Retroperitoneal Extrapleural Approach for Corpectomy of the First Lumbar Vertebra : Technique and Outcome

OBJECTIVE: Corpectomy of the first lumbar vertebra (L1) for the management of different L1 pathologies can be performed using either an anterior or posterior approach. The aim of this study was to evaluate the usefulness of a retroperitoneal extrapleural approach through the twelfth rib for performing L1 corpectomy.METHODS: Thirty consecutive patients underwent L1 corpectomy between 2010 and 2016. The retroperitoneal extrapleural approach through the 12th rib was used in all cases to perform single-stage anterior L1 corpectomy, reconstruction and anterior instrumentation, except for in two recurrent cases in which posterior fixation was added. Visual analogue scale (VAS) was used for pain intensity measurement and ASIA impairment scale for neurological assessment. The mean follow-up period was 14.5 months.RESULTS: The sample included 18 males and 12 females, and the mean age was 40.3 years. Twenty patients (67%) had sensory or motor deficits before the surgery. The pathologies encountered included traumatic fracture in 12 cases, osteoporotic fracture in four cases, tumor in eight cases and spinal infection in the remaining six cases. The surgeries were performed from the left side, except in two cases. There was significant improvement of back pain and radicular pain as recorded by VAS. One patient exhibited postoperative neurological deterioration due to bone graft dislodgement. All patients with deficits at least partially improved after the surgery. During the follow-up, no hardware failures or losses of correction were detected.CONCLUSION: The retroperitoneal extrapleural approach through the 12th rib is a feasible approach for L1 corpectomy that can combine adequate decompression of the dural sac with effective biomechanical restoration of the compromised anterior load-bearing column. It is associated with less pulmonary complication, no need for chest tube, no abdominal distention and rapid recovery compared with other approaches.

Retroperitoneal Extrapleural Approach for Corpectomy of the First Lumbar Vertebra : Technique and Outcome

OBJECTIVE: Corpectomy of the first lumbar vertebra (L1) for the management of different L1 pathologies can be performed using either an anterior or posterior approach. The aim of this study was to evaluate the usefulness of a retroperitoneal extrapleural approach through the twelfth rib for performing L1 corpectomy. METHODS: Thirty consecutive patients underwent L1 corpectomy between 2010 and 2016. The retroperitoneal extrapleural approach through the 12th rib was used in all cases to perform single-stage anterior L1 corpectomy, reconstruction and anterior instrumentation, except for in two recurrent cases in which posterior fixation was added. Visual analogue scale (VAS) was used for pain intensity measurement and ASIA impairment scale for neurological assessment. The mean follow-up period was 14.5 months. RESULTS: The sample included 18 males and 12 females, and the mean age was 40.3 years. Twenty patients (67%) had sensory or motor deficits before the surgery. The pathologies encountered included traumatic fracture in 12 cases, osteoporotic fracture in four cases, tumor in eight cases and spinal infection in the remaining six cases. The surgeries were performed from the left side, except in two cases. There was significant improvement of back pain and radicular pain as recorded by VAS. One patient exhibited postoperative neurological deterioration due to bone graft dislodgement. All patients with deficits at least partially improved after the surgery. During the follow-up, no hardware failures or losses of correction were detected. CONCLUSION: The retroperitoneal extrapleural approach through the 12th rib is a feasible approach for L1 corpectomy that can combine adequate decompression of the dural sac with effective biomechanical restoration of the compromised anterior load-bearing column. It is associated with less pulmonary complication, no need for chest tube, no abdominal distention and rapid recovery compared with other approaches.

Multilevel Percutaneous Vertebroplasty (More than Three Levels) in the Management of Osteoporotic Fractures

OBJECTIVE: Percutaneous vertebroplasty (PV) is a minimally invasive procedure designed to treat various spinal pathologies. The maximum number of levels to be injected at one setting is still debatable. This study was done to evaluate the usefulness and safety of multilevel PV (more than three vertebrae) in management of osteoporotic fractures.METHODS: This prospective study was carried out on consecutive 40 patients with osteoporotic fractures who had been operated for multilevel PV (more than three levels). There were 28 females and 12 males and their ages ranged from 60 to 85 years with mean age of 72.5 years. We had injected 194 vertebrae in those 40 patients (four levels in 16 patients, five levels in 14 patients, and six levels in 10 patients). Visual analogue scale (VAS) was used for pain intensity measurement and plain X-ray films and computed tomography scan were used for radiological assessment. The mean follow-up period was 21.7 months (range, 12–40).RESULTS: Asymptomatic bone cement leakage has occurred in 12 patients (30%) in the present study. Symptomatic pulmonary embolism was observed in one patient. Significant improvement of pain was recorded immediate postoperative in 36 patients (90%).CONCLUSION: Multilevel PV for the treatment of osteoporotic fractures is a safe and successful procedure that can significantly reduce pain and improve patient’s condition without a significant morbidity. It is considered a cost effective procedure allowing a rapid restoration of patient mobility.

