Posterior resection of sacral osteosarcoma utilizing cement-infused chest tube interbody reconstruction and lumbopelvic fusion

Background: Primary osteosarcoma (OS) of the spine is very rare. En bloc resection of spinal OS is challenging due to anatomical constraints. Surgical planning must balance the benefits of en bloc resection with its potential risks of causing a significant neurological deficit. In this case, we successfully performed a posterior-only approach for decompression with S1 reconstruction via a cement-infused chest tube interbody device, along with a navigated L4 to pelvis fusion. Case Description: A 49-year-old female presented with a primary sacral OS. Computed tomography (CT) and magnetic resonance (MR) imaging revealed an S1 lytic vertebral body lesion with severe stenosis and progressive L5 on S1 anterior subluxation. Surgical decompression with tumor resection and S1 corpectomy with S1 reconstruction via a cement-infused 32-French chest tube interbody device accompanied by L4 -pelvis fusion utilizing S2-alar-iliac screws was completed. 6 months postoperatively, the patient continues to have significant pain relief and the instrumentation remains intact. Conclusion: A 49-year-old female with an S1 OS successfully underwent a posterior-only approach that included an S1 corpectomy with anterior column reconstruction via a cement-infused chest tube interbody plus a navigated L4 to pelvis fusion.

Biportal endoscopic posterior lumbar decompression and vertebroplasty for extremely elderly patients affected by lower lumbar delayed vertebral collapse with lumbosacral radiculopathy

Background Lower lumbar osteoporotic vertebral compression fracture in extremely elderly patients can often lead to lumbosacral radiculopathy (LSR) due to delayed vertebral collapse (DVC). Surgical intervention requires posterior instrumented lumbar fusion as well as vertebral augmentation or anterior column reconstruction depending on the cleft formation and intravertebral instability. However, it is necessary to decide on surgery in consideration of the patient’s frail status, surgical invasiveness, and rehabilitation. In the lower lumbar DVC without intravertebral instability, biportal endoscopic posterior lumbar decompression and vertebroplasty (BEPLD + VP) can be simultaneously attempted. This study aimed to assess the clinical outcomes of BEPLD + VP for the treatment of DVC-related LSR. Methods This retrospective case series enrolled 18 consecutive extremely elderly (aged ≥ 75-year-old) patients (6 men and 12 women) who had lower lumbar (at or below L3) DVC-related LSR. Patients who require anterior column reconstruction, such as cleft formation accompanied by intravertebral instability and patients who have not been followed for more than 6 months, were excluded from this study. All patients underwent BEPLD + VP under epidural anesthesia. Clinical results were evaluated by the visual analog scale (VAS) score and the modified Japanese Orthopedic Association (mJOA) scores. Results Most of the patients had DVC affecting level L4, with the deformation being a flat type or concave type rather than a wedge type. The VAS score (back and leg) significantly decreased from 7.78 ± 1.17 and 6.89 ± 1.13 preoperatively to 2.94 ± 0.64 and 2.67 ± 1.08 within 2 postoperative days (p < 0.001). The mJOA score significantly improved from 4.72 ± 1.27 preoperatively to 8.17 ± 1.15 in the final follow-up (p < 0.001). The mean recovery rate (RR) in the last follow-up was 56.07% ± 9.98. Incidental durotomy was reported in two patients and epidural hematomas in another two patients; however, all patients improved with conservative treatment, and no re-operation was required. Conclusions BELPD + VP was a type of salvage therapy that reduces surgical morbidity, requires major spine surgery under general anesthesia and provides good clinical outcomes in extremely elderly patients with DVC-related LSR.

Biportal endoscopic posterior lumbar decompression and vertebroplasty for extremely elderly patients affected by lower lumbar delayed vertebral collapse with lumbosacral radiculopathy

