Journal of spine surgery最新文献

Background: Giant, calcified disc herniation is a rare type of intervertebral disc calcification and herniation where a large calcified, herniated disc occupies more than 40% of the spinal canal. Cases of giant, calcified disc herniations have been reported primarily in the thoracic spine in adults. They are associated with more symptomatic disc disease and can pose surgical challenges. However, little is known about their occurrence in the lumbar spine, especially in association with prior spine surgeries. The aim of this case report is to describe clinical findings and management of rare, giant, calcified disc herniation presenting as adjacent level degeneration in the lumbar spine.

Case description: A 75-year-old man with several previous lumbar spine surgeries, including posterior instrumented fusion at L3-S1, presented with a 5-week history of progressive bilateral lower extremity weakness. Lumbar spine magnetic resonance imaging (MRI) and computed tomography (CT) revealed a large, calcified intraspinal mass in the right paracentral region at L2-L3, adjacent to the prior surgical levels. It resulted in severe narrowing of the right lateral recess. This lesion was new when compared to the lumbar spine MRI performed 6 months prior. The lesion was surgically resected without complications, and the pathology revealed a degenerating disc with bone fragments and calcifications.

Conclusions: This case demonstrates an unusual presentation of a giant, calcified disc herniation in the lumbar spine as a component of adjacent segment degeneration in a patient with prior lumbar spine surgeries. The case illustrates the dynamic nature of intervertebral disc herniations and calcifications as well as management considerations.

Background: Low back pain (LBP) is one of the most prevalent global health issues, often attributed to degenerative lumbar conditions. However, it can occasionally obscure more serious pathologies such as spinal tumors. Conus medullaris syndrome (CMS), a rare and frequently underrecognized cause of chronic LBP, illustrates the consequences of delayed diagnosis and underscores the need for systemic improvements in early detection.

Case description: We present a 48-year-old female with a long-standing history of presumed mechanical LBP, whose progressive neurological decline was initially misattributed to autoimmune comorbidities. Thoracic magnetic resonance imaging (MRI) ultimately revealed an intradural extramedullary tumor at T11-T12, confirmed intraoperatively as a schwannoma. Surgical resection led to restored ambulation within 3 months, with sustained neurological recovery and no recurrence at three years, apart from mild residual urinary symptoms.

Conclusions: This case highlights the diagnostic complexity of CMS and the importance of early thoracic imaging in patients with atypical or progressive symptoms. Broader implementation of subsidized imaging, standardized referral systems, and provider education can reduce diagnostic delays and improve outcomes, especially in resource-constrained environments. International collaboration is essential to enhance equity in the diagnosis and management of rare spinal tumors.

Background and objective: The Scoliosis Research Society-22 revised questionnaire (SRS-22r) is the most widely used patient-reported outcome measure (PROM) to evaluate health-related quality of life (HRQL) for patients with adolescent idiopathic scoliosis (AIS). Here, we seek to critically appraise the development process and psychometric properties of the SRS-22r.

Methods: We evaluated the item generation, item reduction, sensibility and measurement properties including reliability, validity and responsiveness of the SRS-22r. To accomplish this, we examined available literature describing psychometric properties of the SRS-22r and summarized the findings in a narrative review format.

Key content and findings: The SRS-22r represents a multi-dimensional outcome measure that demonstrates generally appropriate responsiveness to outcomes after surgical AIS deformity correction. Despite its strengths, several limitations were identified, including (I) absence of a conceptual framework for HRQL in AIS; (II) lack of direct patient involvement during development of the instrument; (III) minimal evidence of evaluation of the interpretation, appropriateness and importance, comprehensiveness of the items by adolescents; and (IV) the inclusion of a satisfaction with treatment (surgery) domain within a HRQL instrument. Though the SRS-22r is responsive to change after surgical intervention, its ability to discriminate between mild and moderate scoliosis remains limited.

Conclusions: Our findings characterize the strengths and limitations of the SRS-22r. An ideal AIS HRQL measure should be guided by a conceptual framework informed by, and aligned with the priorities and goals of adolescents with idiopathic scoliosis based on their lived experience, complemented by parental perspectives and input from clinician experts with an understanding AIS management.

