Ultrasonic spine surgery for every thoracic disc herniation: a 43-patient case series and technical note demonstrating safety and efficacy using a partial transpedicular thoracic discectomy with ultrasonic aspiration and ultrasound guidance

OBJECTIVE Thoracic disc herniations (TDHs) are a challenging pathology. A variety of surgical techniques have been used to achieve spinal cord decompression. This series elucidates the versatility, efficacy, and safety of the partial transpedicular approach with the use of intraoperative ultrasound and ultrasonic aspiration for resection of TDHs of various sizes, locations, and consistencies. This technique can be deployed to safely remove all TDHs. METHODS A retrospective review was performed of patients who underwent a thoracic discectomy via the partial transpedicular approach between January 2014 and December 2020 by a single surgeon. Variables reviewed included demographics, perioperative imaging, and functional outcome scores. RESULTS A total of 43 patients (53.5% female) underwent 54 discectomies. The most common presenting symptoms were myelopathy (86%), motor weakness (72%), and sensory deficit (65%) with a symptom duration of 10.4 ± 11.6 months. A total of 21 (38.9%) discs were fully calcified on imaging and 15 (27.8%) were partially calcified. A total of 36 (66.7%) were giant TDHs (> 40% canal compromise). The average operative time was 197.2 ± 77.1 minutes with an average blood loss of 238.8 ± 250 ml. Six patients required ICU stays. Hospital length of stay was 4.40 ± 3.4 days. Of patients with follow-up MRI, 38 of 40 (95%) disc levels demonstrated < 20% residual disc. Postoperative Frankel scores (> 3 months) were maintained or improved for all patients, with 28 (65.1%) patients having an increase of 1 grade or more on their Frankel score. Six (14%) patients required repeat surgery, 2 of which were due to reherniation, 2 were from adjacent-level herniation, and 2 others were from wound problems. Patients with calcified TDHs had similar improvement in Frankel grade compared to patients without calcified TDH. Additionally, improvement in intraoperative neuromonitoring was associated with a greater improvement in Frankel grade. CONCLUSIONS The authors demonstrate a minimally disruptive, posterior approach that uses intraoperative ultrasound and ultrasonic aspiration with excellent outcomes and a complication profile similar to or better than other reported case series. This posterior approach is a valuable complement to the spine surgeon’s arsenal for the confident tackling of all TDHs.

Efficacy of Percutaneous Vertebroplasty in the Treatment of Malignant and Benign Vertebral Fractures: Single-Center Experiences

Percutaneous vertebroplasty (PVP) is a method used for vertebral stabilization and pain treatment. This study was performed to demonstrate the efficacy of PVP in treatment of malignant and benign vertebral compression fractures (VCFs). The study was conducted on 45 cases with a total of 106 VCFs. The mean age of the patients was 62.4 years (37–86 years). The vertebral fractures were classified according to Genant’s Classification. Pain was rated using the visual analog scale (VAS). VAS scores were recorded before and after PVP operations. A total of 58 vertebrae (54.8%) were treated via a bipedicular approach, and 48 vertebrae (45.2%) were treated via a unilateral transpedicular approach with the help of biplane imaging and under anesthesia. L1 vertebra (19.8%) fractures and Grade III fractures (46.3%) were more common. Vertebral collapse was the most common cause of malignancy (53.8%). The mean VAS score was measured to be 8.39 before the VP operations and 2.05 after the VP operations. The VAS score dropped to 2.3 through the unipedicular approach and to 1.84 through the bipedicular approach. The decrease in pain due to VP was statistically significant (p < 0.001). There was no statistically significant difference between the unipedicular and bipedicular approaches in terms of pain relief (p> 0.05). Some patients (18.8%) had complications. PVP is a highly therapeutic method for pain relief in case of pain secondary to malignant or benign vertebral fractures.

A transpedicular approach to complex ventrally situated thoracic intradural extramedullary tumors: technique, indications, and multiinstitutional case series

OBJECTIVE Ventrally situated thoracic intradural extramedullary tumors are surgically challenging and difficult to access, and they may be complicated by extensive adhesions and calcifications. Selecting an approach for adequate ventral access is key to complete resection and optimization of outcomes. The authors present a case series of patients who underwent resection of ventral thoracic intradural extramedullary tumors and discuss indications and considerations for this technique. Additionally, they describe the use of a posterolateral transpedicular approach for resection of ventral thoracic intradural extramedullary tumors compared with other techniques, and they summarize the literature supporting its application. METHODS From May 2017 to August 2020, 5 patients with ventral thoracic intradural extramedullary tumors underwent resection at one of the two academic institutions. RESULTS Patient ages ranged from 47 to 75 (mean 63.4) years. All tumors were diagnosed as meningiomas or schwannomas by histological examination. Three of the 5 patients had evidence of partial or extensive tumor calcification. Four of the 5 patients underwent an initial posterolateral transpedicular approach for resection, with positive radiographic and clinical outcomes from surgery. One patient initially underwent an unsuccessful traditional direct posterior approach and required additional resection 2 years later after interval disease progression. There were no postoperative wound infections, CSF leaks, or other complications related to the transpedicular approach. CONCLUSIONS Posterolateral transpedicular tumor resection is a safe technique for the treatment of complex ventrally situated thoracic intradural extramedullary tumors compared with the direct posterior approach. Anecdotally, this approach appears to be particularly beneficial in patients with calcified tumors.

