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.

Posterior vertebral column resection as a safe procedure leading to solid bone fusion in metastatic epidural spinal cord compression

OBJECTIVE Cancer is one of the leading causes of death and greatly decreases a patient’s quality of life. Vertebral metastases often lead to epidural spinal cord compression (ESCC) requiring surgical therapy. It has previously been shown that in patients with metastatic ESCC (MESCC), a surgical intervention leads to an improved outcome. Although the treatment paradigms in spinal metastases have changed and separation surgery followed by stereotactic radiosurgery is considered the best strategy, there are still cases in which 360° decompression with stabilization is indicated. In these patients, a proper bone fusion should be the treatment goal to guarantee good clinical results in extended survival times through progressions in oncological therapies. The aim of this study was to examine the safety and feasibility of posterior vertebral column resection (pVCR) in everyday clinical practice, achievement of bone fusion, and midterm outcome in patients with MESCC. METHODS All patients treated with pVCR due to MESCC between 2013 and 2020 were enrolled in this observational single-center study. Demographics, outcome parameters, numeric rating scale (NRS) score, Frankel grade, and Karnofsky Performance Scale (KPS) score were evaluated. Radiological images routinely acquired during follow-up were reviewed and screened for the presence of bone fusion. RESULTS Sixty-six patients were treated by eight surgeons. The mean follow-up period was 549 ± 739 days. At baseline, the average age was 64.4 ± 10.9 years. Reported NRS scores (preoperative 6.2 ± 1.7 vs postoperative 3.4 ± 1.6) and segmental kyphosis as measured on sagittal CT images (preoperative 13.5° ± 8.6° vs postoperative 3.8° ± 5.4°) decreased significantly (p < 0.001). In only 2 patients (3%), the Frankel grade worsened postoperatively, whereas in 12 patients (18.2%) an improvement was documented. The KPS score remained constant during the observation period (preoperative 73.2% ± 18.2% vs 78.3% ± 18% at last follow-up). Bone fusion was observed in 26 patients (86.7%) receiving CT more than 100 days after the index surgery. CONCLUSIONS pVCR is a reliable surgical technique in daily clinical practice, which proves to be beneficial in terms of short- as well as midterm outcome, as judged by the KPS and NRS. The overall improvement in the Frankel grade shows patient safety. A bone fusion was observed regularly in oncological patients undergoing pVCR. The authors therefore conclude that pVCR is a safe, fast, and efficient strategy to achieve stability and pain relief by achievement of bone fusion in cancer patients.

Management and Mid-Term Outcome After “Real SCIWORA” in Children and Adolescents

Study Design: Retrospective analysis. Objective: The SCIWORA Syndrome (Spinal Cord Injury Without Radiographic Abnormalities) is a rare but potentially severe injury with a peak in childhood and adolescence. With a better understanding of injury patterns and advances in MRI, there is ongoing discussion regarding the “Real SCIWORA” syndrome, a clinical picture of neurologic deficits on clinical examination but absence of radiographic pathologies even on MRI. The purpose of this study was to evaluate mid-term clinical outcome and the psychological impact of the “Real SCIWORA.” Methods: In this retrospective analysis, we evaluated 32 patients treated for “Real SCIWORA” between 2007-2019. Inclusion criteria were: neurologic deficit after trauma, no other cerebral or skeletal injury and a lack of pathological findings in spinal MRI. All patients were followed until complete recovery from initial symptoms. 25/32 patients were re-evaluated after 6.9 years (1-14 years) using the Oswestry Disability Index, the Frankel Score, the EQ-5D score, and the Breslau Short Screening Scale for PTSD. Results: Initial neurologic presentation ranged from Frankel Grade A-D. All patients recovered neurologically during 1-13 days to a Frankel Grade E. The analysis of HR-QoL revealed no difference between the cohort of SCIWORA patients and the German population norm, Oswestry Disability Index showed only minimal disabilities. 4/25 patients showed signs of PTSD. Conclusions: The “Real SCIWORA” syndrome is a diagnosis per exclusionem requiring a full spinal MRI to ensure exclusion of structural and potentially serious reasons of the neurologic impairment. Further clinical re-evaluation, psychological support seems to be essential. Level of Evidence: IV—retrospective study.