Background: The current case study identifies an alternative use of the ProAxis® Table by Mizuho | OSI (ProAxis) during thoracic cord decompression prior to final stabilization. We present two cases of thoracic cord compression with progressive neurologic decline associated with patient positioning during advanced imaging acquisition and intraoperatively, with a solution to intraoperative neurologic deterioration.

Case description: Case 1: a 59-year-old female with history of T11-pelvis posterior instrumented fusion for deformity presented with adjacent segment disease, excessive segmental kyphosis, and herniated disc at T10-T11. The patient reported severe midback pain and progressive neurologic deterioration with weakness in bilateral lower extremities (BLE). The patient was indicated for thoracic decompression and fusion extension. Preoperative somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) were intact. Upon prone positioning on an open Jackson frame, SSEPs were lost in BLE. A Stagnara Wake Up test with the patient positioned in flexion on the hospital stretcher confirmed acute neurologic injury with rapid functional recovery. The patient was ultimately treated with thoracic laminectomy, T9-T11, and extension of fusion to T4 on a ProAxis with decompression performed in 28-degrees flexion and subsequent table flattening to neutral over the course of the procedure. No neuromonitoring abnormalities were identified. The patient awoke with full motor strength. Case 2: a 68-year-old male with history of metastatic prostate cancer presented with high grade epidural spinal cord compression resulting from metastatic tumor to T6-T7 with acute American Spinal Injury Association (ASIA) B neurologic grade after a fall from standing height. The patient was indicated for emergent thoracic decompression and fusion. Upon advanced imaging acquisition, the patients' neurologic function further deteriorated. Intraoperatively the patient was positioned prone in flexion on a ProAxis at baseline 20-degrees thoracic kyphosis. No neuromonitoring changes were appreciated throughout the procedure. The patient's motor strength improved throughout his hospitalization with near full motor strength recovery in his BLE at final follow-up.

Conclusions: We present two cases in which the ProAxis was used to maintain patient alignment during thoracic decompression at a degree associated with preoperative neurologic function with resultant restoration of neurologic function in the postoperative period.

Background: Degenerative spondylolisthesis is a condition characterized by back pain and radiculopathy due to nerve root impingement caused by misalignment of adjacent vertebral bodies. Surgical intervention with interbody fusions has been shown to have better outcomes than non-surgical approaches. Traditionally, static implants have been used to aid in arthrodesis of the unstable joint. A recent development in interbody fusion procedures is the use of expandable interbody devices which can expand bidirectionally to conform to endplate irregularities. This allows the spine to decompress naturally to fit each patient's unique anatomy, restoring spinal alignment and reducing spondylolisthesis in an individualized manner. Previous expandable interbody devices were regarded as inferior to their static counterparts due to high rates of non-union. The emergence of newer expandable implants that use a polyester mesh composed of polyethylene terephthalate thread has provided similar rates of fusion among both types of implants. The primary objective of this study was to illustrate the reduction of grade I/II degenerative anterolisthesis through a percutaneous trans-Kambin triangle far lateral approach using a single implant composed of a polyethylene terephthalate thread.

Methods: A retrospective chart review was performed on patients who received an oblique far lateral trans-Kambin triangle percutaneous approach with placement of the studied implant to correct a grade I or II spondylolisthesis from 2/9/2018 to 5/26/2021. Demographic information was recorded from the electronic medical record system. Spondylolisthesis slip distance, foraminal height, anterior disc height, and posterior disc height were documented for both the pre-operative and post-operative radiographs.

Results: For the 20 patients included in the study, the mean pre-operative spondylolisthesis was 5.2 mm, and the mean post-operative spondylolisthesis was 1.1 mm. The average change in spondylolisthesis was 4.1 mm, an 85.4% reduction. Sixty-five percent of the patients had complete reduction of spondylolisthesis with a post-operative measurement of 0 mm. Significant improvements were also observed in foraminal height as well as anterior and posterior disc height.