Background: Lower lumbar osteoporotic vertebral compression fracture in extremely elderly patients can often lead to lumbosacral radiculopathy (LSR) due to delayed vertebral collapse (DVC). Surgical intervention requires posterior instrumented lumbar fusion as well as vertebral augmentation or anterior column reconstruction depending on the cleft formation and intravertebral instability. However, it is necessary to decide surgery in consideration of the patient’s frail status, surgical invasiveness, and rehabilitation. In the lower lumbar DVC without intravertebral instability, biportal endoscopic posterior lumbar decompression and vertebroplasty (BEPLD+VP) can be simultaneously attempted. In particular, in high-risk elderly patients, BEPLD+VP can be performed under regional anesthesia, can reduce the need for spinal fusion, and can provide good clinical results such as rapid functional recovery. This study aimed to assess clinical outcomes of BEPLD+VP for the treatment of DVC-related LSR. Methods: This retrospective case series enrolled 18 consecutive extremely elderly (aged ≥ 75-year-old) patients (6 men and 12 women) who had lower lumbar (at or below L3) DVC-related LSR. Patients who require anterior column reconstruction, such as cleft formation accompanied by intravertebral instability, and patients who have not been followed for more than 6 months were excluded from this study. All patients underwent BEPLD+VP under epidural anesthesia. Clinical results were evaluated by the visual analog scale (VAS) score and the modified Japanese Orthopedic Association (mJOA) scores. Results: Most of the patients had DVC affecting level L4, with the deformation being flat type or concave type rather than wedge type. The VAS score decreased from 8.1 preoperatively to 3.1 postoperatively (p<0.001). The mJOA score significantly improved from 4.72 ± 1.27 preoperatively to 8.17 ± 1.15 in the final follow-up (p<0.001). The mean RR in the last follow-up was 56.07% ± 9.98. Incidental durotomy was reported in two patients and epidural hematomas in another two patients; however, all patients improved with conservative treatment and no re-operation was required.Conclusions: BELPD+VP was a type of salvage therapy that reduces surgical morbidity, requires major spine surgery under general anesthesia, and provides good clinical outcomes in extremely elderly patients with DVC-related LSR.

Technical nuances of a posterior-only L5 vertebrectomy with anterior column reconstruction

Background: Burst fractures involving the L5 vertebra are quite rare . They can be managed with anterior, posterior, or combined 360 approaches. Here, we report a 25-year-old female who presented with a traumatic cauda equina syndrome attributed to an L5 burst fracture following a motor vehicle accident, and who did well after a posterior-only decompression/fusion. Case Description: A 25-year-old female presented with a traumatic cauda equina syndrome attributed to an L5 burst fracture following a motor vehicle accident. She was treated with a posterior-only vertebrectomy and followed for 5 postoperative months. During this time, she experienced complete resolution of her preoperative neurological deficit and demonstrated radiographically confirmed spinal stability. Conclusion: One of the major pros for the all-posterior L5 corpectomy as in this case, was that the patient underwent a successful single-stage, single-position operation. However, the posterior-only L5 corpectomy approach is technically demanding, and only allows for the placement of a lower profile interbody cage.

Factors influencing the pedicle screw fixation stability in patients with unstable lumbar and thoracolumbar spine injuries

Background. One of the reasons for the lack of standardized approaches for treatment of lumbar and thoracolumbar spine traumatic injuries is inconclusive information on relative contribution of various factors to pedicle screw fixation stability.Objective. To determine risk factors that influence pedicle screw fixation stability in patients with unstable traumatic injuries of a lumbar spine and thoracolumbar junction.Material and methods. This was a retrospective evaluation of 192 spinal instrumentations. Patients with type А3, A4, B1, B2 and C injuries of lumbar and thoracolumbar spine were enrolled. Pedicle screw fixation was used either as a stand-alone technique or in combination with anterior column reconstruction. If required, decompression of nerve roots and spinal cord was performed. Cases with pedicle screw fixation failure were registered. Logistic regression analysis was used to assess predictive significance of potential risk factors. Results. Complication rate growth was associated with a decrease in bone radiodensity, posterior decompression extensiveness, lumbosacral fixation and residual kyphotic deformity. Anterior column reconstruction and additional pedicle screw installation led to a decline in complication rate while anterior decompression and fixation length did not influence fixation stability. Conclusion. In most cases, pedicle screw fixation system failure is associated with altered bone quality; however, surgical approach may also impact complication rate and should be taken into account planning surgical intervention. Anterior column reconstruction and additional pedicle screw installation are associated with the decline in complication rate; the influence of those options is comparable. Anterior decompression does not influence pedicle screw fixation stability; consequently, it is preferable in cases with considerable risk of pedicle screw fixation failure.

