Spinopelvic fixation: modern technical solutions

The paper presents the second part of literature review devoted to modern techniques of spinopelvic fixation for various pathologies of the spine and injuries to the spine and pelvis. The review is non-systematic and was conducted using PubMed and eLibrary databases of medical literature. Modern techniques of spinopelvic fixation using screws installed in the ilium are highlighted, including anatomical and biomechanical features, clinical results of application, as well as the implementation of spinopelvic fixation for tumor lesions of the sacrum, including the use of customized implants and additive technologies. The features of classical installation of iliac screws and installation by the S2AIS technique are considered, and their advantages and disadvantages and possible complications are evaluated.

Histomorphometric study of the soleus muscle under conditions of modeling of spinal cord contusion injury: experimental morphological study

Objective. To conduct a morphometric analysis of the soleus muscle of rats after moderate spinal cord contusion injury.Material and Methods. Experiments were performed on female Wistar rats aged 8–12 months, weighing 270–320 g. Animals of the experimental group (n = 25) underwent laminectomy at the T9 level under general anesthesia and modeling of spinal contusion injury of moderate severity. Intact rats constituted the control group (n = 10). Euthanasia was performed on the 5th, 15th, 30th, 60th, 90th, and 180th days of the experiment. Paraffin sections were stained with hematoxylin-eosin and Masson, the diameters of muscle fibers were determined by computer morphometry, and histograms of their distribution were obtained.Results. In the soleus muscle, the signs of reversible reparative processes prevailed in response to neurotrophic damage. It was evidenced by a local increase in the diversity of myocyte diameters and the loss of polygonality of their profiles, focal destruction of muscle fibers, activation of the connective tissue component, disorganization of some intramuscular nerve conductors, and vascular fibrosis of perimysium. Nevertheless, the histostructure of an intact muscle prevailed in the course of the experiment, which was confirmed by the data of morphometric analysis. All histograms of the distribution of the muscle fiber diameters are unimodal with a mode in the range of 30–41 μm. On the 180th day, the maximum myocyte diameters in the histogram of the left limb muscle belonged to the range of 21–30 μm, which was typical for histograms in the intact group.Conclusion. The nature of the plastic reorganization of the soleus muscle when neurotrophic control is impaired indicates compensatory regeneration of muscle tissue by the type of restitution, which opens up the possibility of predicting the rehabilitation period. It is advisable to take this into account when developing medical and social programs and therapeutic measures, where the most important role is played by superficial neuromuscular and functional electrical stimulation.

Enhanced recovery after surgery in pediatric spine surgery: systematic review

Objective. To conduct a systematic review of the literature on the use of enhanced recovery after surgery (ERAS) protocols in spinalsurgery of children and adolescents to determine the existing evidence of the effectiveness of ERAS implementation in clinical practice.Material and Methods. The authors conducted a systematic review of the literature on ERAS in spinal and spinal cord surgery in children and adolescents selected in the databases of medical literature and search resources of PUBMED/MEDLINE, Google Scholar, Cochrane Library and eLibrary according to the PRISMA guidelines and the PICOS inclusion and exclusion criteria.Results. A total of 12 publications containing information on the treatment of 2,145 children, whose average age was 14.0 years (from 7.2 to 16.1), were analyzed. In the reviewed publications, the average number of key elements of the ERAS program was 9 (from 2 to 20), and a total of 23 elements used in spinal surgery in children and adolescents were identified. The most commonly used elements were preoperative education and counseling, prevention of infectious complications and intestinal obstruction, multimodal analgesia, refusal of routine use of drains, nasogastric probes and urinary catheters, standardized anesthesia protocol, early mobilization and enteral loading. The introduction of the ERAS protocol into clinical practice allowed to reduce the complication rate in comparison with the control group by 8.2 %(from 2 to 19 %), the volume of blood loss by 230 ml (from 75 to 427 ml), the operation time by 83 minutes (from 23 to 144 minutes), theduration of hospitalization by 1.5 days (from 0.5 to 3 days) and the total cost of treatment by 2258.5 dollars (from 860 to 5280 dollars).The ERAS program was implemented in pediatric clinics in the USA (75 %), France (8 %) and Canada (17 %).Conclusion. The conducted systematic review of the literature allows us to conclude that the technology of enhanced recovery after surgery is a promising technology that improves surgical outcomes and is applicable in pediatric practice. There is a significant shortage of published studies evaluating the implementation of ERAS in pediatric surgical practice in general, and in spinal surgery in particular, which requires further prospective randomized studies to evaluate ERAS in spinal surgery in children and adolescents.