Conclusions: The use of the expandable interbody device using a far lateral trans-Kambin approach displayed exceptional ability to reduce grade I/II degenerative spondylolisthesis. Radiographically, this surgical combination provided excellent, long-term decompressive abilities regarding foraminal height, disc height, and spondylolisthesis reduction.

Background: Lumbar ligamentum flavum hematoma (LFH) is a rare cause of nerve root and/or cauda equina compression which is commonly treated using microsurgical laminectomy and posterior fixation. However, technological advances may allow for less invasive options to be used.

Case description: A 70-year-old female with lower back and right lower extremity radicular pain without relevant medical history. Muscle strength and tendon reflexes were normal. Lumbar computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lumbar dural sac and nerve root compression due to lumbar canal stenosis and lumbar LFH at L3-4. Full-endoscopic laminectomy (FEL) was performed at L3-4 after conservative treatment failed to provide sufficient improvement. Intraoperative observation revealed the presence of a hematoma during removal of the lumbar ligamentum flavum. Postoperatively, the lower back and right lower extremity radicular pain resolved. Postoperative MRI and CT demonstrated tomography revealed decompression of the lumbar dural sac and nerve root. The patient was discharged without any perioperative complications. No recurrence was observed for at least 3 months postoperatively.

Conclusions: FEL appears to be an effective and minimally invasive approach for lumbar LFH, owing to its ability to visualize and drain the hematoma from the ligamentum flavum and perform dural sac and nerve root decompression.

Background and objective: Anterior lumbar spine surgery provides a viable efficacious alternative to traditional posterior approaches. Vascular complications are usually managed with simple open surgical techniques. Rarely, massive venous haemorrhage transpires after a venous injury which may be life-threatening. Advanced endovascular devices and techniques provide alternatives to open surgery for the management of massive venous injury (MVI). The majority of descriptions utilise covered stents which often need to be adapted to the emergent situation and the venous anatomy. We aimed to review the venous anatomy, available endovascular devices, and describe techniques used to manage an MVI encountered during anterior lumbar spine surgery, and propose a staged, systematic approach for its endovascular management. These techniques can be used instead of, or combined with open techniques.

Methods: A review of national databases (PubMed, Ovid Medline and Google Scholar) was performed using literature from 2000 to 2024 in English. Keywords included terms "anterior" and "lumbar" and "spine" and "haemorrhage" and "venous injury" and "vascular injury" and "damage control" and "endovascular" and "venous thromboembolism". Studies that described the anatomy, incidence, endovascular surgical techniques, complications, clinical and radiological outcomes of anterior lumbar spine surgery were included.

Key content and findings: We reviewed the relevant anatomy, patient work-up, lists of useful available endovascular equipment and devices, the stages of management, specific endovascular strategies and techniques, and the post-operative management of the patient.

Conclusions: Endovascular surgery can deliver control and definitive management with lower blood loss, reduced physiological insult while preserving venous patency. It is more likely to permit the completion of the spinal procedure than open surgical repair. Expertise in endovascular techniques is mandatory for their deployment. The best outcome is only achieved with a team approach to the situation, with the recruitment of appropriately skilled personnel and equipment. Endovascular techniques should be included in contingency planning for MVI.

L5-S1 pedicle screw (PS) fixation is commonly used to stabilize lumbosacral degenerative disease. Rigid S1 PS fixation is challenging due to sacral morphology. Various S1 PS techniques have been developed to increase screw insertion torque, including the penetrating S1 endplate screw (S1 PES) technique. This study introduces percutaneous sacral endplate penetrating screw (PSEPS) technique using S1 percutaneous pedicle screw (PPS) with a safer and longer screw trajectory and a novel modified hollow probe (M-probe). Penetrating the S1 superior endplate with a conventional straight hollow probe is challenging due to the thickening of the S1 endplate and the shape of the anterior S1 endplate. Therefore, we developed the M-probe that can easily penetrate the S1 endplate. First, the conventional straight probe was inserted 20 degrees inward and directed towards the cranial aspect until it reached the cranial margin of the S1 endplate. It was then confirmed that the probe was positioned beyond the posterior wall of the vertebral body in the lateral view. The M-probe was replaced through the guidewire, and the guidewire was replaced with a cannula before the M-probe was advanced. The M-probe was advanced toward the anterior one-third of the S1 vertebral body endplate. When the tip arrives at the S1 endplate, the M-probe should be oriented cephalad to facilitate penetration of the endplate and then advanced to penetrate the endplate. Rotating the tip of the M-probe enlarges the bone hole in the S1 endplate, eliminating the need for tapping. The PSEPS technique demonstrated significantly higher insertion torque at S1 compared to L5, despite lower Hounsfield unit values at S1 PSEPS: 394.0±104.8 cNm). The M-probe allowed for easier endplate penetration and higher insertion torque without the need for tapping. The PSEPS technique using the M-probe offers enhanced stability and safety for lumbosacral interbody fusion.