Unilateral percutaneous vertebroplasty for osteoporotic lumbar compression fractures: a comparative study between transverse process root-pedicle approach and conventional transpedicular approach

Purpose Percutaneous vertebroplasty (PVP) is a routine operation for the treatment of osteoporotic lumbar compression fractures (OLCFs). As is well known, unilateral puncture is a common method. However, with the conventional transpedicular approach (CTPA), the cement may be asymmetrically dispersed, so some surgeons use the transverse process root-pedicle approach (TPRPA). The objective of this study was to compare the clinical results and bone cement distribution of PVP for OLCF with unilateral TPRPA and CTPA to identify the advantages and disadvantages of the two surgical options. Patients and methods From January 2016 to June 2019, seventy-two elderly patients who underwent unilateral PVP for single-level OLCF were retrospectively reviewed. Operation time, injection amount and type of bone cement distribution, and bone cement leakage and surgical complications were recorded. The visual analog scale (VAS) scores and Oswestry disability index (ODI) scores were used to evaluate the clinical results. All patients were followed up for more than 12 months, and the assessment was based primarily on clinical and radiological outcomes. Results There were significant differences in the surgical time and the volume and the type of bone cement distribution and the lost of operative vertebra height between the two groups. However, there was no significant difference in bone cement leakage. Moreover, there were no significant differences in VAS and ODI between the two groups at 2 days and 12 months after the operation. Conclusions Unilateral TPRPA and CTPA are practical and feasible methods in PVP for the treatment of OLCF, and they have similar clinical effects. However, TPRPA has the advantages of a better distribution of bone cement and a shorter operation time and a better maintenance effect of injured vertebra height, without increasing the rate of bone cement leakage.

Resection of Ventral Thoracic Calcified Meningiomas Through a Transpedicular Approach: 2-Dimensional Operative Video

The surgical resection of ventrally located thoracic lesions carries additional complexity because of the constraints of the mediastinum and pleural cavity as well as the intolerance of the spinal cord to manipulation. The creation of a ventrolateral operative corridor through a transpedicular, transarticular route is effective for accessing the ventral thoracic spinal cord. This operative video demonstrates the surgical management of a 67-yr-old female who presented with progressive gait ataxia and bilateral lower extremity weakness and was found to have noncontiguous calcified ventral thoracic meningiomas at T6 and T10. The surgical plan consisted of T4-11 posterior instrumentation, T5-6 and T9-10 laminectomies with unilateral facetectomies and pediculectomies at both segments, and microsurgical resection of both tumors. Postoperatively, the patient's gait and paraparesis improved. Although instrumentation is infrequently utilized when managing intradural pathology, it permitted aggressive bone removal in order to create an unobstructed ventrolateral corridor to the tumor. This allowed us to perform generous durotomies spanning the length of each lesion and obviated the need for spinal cord manipulation during tumor resection. The patient provided informed consent for the surgery and video recording, and institutional review board approval was determined to be unnecessary.

Unilateral Percutaneous Vertebroplasty For Osteoporotic Lumbar Compression Fractures: A Comparative Study Between Transverse Process Root-Pedicle Approach And Conventional Transpedicular Approach

Purpose: Percutaneous Vertebroplasty (PVP) is a routine operation for the treatment of osteoporotic lumbar compression fracture (OLCF). Because of bilateral puncture takes a long operation time and patients receive more X-ray irradiation, more and more scholars deem that the unilateral approach should be adopted. But, with conventional transpedicular approach (CTPA), the cement may asymmetrically dispersed, so some surgeons use the transverse process root-pedicle approach (TPRPA). The objective of this study is to compare the clinical results and bone cement distribution of PVP for OLCF with unilateral TPRPA and CTPA, determine the advantages and disadvantages of the two surgical options.Patients and methods: From January 2016 to June 2019, seventy-two elderly patients who underwent unilateral PVP for single-level OLCF were retrospectively reviewed. Operation time, injection amount and distribution type of bone cement, and bone cement leakage and surgical complication were recorded. The visual analogue scale (VAS) scores and Oswestry disability index (ODI) scores were used to evaluate the clinical results. All patients were followed up for at more than 12 months and the assessment was based primarily on clinical and radiological outcomes.Results: There were significant difference in the surgical time, the volume and distribution type of bone cement between the two groups. But, there was no statistical difference in bone cement leakage. Moreover, there were no significant differences in VAS and ODI between the two groups at 2 days and 12 months after operation.Conclusion: Unilateral TPRPA and CTPA are practical and feasible methods in PVP for treatment of OLCF, with similar clinical effects. However, TPRPA has the advantages of fair distribution of bone cement and short operation time, without increasing the rate of bone cement leakage.