Recommendatory base for the delivery of specialized medical care to patients with spine and spinal cord injury in Russia: subject field review

Objective. To evaluate the composition and content of the recommendatory base for delivery of specialized medical care to patients with spine and spinal cord injury on the territory of the Russian Federation.Material and Methods. The published recommendations specifying the content of the diagnostic, therapeutic, rehabilitation and preventive components of the provision of medical care to patients with spine and spinal cord injury were reviewed. The search for information was carried out in the eLibrary.ru bibliographic resource, documents of the Ministry of Health of the Russian Federation, publications of specialized medical professional non-profit organizations, and other manuals. The depth of information selection was 18 years (since 2003). The review was prepared following the PRISMA-ScR and PRISMA-S guidelines.Results. The current Russian recommendatory base in the field under consideration includes articles in peer-reviewed scientific journals, practical guidelines, regulatory documents and eight clinical guidelines prepared by the Association of Traumatologists and Orthopedists of Russia and by the Association of Neurosurgeons of Russia approved or submitted for approval by the Ministry of Health. A significant degree of cross-use of information has been established, in general covering a wide range of diagnostic, therapeutic, rehabilitation and preventive issues.Conclusion. Most of the Russian recommendations on the provision of medical care to patients with spine and spinal cord injury do not have high strength, are not based on high-certainty evidence, are general in nature, especially in terms of diagnostic and therapeutic tactics, and are created without consideration of the medical care delivery setting. The methodology for their development is reported extremely poorly.

Actual concepts of classification, diagnosis and treatment of atlanto-occipital dislocations in adults: non-systematic literature review

Objective. To review the literature on atlanto-occipital dislocation (AOD) in adults to determine the optimal classification, diagnostic method and treatment.Material and Methods. A search was conducted in the PubMed database for the period from 1966 to 2020. The initial search revealed 564 abstracts of articles. A total of 95 studies were selected for a detailed study of the full text, of which 47 studies describing data from 130 patients were included in this review.Results. The paper describes all the available AOD classifications, and discusses their advantages and disadvantages. The clinical picture, features of the diagnosis in published observations of AOD in adults, as well as the applied treatment methods and their results are presented.Conclusion. Atlanto-occipital dislocation is one of the most severe types of injuries of the cervical spine in adults, which is accompanied by damage to the medulla oblongata and gross neurological deficit in 70 % of cases. The sensitivity of radiography for the diagnosis of AOD was 56.3 %. In 18.5 % of patients, its use led to untimely diagnosis and could cause subsequent deterioration. The CT sensitivity was 96.8 %. The most accurate method of AOD verification was to determine the atlanto-occipital interval (100 % sensitivity and specificity). The optimal method of treating victims with AOD is surgical one.

