterior cervical discectomy and arthrodesis of the lower cervical spine are predictors of a satisfactory outcome. We did not find statistical differences in the outcome between male and female patients or between patients with or without subsidence of the cage.
Conclusions: Good results can be achieved by early operative therapy. The subsidence of the cage does not affect the outcome.

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Comparative study of anterior versus posterior decompression in elderly patients of cervical myelopathy with co-morbid conditions

Eur J Orthop Surg Traumatol (2009) 19:397–401 DOI 10.1007/s00590-009-0444-8

Study design: Prospective.

Objective: To assess the results of laminectomy in patients suffering from multilevel multidirectional compressive cervical myelopathy with co-morbid conditions and to compare results of anterior and laminectomy clinically, radiologically and functionally.

Summary of background data: Cervical myelopathy or myeloradiculopathy is a progressive degenerative disorder that usually starts in the middle age. It leads to circumferential cord compression leading to a constellation of signs and symptoms.

Methods: Prospective study of 30 cases in which we had compared the results of anterior and posterior decompression surgery. Our follow-up ranged from 18 to 60 months with an average follow-up of 31.8 months.

Results: Eighteen patients underwent laminectomy by posterior midline approach in which lamina and if required, medial one-third of the facet was also removed. Diskectomy and bone grafting was done in eight patients by standard anterior approach with removal of disc at two or three levels. Corpectomy and diskectomy above and below with bone grafting was done in four patients. Out of these two were fused with tricortical iliac crest and two with fibula.

Conclusion: Anterior decompression is the gold standard. However, in medically unfit patients with multi-level circumferential compression, laminectomy is an equally rewarding option.

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Posterior Lumbar Interbody Fusion: Comparison of Single Intervertebral Cage and Single Side Pedicle Screw Fixation versus Bilateral Cages and Screw Fixation

Minim Invas Neurosurg 2009; 52: 132 – 136. DOI 10.1055/s-0029-1224097

Introduction: The efficacy and economy of an alternative sparing method for posterior lumbar interbody fusion (PLIF) using a single cage fixed with pedicle screws placed on a single side (SS group, n = 22) was compared to that of a standard bilateral protocol using two cages and pedicle screws placed bilaterally (BL group, n = 15).

Methods: All PLIFs were non-compensation cases done at a single level by a single surgeon and were similar in most background characteristics. Significant differences were not found between the two groups in fusion rates, complications or in 2-year prospectively collected outcomes including percent improvement in back and leg pain (visual analog scales) and the Oswestry disability index.

Results: Perioperative results significantly favored the SS group: BL patients lost 81 % more blood, used 74 % more time for surgery, stayed in hospital 1.7 days longer, and the hospital-related cost per procedure was twice as high. Currently, the SS procedure typically averages less than 1 hand blood loss less than 50 mL. In summary, the BL and SS groups had similar outcomes while the SS procedure provided substantially superior efficiency and economy.

Conclusion: In conclusion, the results of this retrospective comparative level III study warrant further studies on the SS protocol which may lead to the adoption of this minimally invasive protocol in the standard practice of PLIF in selected cases.

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Minimally Invasive Lumbar Discectomy Had Worse Outcome than Conventional Open Microdiscectomy. A Randomized Controlled Trial

JAMA. 2009;302(2):149-158.

Context Conventional microdiskectomy is the most frequently performed surgery for patients with sciatica due to lumbar disk herniation. Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence is lacking of its efficacy.

Objective To determine outcomes and time to recovery in patients treated with tubular diskectomy compared with conventional microdiskectomy.

Design, Setting, and Patients The Sciatica Micro-Endoscopic Diskectomy randomized controlled trial was conducted among 328 patients aged 18 to 70 years who had persistent leg pain (>8 weeks) due to lumbar disk herniations at 7 general hospitals in the Netherlands from January 2005 to October 2006. Patients and observers were blinded during the follow-up, which ended 1 year after final enrollment.

Interventions Tubular diskectomy (n = 167) vs conventional microdiskectomy (n = 161).

Main Outcome Measures The primary outcome was functional assessment on the Roland-Morris Disability Questionnaire (RDQ) for sciatica (score range: 0-23, with higher scores indicating worse functional status) at 8 weeks and 1 year after randomization. Secondary outcomes were scores on the visual analog scale for leg pain and back pain (score range: 0-100 mm) and patient’s self-report of recovery (measured on a Likert 7-point scale).

Results Based on intention-to-treat analysis, the mean RDQ score during the first year after surgery was 6.2 (95% confidence interval [CI], 5.6 to 6.8) for tubular diskectomy and 5.4 (95% CI, 4.6 to 6.2) for conventional microdiskectomy (between-group mean difference, 0.8; 95% CI, –0.2 to 1.7). At 8 weeks after surgery, the RDQ mean (SE) score was 5.8 (0.4) for tubular diskectomy and 4.9 (0.5) for conventional microdiskectomy (between-group mean difference, 0.8; 95% CI, –0.4 to 2.1). At 1 year, the RDQ mean (SE) score was 4.7 (0.5) for tubular diskectomy and 3.4 (0.5) for conventional microdiskectomy (between-group mean difference, 1.3; 95% CI, 0.03 to 2.6) in favor of conventional microdiskectomy. On the visual analog scale, the 1-year between-group mean difference in improvement was 4.2 mm (95% CI, 0.9 to 7.5 mm) for leg pain and 3.5 mm (95% CI, 0.1 to 6.9 mm) for back pain in favor of conventional microdiskectomy. At 1 year, 107 of 156 patients (69%) assigned to tubular diskectomy reported a good recovery vs 120 of 151 patients (79%) assigned to conventional microdiskectomy (odds ratio, 0.59 [95% CI, 0.35 to 0.99]; P = .05).

