Vertebral metastasis of renal carcinoma at diagnosis: mechanical and clinical evaluation: surgical management / Metástasis vertebral de carcinoma renal en el momento del diagnóstico: evaluación mecánica y clínica: manejo quirúrgico

Renal cell carcinoma accounts for 2-3% of all malignant neoplasms. Metastatic disease of the spine is common and 50% of bone metastases are already present at the time of primary diagnosis. Bone metastases from renal cell carcinoma are difficult to manage, especially vertebral localization.A 48-year-old woman was diagnosed with renal cell carcinoma in the context of low back pain. The patient presented two skeleton metastases at diagnosis (T11 and 5th rib). The patient received neoadjuvant treatment with cabozantinib, followed by removal of the renal tumor. Radiotherapy was administered for the lumbar lesion. In spite of the radiotherapy treatment, increased low back pain limiting mobility and ambulation. MRI showed an occupation of the spinal canal, without neurological lesion. The SINS scale revealed a score of 14 (vertebral instability). The patient's prognosis was greater than 12 months according to the Tokuhashi score. Based on clinical and mechanical criteria, surgical treatment of the vertebral lesion was decided. T11 vertebrectomy was performed, the reconstruction was made with an expandable cage, and T8 a L2 posterior spinal arthrodesis. A partial resection of the fifth rib was performed in order to remove the whole macroscopic tumor. After 3 months, she was diagnosed with a local infection, treated by irrigation, debridement and antibiotherapy, with good evolution. At 1-year follow-up, she has no low back pain or functional limitation. Follow-up chest-abdomen-pelvis computed CT scan showed absence of disease progression, furthermore, the vertebral arthrodesis shows fusion signs. At the time of this report, there are no clinical or radiological data of infection

El carcinoma de células renales representa el 2-3% de todas las neoplasias malignas. La enfermedad metastásica de la columna vertebral es frecuente y el 50% de las metástasis óseas ya están presentes en el momento del diagnóstico. Las metástasis óseas del carcinoma de células renales son difíciles de manejar, especialmente en localización vertebral.Una mujer de 48 años fue diagnosticada de carcinoma de células renales en el contexto de un dolor lumbar. La paciente presentaba dos metástasis óseas en el momento del diagnóstico (T11 y 5ª costilla). Inicialmente recibió tratamiento neoadyuvante con cabozantinib, seguido de la extirpación quirúrgica del tumor renal. Se administró radioterapia para la lesión lumbar. A pesar del tratamiento radioterápico, aumentó el dolor lumbar con limitación para la movilidad y la deambulación. La RM mostró una ocupación del canal espinal, sin lesión neurológica. La escala SINS reveló una puntuación de 14 (inestabilidad vertebral). El pronóstico de la paciente era superior a 12 meses según la puntuación de Tokuhashi. Basándose en criterios clínicos y mecánicos, se decidió el tratamiento quirúrgico de la lesión vertebral. Se realizó una vertebrectomía de T11, para la reconstrucción se usó una caja extensible, junto con una artrodesis vertebral T8-L2. Se realizó una resección parcial de la quinta costilla para eliminar todo el tumor macroscópico. A los 3 meses de la cirugía la paciente fue diagnosticada de infección local, tratada mediante irrigación, desbridamiento y antibioterapia, con buena evolución. Al año de seguimiento, no presenta dolor lumbar ni limitación funcional. La tomografía computarizada de tórax-abdomen-pelvis de seguimiento mostró ausencia de progresión de la enfermedad, además, la artrodesis vertebral muestra signos de fusión. En el momento de este informe, no hay datos clínicos ni radiológicos de infección.

Utilidad de la cirugía espinal mínimamente invasiva (MISS) en el manejo de las metástasis espinales toraco-lumbares / Utility of minimally invasive spinal surgery (MISS) in the management of thoraco-lumbar spinal metastases

