Skip hemilaminectomy for the treatment of holospinal epidural abscess: A single-center experience

Background: Holospinal epidural abscesses (HEAs) are rare with potentially devastating consequences. Urgent bony decompression and abscess evacuation with long-term antibiotic therapy are typically the treatment of choice. Methods: We reviewed cases of holospinal HEAs operated on between 2009 and 2018. Variables studied included preoperative laboratories, CT/MR studies plus clinical and radiographic follow-up for between 34 and 60 postoperative months. Results: We utilized skip hemilaminectomies to minimize the risks of segmental instability. Targeted antibiotic therapy was also started immediately and maintained for 6 postoperative weeks. MR/CT studies documented full radiographic and neurological recovery between 6 and 12-months later. Conclusion: HEAs may be treated utilizing multilevel skip hemilaminectomies to help maintain spinal stability while offering adequate abscess decompression/resolution.

The Incidence of Atlanto-Occipitalization and Additional Foramina Present in The Dry Skulls of Nepalese Population

Introduction: Atlanto-occipitalization(AOZ) is one of the congenital anomalies related to craniovertebral synostosis. The clear understanding of its anatomical features and cranial foraminal variants plays a critical role in finding the possible coping mechanism with its pathogenesis such as segmental instability or neurologic deficits. Objective: This study aimed to investigate the incidence of occipitalization of Atlas and related variant foramina, as the baseline awareness of these conditions among the Nepalese population is yet to be documented. Methodology: A retrospective study was performed for the total 86 dry skulls available in the department of Anatomy in Katmandu University of Medical Sciences, Institute of Medical Science, and B.P. Koirala Institute of Health Sciences. The skulls were examined thoroughly to evidence the occurrence of cranio-vertebral variations. Result: Out of 86 human adult skulls, 2 cases (2.32 %) were found with partial AOZ presenting posterior spina bifida close to the midline. Sphenoidal emissary foramen (SEF) was also observed in 17 skulls (19.76 %), an additional foramen lying anteromedial to the foramen ovale. Moreover, one of the skulls (1.16 %) was found with the presence of pterygospinous bar creating an additional foramen ‘foramen of Civinini’ in the lateral pterygoid plate of the sphenoid bone. Conclusion: The incidence of AOZ and pterygospinous bar seems to be quite low as compared to the cases of SEF. However, the knowledge of such variations and the presence of additional foramina carry great significance for orthopedists and neurosurgeons to have prognostic implications and an accurate surgical approach.

Pain Control Affects the Radiographic Diagnosis of Segmental Instability in Patients with Degenerative Lumbar Spondylolisthesis

Background: Diagnosing intervertebral instability is crucial for the treatment of degenerative lumbar spondylolisthesis (DLS). Disabling back pain will reduce spinal mobility which leads to an underestimate of the incidence of intervertebral instability. We hypothesized that adequate analgesia could alter the flexion/extension exam performance, and thus increase the diagnostic accuracy of segmental instability. Materials and methods: One hundred patients with low-grade DLS were prospectively enrolled in the before–after cohort study. Standing lateral flexion/extension radiographs of lumbar spines were examined and analyzed before and after intramuscular injections of 30 mg ketorolac. Results: Pain score decreased significantly after analgesic injections (p < 0.001). Dynamic slip (DS), dynamic segmental angle (DA), dynamic lumbar lordosis, and slip percentage (SP) were significantly increased after pain reduction (all p < 0.001). According to the diagnostic criteria for segmental instability (DS > 4.5mm, DA>15°, or SP >15%), there were 4%, 4%, and 0.7% of total motion segments fulfilling the criteria which markedly increased to 42%, 32%, and 16.7% after analgesia was administered. The incidence of instability also increased from 6% to 38% after analgesia. Conclusions: The diagnosis rate of intervertebral instability is commonly underestimated in the presence of low back pain. This short-term pain relief facilitates reliable functional imaging adding to the diagnosis of intervertebral instability.