Short Segment versus Long Segment Posterior Pedicle Screws Fixation for Treatment of Thoracolumbar Burst Fracture: A Comparative Prospective Study

Background: The surgical treatment of unstable burst fracture (TLICS >4) of the thoracolumbar vertebrae remain controversial. This study is aimed to compare the short segment versus long-segment posterior fixation for thoracolumbar burst fracture.The objective of the study is to study comparison of outcome of the Short-Segment Posterior Fixation (SSPF) versus Long-Segment Posterior Fixation (LSPF) for treatment of thoracolumbar burst fracture in term of surgical, radiological, neurological and functional outcome. Subjects & Methods: In this prospective study, we included 32 patients with Burst fracture AO type A3, A4 of Thoracolumbar spine (T10-L2), who underwent posterior pedicle screw fixation for Burst fracture Thoracolumbar spine. A total of 18 of the patients underwent Short-Segment Posterior Fixation (SSPF) (Group A); group A is further divided into three subgroups A1: short-segment only(n=10), A2: short-segment with index screw(n=4) and A3: short-segment with anterior column reconstruction(n=4) with cage, Whereas 14 patients had Long-Segment Posterior Fixation (LSPF) (Group B). Surgical (duration of surgery, blood loss, complication), Clinical (Oswestry questionnaire, spinal cord independent measuring scale), radiological (percentage of anterior body height compression, kyphosis correction loss, Mc Cormack classification) and Neurological (Frankel grading) outcomes were analyzed. Results: The operative time Group A (159.85 min 22.5) was significantly shorter than Group B (198.7 31.5). Blood loss was significantly less in Group A (478 ml 259.3) than Group B (865ml 275.7). Kyphosis Correction loss at 6th month follow up in Group A (subgroup A1: 10.7deg 6.2, subgroup A2: 7.1deg 7.4 and subgroup A3: Subgroup A3: 6.1deg 5.2) was higher than that of group B (6.2deg 6.3). Complication (surgical site infection) occurred in Two patients in group B. There was no significant difference in terms of improvement in functional and neurological outcomes among both groups. The functional outcomes as per the SCIM and ODI score at 6th month follow up in group A: 74.7 +-22.29, 31.5+-13.73 respectively, and group B: 73.8+-26.07, 26.7+-17.9, respectively. Conclusion: Short-Segment Posterior Fixation (SSPF) is a significantly decreased duration of surgery and blood loss compare with Long-Segment Posterior Fixation (LSPF). Loss of kyphosis correction in Short-Segment Posterior Fixation (SSPF) may be decreased with index screws or anterior column reconstruction.

Radiographic Features Associated With Increased Surgical Invasiveness in Pyogenic Vertebral Column Osteomyelitis

Study Design: Single center retrospective cohort study. Objectives: Assess the association between well-known radiographic features for spinal instability from the Spinal Instability in Neoplasia Score (SINS) and surgical invasiveness in treating vertebral column osteomyelitis (VCO). This will potentially help surgeons in surgical planning and aid in developing a pathology specific score. Methods: Patients with VCO were identified from hospital coding. On preoperative computed tomography radiographic features, including spinal alignment, vertebral body collapse, location, type of bone lesion, and posterolateral involvement were assessed and scored 0 (stable) to 15 (highly unstable). Surgical invasiveness was graded as 0 = no surgery, 1 = decompression alone, 2 = shortening or posterior stabilization, or 3 = anterior column reconstruction. Results: A total of 41 patients were included. The mean age of the cohort was 63.3 years (SD 12.0) with male comprising 78%. The mean total radiographic score for the nonsurgical group was 6.39 (3.14) and for the surgical group 10.38 (3.06), P < .001. Spinal alignment, vertebral body collapse, type of bone lesion, and posterolateral involvement correlated with surgical invasiveness (all Ps < .05). Subgroup comparison following analysis of variance showed that only spinal alignment was significantly different between groups 2 and 3. Conclusions: Our findings show correlation of the radiographic components of the SINS with surgical invasiveness in management of pyogenic VCO—these findings should aid development of an “instability score” in pyogenic VCO. While most radiographic features assessed correlated with surgical invasiveness spinal alignment appears to be the key feature in determining the need for more invasive surgery.