Background: The benefits of minimally invasive spinal surgery have seen an increase in uptake by surgeons and an increase in acceptability by patients. This retrospective cohort study aims to evaluate the efficacy and safety of unilateral biportal endoscopic (UbE) lumbar decompressive surgery with a focus on outcomes, technique, and temporal relationship between surgeon experience and operative times.

Methods: We performed a retrospective analysis of the first consecutive 105 patients undergoing UbE lumbar decompression (99 single-level and 6 double-level) for symptomatic herniated disc and/or spinal stenosis by a single surgeon at our institution. Data encompassed demographics, preoperative and postoperative assessments, operative details, complications, as well as patient-reported outcome measures (PROM).

Results: The 105 Asian patients presented with diverse symptoms, predominantly leg pain/radiculopathy (93.3%) and lower back pain (75.2%). The commonest level operated on was L4/5 (56.2%), and the operative time averaged 117.58 minutes per level, with shorter times being associated with increased surgical experience (r=-0.254, P=0.009) and longer times associated with higher body mass index (BMI) (r=0.209, P=0.03). Left-sided and L5/S1 level decompression were associated with quicker operative time, but without reaching statistical significance. In the immediate postoperative period, all patients experienced an improvement of symptoms with 54.3% experiencing complete symptomatic relief. The average length of hospitalization was 1.88 days. Complications were minimal with 3 dural tears (2.86%), 1 postoperative wound bleeding (0.95%) and no infective sequelae. PROM at 1- and 3-month mark showed significant improvements in Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and 36-item Short Form Survey (SF-36).

Conclusions: UbE lumbar decompression in Asian patients at our institution demonstrated favorable outcomes, in terms of symptomatic relief, functional scores and length of stay with few complications. Surgical times improved with increased experience, suggesting feasibility with practice. We recommend having adequate surgical experience in traditional approaches before transitioning to endoscopic decompression, and to embark on learning UbE approach with careful patient selection. Given inherent limitations such as retrospective single-cohort design and a short follow-up, further longer-term comparative studies are warranted to establish its superiority definitively.

Background: As healthcare becomes more expensive, hospitals and providers need to develop "value engineering" as a method to deliver the same quality of care for a lower cost. One key concept is to look at the entire cost of a procedure and begin to reduce costs one at a time within that procedure. We developed the BDC-15 as a method to harvest high quality bone graft and at a low cost while maintaining excellent results.

Methods: In this study, we present the first series of patients who underwent cervical fusion and lumbar fusion using exclusively the BDC-15 without any additional allograft.

Results: A total of 232 patients were entered into the study with 107 patients undergoing anterior cervical fusion surgery (one-, two-, or three-level) and 125 patients undergoing posterior lumbar fusion surgery (one- or two-level). Patients were followed for a mean of 13.4 months assessing fusion. For the cervical group, 95.3% of patients were fused at 6 months and for the lumbar group, 92% of patients were fused at 12 months. Complication rate was 4.7% (11 patients) due to admission for post-operative pain (6 patients), wound infection (3 patients), and hardware failure (2 patients). Average cost savings across all groups was $441,850 or approximately $1,904 per patient.

Conclusions: Autograft results in acceptable fusion rates and patient outcomes at a fraction of the cost of Allograft.