Multilevel Percutaneous Vertebroplasty (More than Three Levels) in the Management of Osteoporotic Fractures

OBJECTIVE: Percutaneous vertebroplasty (PV) is a minimally invasive procedure designed to treat various spinal pathologies. The maximum number of levels to be injected at one setting is still debatable. This study was done to evaluate the usefulness and safety of multilevel PV (more than three vertebrae) in management of osteoporotic fractures. METHODS: This prospective study was carried out on consecutive 40 patients with osteoporotic fractures who had been operated for multilevel PV (more than three levels). There were 28 females and 12 males and their ages ranged from 60 to 85 years with mean age of 72.5 years. We had injected 194 vertebrae in those 40 patients (four levels in 16 patients, five levels in 14 patients, and six levels in 10 patients). Visual analogue scale (VAS) was used for pain intensity measurement and plain X-ray films and computed tomography scan were used for radiological assessment. The mean follow-up period was 21.7 months (range, 12–40). RESULTS: Asymptomatic bone cement leakage has occurred in 12 patients (30%) in the present study. Symptomatic pulmonary embolism was observed in one patient. Significant improvement of pain was recorded immediate postoperative in 36 patients (90%). CONCLUSION: Multilevel PV for the treatment of osteoporotic fractures is a safe and successful procedure that can significantly reduce pain and improve patient’s condition without a significant morbidity. It is considered a cost effective procedure allowing a rapid restoration of patient mobility.

Intracerebral hemorrhage in children

Intracerebral hemorrhage [ICH] in children is relatively less common as compared to adults. It could be traumatic or spontaneous. There are limited studies about ICH in children. In this study, we analyze the etiology, clinical features, management options and outcome assessment in this population. All patients with intracerebral hemorrhage under 18 years of age admitted to the neurosurgery department; Alexandria University Main Hospital and Medical Research Institute over a period of one year [June 2008-May 2009] were subjected to clinical examination, laboratory and radiological investigations and the cause of hemorrhage was determined. Thirty patients with ICH were included in this study. Age of patients ranged from one month to 17.5 years with a higher predilection in males. Presenting features were symptoms of raised intracranial pressure [60%], deterioration in sensorium [46%], limb weakness [36%] and seizures [30.0%]. Trauma was the most common cause of ICH and was found in 13 patients [43%], followed by bleeding diathesis in nine patients [30%], arteriovenous malformation [AVM] in five patients [17%], intracranial tumor in two patients and an aneurysm in one patient. Treatment modalities consisted of: hematoma evacuation, excision of AVM, AVM emobilization, aneurysm clipping, tumor excision, and conservative management. Eleven patients were treated conservatively and 19 patients were treated surgically. The outcome showed: good recovery in 14[47%], fair recovery in seven [23%], poor recovery in seven [23%], and death in two patients [7%]. Trauma is the leading cause of ICH in children. Bleeding diathesis and AVM come next. The initial neurological status of patients, the size, location and underlying pathophysiology of the hematoma are the most important determinants of patient outcome. Intracerebral hemorrhage due to bleeding diathesis was generally associated with a better outcome