Objetivo: Describir los resultados quirúrgicos y evolución de pacientes con metástasis espinales toraco-lumbares operadas con técnica mínimamente invasiva (MISS) utilizando para la decisión terapéutica la evaluación: Neurológica, Oncológica, Mecánica y Sistémica (NOMS). Material y Métodos: Se incluyeron en forma prospectiva pacientes con metástasis espinales toraco-lumbares operados con técnica MISS por el Servicio de Neurocirugía del Hospital Italiano de Buenos Aires, entre junio de 2014 y junio de 2017. Se utilizó en todos los casos el algoritmo de evaluación NOMS para la decisión terapéutica. Se analizaron los resultados quirúrgicos postoperatorios como el Karnofsky Performance Status (KPS), dolor (VAS: Visual Analogue Scale), Frankel, pérdida sanguínea, necesidad de transfusiones, complicaciones, uso de opioides y días de internación. Se consideró como estadísticamente significativo una p<0,05. Resultados: Durante el período de estudio 26 pacientes cumplieron los criterios de inclusión, de los cuales 13 fueron mujeres. La edad promedio fue 57 (27-83) años. El origen más frecuente de las lesiones fue cáncer de mama (27%). El síntoma más constante fue el dolor (96%), aunque 12 pacientes manifestaron inicialmente mielopatía (46%). Se observaron grados avanzados de invasión del canal con requerimiento de descompresión en el 65% de los casos. Acorde al Spinal Instability Neoplastic Score (SINS), 23 pacientes (89%) presentaron lesiones potencialmente inestables o inestables, requiriendo estabilización. Se evidenció una mejoría estadísticamente significativa del VAS en el 77% y del Frankel en el 67% de los casos tras la cirugía. No hubo necesidad de transfusiones. Se registró sólo una complicación quirúrgica leve (4%). La media de internación fue de 5,5 días. Conclusión: En nuestra serie y utilizando como algoritmo terapéutico el NOMS, la cirugía MISS resultó efectiva tanto para la descompresión para la estabilización espinal, con baja tasa de complicaciones y rápida recuperación postoperatoria.

Objective: To describe the surgical results and evolution of patients who undergo minimally-invasive spinal surgery (MISS) to treat thoracolumbar metastases, using the NOMS (Neurological, Oncological, Mechanical, Systemic) assessment tool to aid therapeutic decisions. Methods: Patients who underwent MISS to treat thoracolumbar metastases were prospectively enrolled at the Hospital Italiano de Buenos Aires, from June 2014 to June 2017. In all cases, the NOMS assessment tool was employed for therapeutic decision-making. Surgical results were analyzed, in terms of improvements in Karnofsky Performance Status (KPS), pain severity (VAS), and the Frankel neurological scale; also measured were blood loss and the need for transfusions, complications, use of opioids, and the length of hospitalization. P values <0.05 were considered statistically significant. Results: Twenty-six patients were enrolled (13 women) of mean age 57 years old (27-83). Breast cancer was the most frequent primary tumor (27%). The main presenting symptom was pain (96%), although 12 patients presented with myelopathy (46%). High-grade epidural spinal cord compression requiring decompression was observed in 17 patients (65%). According to the SINS (Spinal Instability Neoplastic Score), most lesions were either potentially unstable or unstable (89%), requiring stabilization. After surgery, pain severity and neurological status improved significantly in 77% and 67% of patients, respectively, with low intraoperative blood loss and no need for transfusions. Only one minor surgical complication occurred (4%). The average hospital stay was 5.5 days. Conclusion: In our series, using the NOMS instrument as the therapeutic algorithm, MISS was effective for spinal decompression and stabilization, with a low rate of complications and rapid postoperative recovery.

Prognosis of Single Spinal Metastatic Tumors: Predictive Value of the Spinal Instability Neoplastic Score System for Spinal Adverse Events

STUDY DESIGN: This was a retrospective cohort study. PURPOSE: We evaluated the predictive value of the Spinal Instability Neoplastic Score (SINS) system for spinal adverse events (SAEs) in patients with single spinal metastatic tumor. OVERVIEW OF LITERATURE: The SINS system was developed to assess spinal instability in patients with single metastatic spinal tumor. However, the system’s potential predictive value for SAEs has been partially studied. METHODS: This system was applied to a retrospective cohort of 78 patients with single spinal metastatic tumors. The patients underwent surgical treatment and were postoperatively followed up for at least 2 years or until death. The attribution of each score and total SINS to SAE (vertebral compression fracture [VCF] and spinal cord compression [SCC]) occurrence was assessed using the Cox proportional hazards model. RESULTS: SAEs occurred on average 7 months after diagnosis of spinal metastasis. The mean survival rate post diagnosis was 43 months. Multivariate analysis using the Cox proportional hazards model revealed that the pain (p=0.029) and spinal alignment (p=0.001) scores were significantly related to VCF occurrence, whereas the pain (p=0.008) and posterolateral involvement (p=0.009) scores were related to SCC occurrence. CONCLUSIONS: Among the components of the SINS system, while pain and spinal alignment showed a significant association with VCF occurrence, pain and posterolateral involvement showed association with SCC occurrence.