Long-Segmental Posterior Fusion Combined With Vertebroplasty and Wiring: Alternative Surgical Technique for Kummell’s Disease With Neurologic Deficits-A Retrospective Case Series

Purpose: Various surgical methods have been reported for Kummell’s disease with neurologic deficits. The aim of this study was to introduce long-segmental posterior fusion (LPF) combined with vertebroplasty (VP) and wiring as an alternative surgical technique. Material and Methods: We retrospectively analyzed 10 patients undergoing posterior decompression and LPF combined with VP and wiring for Kummell’s disease with neurologic deficits from January 2011 to December 2014. The radiologic outcomes included the local kyphotic angle (LKA) and segmental kyphotic angle (SKA). Clinical outcomes, including the visual analog scale (VAS), the Oswestry Disability Index (ODI) and the Frankel grade were assessed. Surgery-related complications were also evaluated. Results: The mean age of the included patients was 77 ± 8 years with a mean follow-up period of 31.4 ± 4.9 months and a mean bone mineral density of −3.5 ± 0.7 (T-score). The mean operation time was 220 ± 32.3 minutes with a mean blood loss of 555 ± 125.7 mL. The preoperative LKA and SKA were significantly corrected postoperatively (37.9 ± 8.7° vs. 15.3 ± 5.3°, p = 0.005 for LKA; 21.3 ± 5.1° vs. 7.6 ± 2.8°, p = 0.005 for SKA) without a loss of correction at the last follow-up. The VAS and ODI were also significantly improved (7.7 ± 1.1 vs. 3.0 ± 1.6, p = 0.007 for VAS; 90.3 ± 8.9 vs. 49.6 ± 22.7, p = 0.007 for ODI). The Frankel grade of all patients was improved by at least 1 or 2 grades at the last follow-up. Surgery-related complications such as intraoperative cement leakage and implant loosening during the follow-up were not observed. Conclusions: LPF combined with VP and wiring might be an effective surgical option for Kummell’s disease with neurologic deficits, especially for the elderly patients with morbidities. Level of Evidence: level IV.

Strategies for posterior-only minimally invasive surgery in thoracolumbar metastatic epidural spinal cord compression

Background: Metastatic epidural spinal cord compression (MESCC) is a debilitating sequela of cancer. Here, we evaluated various subtypes of posterior-only minimally invasive spinal (MIS) procedures utilized to address different cancers. Methods: Within this retrospective review, we analyzed the treatment of thoracolumbar MESCC treated with three MIS techniques: decompression and fusion (Subgroup A), partial corpectomy (Subgroup B), and full corpectomy (Subgroup C). Results: There were 51 patients included in the study; they averaged 58.7 years of age, and 51% were females. Most tumors were in the thoracic spine (51%). The average preoperative Frankel grade was D (62.7%); 69% (35) improved postoperatively. The patients were divided as follows: subgroup A (15 patients = 29.4%), B (19 patients = 37.3%), and C (17 patients = 33.3%). The length of hospitalization was similar (~5.4 days) for all groups. The overall complication rate was 31%, while blood loss was lower in Subgroups A and B versus C. Conclusion: Different MIS surgical techniques were utilized in patients with thoracic and/or lumbar MESCC. Interestingly, clinical outcomes were similar between MIS subgroups, in this study, with a trend toward higher complications and greater blood loss associated with those undergoing more aggressive MIS procedures (e.g., full corpectomy and fusion).

Recovery of Long Standing Neurological Deficit in Pediatric Dorsal Spinal Tuberculosis: A Single Center Experience of 13 Cases

Study Design: Retrospective analysis of case series. Objective: The aim is to study the recovery of neurological deficit in pediatric spinal tuberculosis cases presenting to us more than 6 months after onset of motor weakness in lower limbs. Methods: This is a retrospective analysis of 13 consecutive patients of pediatric spinal tuberculosis presenting to us at least 6 months after the onset of neurologic deficit. All these patients underwent surgical intervention at our center and their neurological recovery was noted in terms of improvement in Frankel grading and spasticity improvement by modified Ashworth scale. All the patients were followed up to at least 18 months post op and final neurologic status was assessed at that time. Results: The mean age of the patients at presentation was 8.5 years. The mean duration of neurologic deficit at the time of presentation was 10.23 months (6-24 months). Seven patients had a Frankel grade B at presentation out of which 6 improved to Frankel grade D and one improved to Frankel C at final follow up. Out of the other 3 patients with Frankel A at presentation, 2 improved to Frankel grade D and 1 to Frankel grade C. The remaining 3 patients presented with Frankel grade C at presentation, 2 improved to Frankel D and one improved to Frankel E at the time of final follow up. Conclusion: Neurologic recovery in patients with neurological deficit is possible even in cases of long standing deficit more than 6 months and in some cases upto 24 months as shown in our study.