X-ray and CT scan predictors of damage to the posterior ligamentous complex in fractures of the vertebral bodies of the thoracolumbar junction: systematic review and meta-analysis

Objective of the review was to identify, basing on literature data, the most reliable X-ray and CT signs of damage to the posterior ligamentous complex (PLC) in fractures of the vertebral bodies of the thoracolumbar junction, initially interpreted as type A according to the AOSpine classification. The systematic review was carried out according to the recommendations of PRISMA. The search in PubMed, MEDLINE and Cochrane Library databases revealed 491 articles on relevant issues. Once the inclusion and exclusion criteria have been met, 7 original articles from peer-reviewed scientific journals for the last 10 years were selected for a systematic review, 6 of which were included in the meta-analysis. In all articles, the authors identified two groups of patients: with and without damage to the PLC. The PLC damages were confirmed by MRI and intraoperatively. Radiographic and CT spondylometric parameters were identified, which had statistically significant differences between the groups. To determine predictors of PLC damage, the values of these parameters were subjected to regression analysis. This was followed by a meta-analysis of random and fixed effects models depending on the homogeneity of the data. Statistical heterogeneity was assessed using the X-square test with the null hypothesis of the absence of significant differences in all studies, as well as the heterogeneity index – I2. For the graphical display of the results, forest plots were built. Local kyphosis angle >25°, Cobb angle >16° and difference between interspinous distances >2.54 mm are CT scan predictors of PLC damage. The parameters characterizing the interspinous relationship were studied in no more than two studies, but at the same time they always had statistically significant differences between the groups with and without PLC injuries, therefore, they cannot be ignored during diagnosis. Anterior/posterior vertebral height ratio, anterior vertebral height ratio, sagittal index and suprajacent/subjacent parameters are not the predictors of PLC damage.

Factors influencing the development of recurrence and continued growth of primary extramedullary tumors removed using Nd:YAG laser

Objective. To assess the significance of clinical factors of extramedullary tumors and new methods of their resection as potential predictors of their recurrence and continued growth.Material and Methods. The long-term results of removal of primary extramedullary tumors in 412 patients operated on in 1998–2014 were analyzed comparing the use of standard methods of microsurgical technique for tumor removal (277 patients) and of those with additional use of neodymium laser radiation (135 patients).Results. The use of laser technologies for resection of extramedullary tumors can significantly reduce the number of their recurrences and continued growth, along with other clinical factors is a significant prognostic indicator in determining the nature of the disease course and can be a predictor of their occurrence. The most reliable clinical factors determining the prognosis of a decrease in the incidence of recurrences and continued growth when using laser techniques of surgical resection were repeated operations (p = 0.002), the presence of ependymomas of the cone and cauda equina (p = 0.017), operations for primary tumors in the thoracic spine (p = 0.039) and extramedullary tumors with Grade I anaplasia (p = 0.007). An increase in the number of these conditions was associated with operations on the cervical spine (p = 0.027), the presence of a tumor with Grade II anaplasia (p = 0.007), and a primary extramedullary tumor involving more than three vertebrae (p = 0.017).Conclusion. The use of the laser is indicated for reoperations when removing neoplasms, that have arisen as a result of recurrence or continued growth of extramedullary tumors of any level and length after removal of primary neoplasms with a Grade I malignancy confirmed by intraoperative cytological examination involving no more than three vertebrae in the thoracic, lumbar and sacral spine and during resection of ependymomas with extramedullary growth.

The role of denosumab in the complex treatment of giant cell tumor of the spine: reducing of local recurrence rate, surgery time and blood loss

Objective. To assess the effect of the combined treatment method including preoperative denosumab therapy on the results of treatment of patients with giant cell tumors of the spine.Material and Methods. A single-center retrospective-prospective study of a series of clinical cases included 15 patients with giant cell tumors of vertebrae. The average follow-up period was 56 months. A total of 11 patients received denosumab therapy according to the following scheme: 120 mg subcutaneously on the 1st, 8th, 15th and 28th days of the first month and then once every 28 days. Surgical options included marginal resection, segmental resection, or en-bloc resection with or without spinal reconstruction/stabilization. In the case of locally advanced and inoperable disease, long-term therapy with denosumab was carried out until the disease progressed or serious adverse events appeared.Results. Thoracic vertebrae were involved in 7 (46.6 %) of 15 cases, lumbar in 4 (26.7 %) and cervical in 4 (26.7 %). Local recurrence rate after surgery alone was 40 % (2/5), average time to recurrence onset was 4.5 months. No relapses were observed after combined treatment performed in four patients. Disease progression during long-term denosumab therapy for inoperable disease recurrence was not recorded (0/7). The average number of denosumab injections before surgery and during long-term therapy was 15 and 24 injections, respectively. Denosumab therapy allows reducing the duration of surgery and the volume of blood loss.Conclusion. Combined therapy of giant cell vertebral tumor allows to reduce the risk of recurrence of the disease, as well as to reduce surgery duration and blood loss. Long-term continuous therapy for inoperable cases allows achieving long-term stabilization of the effect. Due to the rarity of giant cell tumors of the spine, a further prospective recruitment of patients is required to study the efficacy and safety of combined therapies.