Conclusions Use of tubular diskectomy compared with conventional microdiskectomy did not result in a statistically significant improvement in the Roland-Morris Disability Questionnaire score. Tubular diskectomy resulted in less favorable results for patient self-reported leg pain, back pain, and recovery.

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The evolution of thoracolumbar injury classification systems

The Spine Journal 9, Issue 9, September 2009, Pages 780-788doi:10.1016/j.spinee.2009.04.003

An ideal classification system for thoracolumbar (TL) spine fractures should facilitate communication between treating physicians and guide treatment by means of outlining the natural history of injuries. The classification scheme should also be comprehensive, intuitive, and simple to implement. At the present time, no classification system fully meets these criteria. In this review, the authors attempt to describe the evolution of TL fracture classification systems from their inception to the present day.

The article reviews the salient classification systems that have addressed TL injuries since Boehler’s first attempt in 1929. This progression culminates in the Thoracolumbar Injury Severity Score/Thoracolumbar Injury Classification and Severity Score (TLISS/TLICS), a system which incorporates features from earlier scales and represents the most comprehensive grading scale to date.

Each successive system played an important role in advancing contemporary understanding of TL injuries. Most classifications were, however, based on a single individual’s, or a comparatively small group’s, retrospective review of a case series. In most instances, these grading systems were never validated or modified by their original developers, a shortcoming that prevented their continued evolution. Despite the many advantages of the TLISS/TLICS system, more work in terms of refining the classification and defining its validity remains to be performed.

The classification of TL injuries has evolved significantly over the course of the last 75 years. Most of these schemes were limited by their complexity, relevance, and/or poor reliability. The TLISS classification system represents the most recent evolution as it combines several important factors capable of guiding the management of TL injuries. Nonetheless, more research regarding this rating scale remains to be performed.

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Management of disc herniations with bi-radicular symptoms via combined lateral and interlaminar approach

Neurosurg Review

Large lumbosacral disc herniations causing bi-radicular symptoms are very rare clinical entities and may present a surgical challenge. This study was undertaken to evaluate the effectiveness of the simply modified combined lateral and interlaminar approach for the treatment of these unique disc herniations. Between 2000 and 2005, 18 patients with bi-radicular symptoms secondary to large disc herniations of the lumbar spine underwent surgery. There were 13 men and five women, ranging in age between 25 and 64 years (mean 54.3 years). In this three-step operation, the osseous areas that are not essential for the facet joint were removed and both upper and lower nerve roots were decompressed. There were no intraoperative or postoperative complications, except transient dysesthesia in one (5.5%) patient. The mean follow-up period was 62.6 months (range 36–96 months). At the latest follow-up examination, outcomes using the Macnab classification were excellent in 13 patients (72.2 %), good in four (22.2%) and fair in one (5.5%). Recurrent disc herniations and/or instability, either symptomatic or radiographic, have not occurred as a result of the procedure during the follow-up period. The combined approach described here is a safe and effective procedure in the surgical treatment of this subtype of disc herniations with bi-radicular involvement. It permits optimum decompression of both nerve roots, avoiding the risk of secondary spinal instability.

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A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures

NEJM (361): 569-579. Aug 6, 2009

Vertebroplasty is commonly used to treat painful, osteoporotic vertebral compression fractures.

Methods In this multicenter trial, we randomly assigned 131 patients who had one to three painful osteoporotic vertebral compression fractures to undergo either vertebroplasty or a simulated procedure without cement (control group). The primary outcomes were scores on the modified Roland–Morris Disability Questionnaire (RDQ) (on a scale of 0 to 23, with higher scores indicating greater disability) and patients’ ratings of average pain intensity during the preceding 24 hours at 1 month (on a scale of 0 to 10, with higher scores indicating more severe pain). Patients were allowed to cross over to the other study group after 1 month.

Results All patients underwent the assigned intervention (68 vertebroplasties and 63 simulated procedures). The baseline characteristics were similar in the two groups. At 1 month, there was no significant difference between the vertebroplasty group and the control group in either the RDQ score (difference, 0.7; 95% confidence interval [CI], –1.3 to 2.8; P=0.49) or the pain rating (difference, 0.7; 95% CI, –0.3 to 1.7; P=0.19). Both groups had immediate improvement in disability and pain scores after the intervention. Although the two groups did not differ significantly on any secondary outcome measure at 1 month, there was a trend toward a higher rate of clinically meaningful improvement in pain (a 30% decrease from baseline) in the vertebroplasty group (64% vs. 48%, P=0.06). At 3 months, there was a higher crossover rate in the control group than in the vertebroplasty group (43% vs. 12%, P<0.001). There was one serious adverse event in each group.

Conclusions Improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in a control group. (ClinicalTrials.gov number, NCT00068822 [ClinicalTrials.gov] .)
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