Clinical Features of Herniated Disc at Cervicothoracic Junction Level Treated by Anterior Approach

OBJECTIVE: The anterior approach for C7-T1 disc herniation may be challenging because of obstruction by the manubrium and the narrow operative field. This study aimed to investigate the clinical and neurological outcomes of anterior approach for C7-T1 disc herniation. METHODS: We retrospectively evaluated 13 patients who underwent the anterior approach for C7-T1 disc herniation by a single surgeon within a period of 11 years (2003-2014). The minimum follow-up duration was 6 months. We describe the clinical presentation, radiographic findings, neurological outcome, and related complications. RESULTS: Of 372 patients with single-level anterior discectomy and fusion or artificial disc replacement for cervical disc herniation, 13 (3.5%) had C7-T1 disc herniation. The main clinical presentation was unilateral motor weakness in intrinsic hand muscles (11 patients), along with numbness, pain, and tingling sensation that radiate down the arm to the little finger. Most of the patients improved after surgery via the anterior approach. Ten patients underwent successful anterior discectomy and fusion by the standard supramanubrial Smith-Robinson approach, but 2 needed additional manubriotomy and sternotomy. In 1 patient, we performed surgery at a wrong level because the correct level was difficult to identify intraoperatively. Two patients had transient vocal dysfunction, but none had major complications related to injuries of the great vessels such as the thoracic duct or esophagus. CONCLUSION: For patients who require direct anterior decompression for C7-T1 disc herniation, the anterior approach is relatively feasible. However, care should be taken to overcome physical constraints by the manubrium and slope.

Minimally Invasive Extraforaminal Lumbar Interbody Fusion for Revision Surgery: A Technique through Kambin's Triangle

OBJECTIVE: The purpose of this study was to evaluate the clinical outcomes of minimally invasive extraforaminal lumbar interbody fusion (ELIF) for revision surgery. METHODS: From January 2011 to December 2012, 12 patients who underwent minimally invasive ELIF through the Kambin's triangle for revision surgery were included in this study. All patients underwent the surgical procedure in the following sequence: (1) epidural anesthesia, (2) exposing the Kambin's triangle toward the lateral part of the dura (partial resection of the superior articular process), (3) bilateral cage insertion for reinforcement of stabilization and fusion, and (4) percutaneous transpedicular screwing. Clinical outcomes were assessed using the visual analogue scale (VAS), and Oswestry disability index (ODI). Imaging and clinical findings including surgical techniques, clinical outcomes, and related complications were depicted and analyzed. RESULTS: The mean age of the patients (5 men, 7 women) was 60.7+/-13.4 years, and the mean follow-up period was 27.1+/-4.9 months. The mean VAS (back and leg) score improved significantly at final follow-up. The mean ODI score decreased as follows: preoperative, 76.78+/-6.08; 3 months after the surgery, 37.74+/-6.67; and at final follow-up, 29.91+/-2.98. Two patients presented with transient nerve root irritation, but there were no cases of incidental dural tear or serious infection. No significant neurological deterioration or major complication was noted in any of the patients. CONCLUSION: Minimally invasive ELIF for revision surgery is an effective surgical option with a low complication rate.

Repeated Migration of a Fusion Cage after Posterior Lumbar Interbody Fusion

Although posterior lumbar interbody fusion (PLIF) is a widely accepted procedure, perioperative and postoperative complications are still encountered. In particular, cage migration can result in severe sequelae, and revision surgery is technically demanded. Here, we report a rare case of repeated migration of a fusion cage after PLIF. To the best of our knowledge, no report has been previously issued on repeated migration of a fusion cage after PLIF. The authors discuss the radiological and clinical findings of this unusual complication with a review of the literature.