A clinical study regarding the outcomes of symptomatic spinal epidural haematoma after adult spinal deformity surgery

Symptomatic spinal epidural haematoma (SSEH) is a rare but serious postoperative complication. This study aimed to assess the prevalence, causes and treatment of SSEH after adult spinal deformity (ASD) surgery. The patients admitted from August 2012 till August 2016 were retrospectively reviewed using case notes. During these four years, 102 patients were admitted with adult spinal deformity, out of which 3 (2.9%) developed post-operative SSEH. The duration between surgery to onset of SSEH was 10-13 hours (average 11.7 hours) post-operatively. Three patients were treated by haematoma evacuation at 8.5-14 hour (average 11.4 hours) after the symptoms appeared. One patient had improved by 2 Frankel grades, and two patients had improved by1 Frankel grade at the last follow-up. The results concluded that post-operative SSEH occurred in 2.9% of ASD patients who underwent corrective spinal procedures. Improvement in neurological deficits can be achieved by early haematoma evacuation. Continuous.....

Multilevel Spinal Injury: Incidence, Distribution and Neurological Patterns

Introduction Fractures and dislocation of spine are serious injuries that most commonly occur in young people. Spinal injury at more than one level is not uncommon. Awareness of multilevel injury of the spine and associated neurological patterns is important for the proper initial management of the patient. MethodsThis was a prospective observational study carried out in Department of Orthopedics, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal from February 2012 to September 2013. Sixty cases of age group between 18 to 63 years of traumatic spinal injury were enrolled. Patients were examined clinically and radiographically. ResultsOut of 60 patients, multilevel spinal injury occurred in 26 (43.3%) patients; 10 (16.67%) had contiguous spinal injury and 16 (26.67%) had non-contiguous spinal injury. There were 5 type A pattern spinal injury. Contiguous spinal injury most commonly occurred at level L1/L2 (n=4, 40%) and most had Frankel grade E neurology (n=6, 60%) followed by Frankel grade D (n=2, 20%). Non-contiguous lesions most commonly occurred at thoracic spine and had Frankel grade E neurology in most cases (n=10, 16.67%) followed by grade B and C (n= 2, 2.33% each). ConclusionMultiple spinal injury was a common pattern of injury, which occurred in 26 (43.3%) patients out of 60 patients enrolled in our study. Multilevel spinal injury is common. We should be aware about its occurrence. We should evaluate for multilevel spinal injuries, so as not to miss them, especialy non-contiguous injuries, in the patients presenting with spinal injury.

A Nerve Sparing Procedure for Posterior Access Thoracolumbar Fracture Surgery

Background: Treatment of thoracolumbar fractures often requires surgery, but there is no consensus as to the preferred method. The results of a nuanced surgical procedure use a posterior approach and aimed at preserving the integrity of the neural elements. Methods: The files of 14 patients who underwent surgery for complex thoracolumbar fractures at a single tertiary hospital during a four-year period were reviewed. During a single-stage procedure, performed via a posterior approach, a titanium mesh cage was inserted into the vertebral cavity using a maneuver which protected the nerve roots. Outcome measures included neurological status, sagittal profile of the spine, spinal stability, height restoration and decompression. Results: Seven patients presented with Type A fractures according to the AOSpine classification, three of them with two simultaneous fractures. One patient suffered from a type B fracture and three patients from type C fractures. While most patients displayed a preserved neurological status, three were paraplegic on admission (Frankel grade A). The suggested procedure has allowed for direct canal decompression and has resulted in immediate stability and optimal height restitution. The spinal profile has also improved. Conclusion: The nerve sparing procedure offered considerable benefits to the patients. Additionally, the technique may be applied also to fractures above and below the T11-L2 segment, and to patients with Frankel grade A lesion.

Clinical efficacy of single intraoperative 500 mg methylprednisolone management therapy for thoracic myelopathy caused by ossification of the ligamentum flavum

Background: The objective of our study was to compare clinical outcome and postoperative complications between patients with thoracic myelopathy caused by ossification of the ligamentum flavum (OLF) treated with and without intraoperative methylprednisolone (MP).Methods: This retrospective study enrolled 101 patients who underwent posterior approach surgery for OLF and were followed up at least 1 year. Patients were divided into two groups according to MP use in the operation: MP group (n=47) and non-MP group (n=54). Clinical outcomes and complications were evaluated before and after operation and at the last follow-up. Results: Significant differences were found in modified Japanese Orthopedics Association (mJOA) scores and proportion of Frankel grade (A-C) between the two groups immediately after surgery and at 2-week follow-up. No significant differences were found between the two groups in mJOA score before operation and at the final follow-up. Moreover, no significant differences were observed in recovery rate according to mJOA score at any time points, and there was no significant difference in the proportion of Frankel grade (A-C) between the two groups at final follow-up. There were 13 documented infections: 10 in the MP group and 3 in the non-MP group (P=0.034).Conclusion: Management therapy with intraoperative 500 mg MP showed better recovery of nerve function within 2 weeks in patients with thoracic myelopathy caused by OLF compared with those did not receive MP. However, long-term follow-up results showed that there was no significant difference in neurological recovery between patients with intraoperative MP or not. Moreover, intraoperative MP increased the rate of wound infection.