Scheuermann’s disease surgery. Major problems: non-systematic literature review (part II)

Objective. To analyze literature data on the frequency of junctional kyphosis in surgery for Scheuermann’s disease, its relationship withspinopelvic parameters, risk factors and prevention of its development.Material and Methods. A search for sources in Scopus and Web of Science databases revealed 62 articles published from 1975 to 2021 and containing the required information. Of these, 56 publications meet the inclusion criteria.Results. The selected 56 articles contain data on 2,110 patients. In total, 247 (11.8 %) cases of proximal junctional kyphosis were diagnosed, including 6 (0.3 %) cases of proximal junctional failure. The total number of distal junctional kyphosis cases was 124 (5.9 %). Forty-five reoperations were performed. Many potential risk factors have been identified in publications, but there is no consensus on any of them.As a result, there is no a well-founded common position on the prevention of junctional kyphosis development. Spinopelvic parameters in Scheuermann’s disease are significantly less than those in the general population and do not tend to change after surgical correction of kyphosis. As for their relationship with the risk of development of proximal and distal junctional kyphosis, there is no consensus to date.Conclusion. This review is the largest in terms of coverage of literary sources on the problem of the development of junctional kyphosis in surgery for Scheuermann’s disease. The causes for the development of this complication remain unknown, hence there is the lack of generally accepted methods of prevention. New studies with long postoperative follow-up are needed.

Chronic infectious lesions of the cervical spine in adults: monocentric cohort analysis and literature review

Objective. To analyze the results of surgical treatment of chronic infectious cervical spondylitis and literature data.Material and Methods. Design: retrospective monocentric cohort study for 2017–2020. The study included medical history and clinical and instrumental data of 25 patients who underwent 28 reconstructive surgeries on the suboccipital (n1 = 3) and subaxial (n2 = 25) spine. The average follow-up period was 1 year 2 months ± 4 months. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 22.0.Results. The effect of the duration of the therapeutic pause (p = 0.043) and the T1 slope (T1S) (p = 0.022) on the intensity of vertebrogenic pain syndrome was established. When assessing the parameters of the sagittal balance a direct relationship between the age of patients and the value of cervical sagittal vertical axis (CSVA) (p = 0.035) was revealed, while CSVA (p = 0.514) and neck tilt angle (NTA) (p = 0.617) did not significantly affect the intensity of vertebral pain syndrome. The extent of vertebral destruction did not affect either the intensity of vertebral pain (p = 0.872) or the indices of the sagittal balance: CSVA (p = 0.116), T1S (p = 0.154), and NTA (p = 0.562). A significant predictor of postoperative complications is the level of comorbidity with an index of 7 or more (p = 0.027) according to the Charlson scale.Conclusion. The leading predictors of complications of surgical treatment of cervical infectious spondylitis are the Charlson comorbidity index (7 points or more) and the variant of anterior reconstruction (the use of a blocked extraspinal plate). The factors influencing the intensity of vertebrogenic pain syndrome in this pathology are the duration of the therapeutic pause and the magnitude of T1S compensation. Anterior reconstruction of the cervical spine in the presence of infectious spondylitis provides a correction of the sagittal balance parameters, with the possibility of long-term maintaining the achieved values.