Kinematics of an intervertebral disc with type 1 Modic change: mechanical and non-mechanical causes

BackgroundType 1 Modic change (MC) is associated with chronic low back pain and attributed to segmental instability. However, the relationship between type 1 MC and segmental instability is unclear. This study sought to clarify the role of mechanical abnormalities in type 1 MC.MethodReview of magnetic resonance images obtained for 727 patients over a 1-year period at our institution revealed 161 cases of type 1 MC. In 86 of these, the following indicators of mechanical abnormality could be evaluated on dynamic radiographs: segmental scoliosis (> 5°), forward slippage (> 1%), and posterior disc opening in flexion. Patients with one or more of these abnormalities were allocated to a mechanical group (n = 62, 70%) and those with no abnormality to a non-mechanical group (n = 26, 30%). The Pfirrmann grade of disc degeneration at the affected level was compared between the groups.ResultsSegmental scoliosis, slippage, and posterior opening was observed in 34, 21 and 37 cases, respectively. Severe disc degeneration (grade IV or V) was present in 43 cases (69%) in the mechanical group and in 12 cases (46%) in the non-mechanical group; the difference was statistically significant (p = 0.04).ConclusionWe propose that there are mechanical and non-mechanical variants of type 1 MC.

Bilateral facet effusion is a risk factor for segmental instability with cervical injury without vertebral fracture

Magnetic resonance imaging (MRI) is effective in identifying cervical spine injury after trauma. However, cervical instability without major bone injury or dislocation is challenging to assess. Hence, the current study aimed to investigate and compare the MRI and radiography findings of segmental instability in patients with cervical spine injury. We investigated 34 participants with cervical spine injury without vertebral fracture. Based on the radiography findings, the participants were categorized into two: group A with segmental instability (n = 11) and group B without segmental instability (n = 23). Both groups were compared in terms of the presence of segmental instability on radiography and MRI. Anterior longitudinal ligament (ALL) injury, disc injury, and bilateral facet effusion were observed in 6/11, 5/11, and 7/11 patients in group A and in 5/23, 2/23 and 7/23 patients in group B, respectively. The results showed significant differences (p < 0.05). Moreover, 2 and 10 of 11 patients in group A and 16 and 7 of 23 patients in group B presented with hemi lateral facet effusion and paravertebral muscle injury, respectively. However, the results did not significantly differ. According to a logistic regression analysis, bilateral facet effusion after trauma was associated with cervical segmental instability (odd ratio: 10.6, 95% confidence interval: 1.31–84.7). Facet joint effusion might be caused by capsule injury during trauma. Most participants with segmental instability had ALL, disc, and flavum injury and bilateral facet effusion. Therefore, we need to consider bilateral facet effusion with other soft tissue damage of the cervical spine as an association factor to show the instability.

Laminoplasty with selective fusion at unstable segment versus laminectomy with fusion for multilevel cervical myelopathy: a case‐control study

Background Segmental cervical instability is a risk factor for the progression of osteophytic bone spurs and development of myelopathy, and is treated as a relative contraindication of cervical laminoplasty. The aim of this study was to compare laminoplasty with selective fixation (LPSF) versus laminectomy with fusion (LCF) in patients with multilevel cervical myelopathy accompanied by segmental instability. Methods A case-control study was conducted by reviewing data from 63 patients who underwent LPSF (n = 30) or LCF (n = 33). Cervical alignment, range of motion (ROM), neurologic status and axial symptom severity pre-operation, 3-days after operation, and at the final follow-up (minimum 24 months) were measured and compared between groups. Results Postoperation, patients in the LPSF group lost 31.1 ± 17.3 % of cervical lordosis and 43.2 ± 10.9 % cervical ROM while patients in the LCF group lost 5.7 ± 8.2 % and 67.9 ± 15.5 %, respectively. Both LPSF and LCF groups significantly improved neurologic status and axial symptom severity at the final follow-up with similar between-group results(P > 0.05). Blood loss, operation time, hospital stay, and medical cost in the LPSF group were significantly less than in the LCF group(P < 0.05). Conclusions In 2 years of clinical observation, LPSF was effective in maintaining the stability of the cervical spine with less sacrifice of mobility and surgical trauma for multilevel myelopathy with segmental instability compared to LCF.