Occipitocervical fixation in the management of craniocervical instabilities

The occipitocervical junction presents a unique, complex, biomechanical interface between the cranium and the upper cervical spine. Occipitocervical fixation has undergone significant evolution due to advances in operative techniques and instrumentation techniques. This study was done to evaluate clinical picture, radiographic findings and results of occipitocervical fusion in 10 patients with craniocervical instabilities. Also to compare these results with other results reported in the literature. This retrospective study reviewed 10 patients who underwent occipitocervical fixation for craniocervical instabilities between April 2007 and October 2010 in Alexandria hospitals. There were 7 males and 3 females and their ages ranged from 16 to 63 years with mean age of 42.1 years. As regards the clinical presentation, all patients had presented with neck pain before surgery, 8 patients [80%] with myelopathy, and 8 patients [80%] had presented with a neurological deficit either motor or sensory or both. The etiologies of occipitocervical instability in this study were trauma in three patients, rheumatoid arthritis in three patients, tumor in two patients and Down syndrome in two patients. All patients had preoperative craniocervical plain X-ray, CT and MRI examination. All patients underwent occipitocervical fixation surgery with various fixation systems and autologous bone grafts for fusion. Fusion was assessed by plain cervical X-ray films and CT scan, and the neurological outcome by Frankel grade. The mean follow-up period was 14.7 months [range, 4-24 months] including both clinical and radiological examinations. There were no operative mortalities or vascular injuries in this series. Two patients showed transient neurological deterioration postoperatively that had resolved within three months. Two cases had superficial wound infection and one case had cerebrospinal fluid leak. The mean operation time was 207 min [range 130-320 min] and the mean volume of blood loss was 354 mL [range 120-750 mL]. Neck pain improved in all patients and no new instability developed at adjacent levels. Regarding the Frankel grade, five patients had shown improvement [Three patients improved from Frankel grade C to grade D, one patient from grade A to grade B and one patient from grade D to grade E], while five patients remained stationary at the same grade. At the last follow-up examination period, a solid fusion was achieved in nine patients out of ten [90%]. Occiptocervical fixation is indicated in the management of craniocervical instabilities resulting from trauma, rheumatoid arthritis, tumors and congenital anomalies of the craniocervical junction. Accurate imaging studies and proper patient selection are the keys to a successful outcome. Occipitocervical fusion procedures can be performed with low morbidity. A comprehensive knowledge of the anatomy of the occipital-cervical junction is imperative. A wide variety of stabilization techniques and instrumentation systems are currently available, each of which has its own advantages and disadvantages

Management of posterior fossa medulloblastoma in adults

Medulloblastoma is a malignant tumor of the cerebellum that occurs predominantly in children. It is rare in adults and accounts for less than 1% of all adult primary brain tumors. This study was done to study clinical picture, radiological findings, to evaluate the surgical outcome and to assess the effects of postoperative adjuvant therapy in 12 adult patients who had posterior fossa medulloblastoma This prospective study was carried out on consecutive 12 adult patients who had posterior fossa medulloblastoma. This study was done in Alexandria hospitals over a period of 3 years starting from March 2006 to March 2009. The male to female ratio was 2 to 1[8 males and 4 females] and their ages ranged from 19 to 51 years with mean age of 33, 8 years. Headache was the most frequent symptom [93, 5% of patients]. As regards the clinical presentation, manifestations of increased intracranial pressure was found in 10 patients [83, 3%], cerebellar dysfunction in 8 patients [66, 6%], cranial nerve deficits in half of the cases. The tumour was hemispheric in 10 cases [6 lateral and 4 paramedian] and vermian in 2 cases. All patients had preoperative craniospinal MRI examination. No distant or spinal metastases were detected in our patients at the time of diagnosis. All cases underwent surgery in the form of resection of the tumour followed by postoperative craniospinal irradiation. Also two patients with recurrence and metastases received adjuvant craniospinal radiotherapy and systemic chemotherapy. Mean postoperative follow up period was 24 months, including both clinical and MRI examination. There were no operative mortality, and surgery did not provoke any permanent neurological aggravation. Postoperative MRI studies showed complete tumour resection was achieved in 9 patients [75%]. After initial treatment only two patients relapsed in the posterior fossa after one and half year. Recurrence was probably related to incomplete tumor resection and long delay in initiating radiotherapy [3 months after operation]. Two of the patients that received adjuvant treatment died: one from distant metastasis and one from recurrent disease. Ten patients remained alive and disease-free with Karnofsky performance status ranging from 80 to100. Adult medulloblastoma was predominant in males and the majority of patients had hemispheric cerebellar tumors. Adults are more likely to have heterogeneous cerebellar tumours on MRI, and this is thought to be related to the greater prevalence of desmoplastic variant in adulthood. Long-term survival was not uncommon. The outcome depends on the site of the tumour with better results obtained in cases with lateral hemispherical tumour that facilitate its complete surgical resection and good irradiation planning