The Spinal Instability Neoplastic Score (SINS) as a Surgical Decision-Making Tool for the Treatment of Spine Metastasis

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To investigate the potential clinical use of the spinal instability neoplastic score (SINS) for determining the surgical strategy, especially regarding the need for anterior support. SUMMARY OF LITERATURE REVIEW: The SINS seems to enable an improved qualitative and quantitative assessment of spinal instability in patients with spinal metastasis. MATERIALS AND METHODS: We retrospectively reviewed 69 consecutive patients who underwent surgical treatment for spinal metastasis. We assessed the patients' preoperative status with respect to each component of the SINS. Multiple logistic regression was performed to calculate odds ratios (ORs) representing the associations among SINS, age, Eastern Cooperative Oncology Group performance status, modified Tokuhashi score, as well as the preoperative Nurick grade variables and reconstruction of the anterior spinal column. RESULTS: Among the 6 items in the SINS, those indicating the degree of collapse and alignment had significantly higher scores in those who underwent corpectomy and anterior support (p<0.001). Multiple logistic regression revealed that the total SINS was the only factor significantly associated with predicting whether anterior support should be performed (adjusted OR=1.595). Receiver operating characteristic (ROC) curve analysis suggested that a cut-off value of 10 points on the SINS scale could be used to decide whether anterior support following corpectomy should be performed (AUC=0.706). CONCLUSIONS: The SINS, insofar as it assesses the degree of collapse and alignment, is a potentially useful tool for determining the surgical strategy in patients with spinal metastasis, especially for deciding upon the necessity of additional anterior support procedures.

Comparison of the clinical efficacy between obesity and non-obesity with lumbar spinal stenosis and instability by transforaminal lumbar interbody fusion / 重庆医学

Objective To observe the clinic efficacy of open transforaminal lumbar interbody fusion (TLIF) compared with minimally invasive operation in treating lumbar spinal stenosis and instability among obese and non‐obese patients .Methods A ret‐rospective analysis was performed in these cases of mono‐segmental lumbar spinal stenosis and instability between January 2011 and January 2013 .Perioperative index ,clinical efficacy ,and imaging results were observed and compared between different groups .Re‐sults Thirty‐four obese cases and 105 non‐obese cases were divided into two groups ,including conventional posterior open TLIF and minimally invasive TLIF operation ,to compare the results .Perioperative indexes of obese patients were more than non‐obese patients undergone open TLIF operation way and there was significant difference(P0 .05) .No cases of slippage or breakage of implants were found among all these patients after 6 months of follow up .Postoperative VAS and ODI among these four groups were better than before(P0 .05);undergoing minimally invasive postoperative VAS in obese group and in non‐obese group ,there was not significant difference(P>0 .05) .Conclusion Therefore ,obese may be risk factor in treating lumbar spinal stenosis and instability .

Restructuring morphogenesis protein-2 combined with nanocrystalline bone collagen bone material fusion between treating lumbar protrusion of the lumbar spine instability of clinical curative effect and safety evaluation / 中国综合临床

Objective To explore and analyze clinical efficacy and safety of restructuring morphogenesis protein-2 bones(rhBMP-2) combined with nanocrystalline collagen bone material(nHAC) fusion between treating lumbar protrusion of the lumbar spine instability.Methods Ninety cases of patients with lumbar instability syndrome who were treated in the People's Hospital of Heze from March 2013 to May 2013were selected and divided into restructure morphogenesis protein-2 combined with nanocrvstalline bone collagen bone material treatment group,purely in nanocrystalline collagen bone material treatment of the control group according to the random number table method,45 cases in each group.JOA evaluation results,intraoperative blood loss,postoperative infection,pulmonary complications within three months of the two groups were compared.Results The male proportion of experimental group and control group was 46.67％ and 48.89％respectively,the difference was significant(x2 =0.03,P =0.84).The excellent rate ofexperimental group and control group was respectively 93.33％,57.78％,the difference was significant (x2 =5.49,P ＜ 0.05).The incidence of deep vein thrombosis,infection rate,incidence of pulmonary complications of experimental group were 4.44％,8.88％,6.67％,of control group were 13.33％,24.44％,20.00％,the differences were significant (x2=5.12,3.78,3.56;P＜0.05).Conclusion Restructuring morphogenesis protein-2 bones combined with nanocrystalline collagen bone material treating lumbar fusion between the clinical curative effect of treating lumbar instability syndrome is better,with a lower incidence of complications,security is relatively high,compared to traditional surgery method has many advantages,can be used as a kind of ideal method used in the clinical work.

Research Progress on Lower Back Pain and Spinal Stability Theory / 世界科学技术-中医药现代化

Lower back pain refers to the pain in the lower back. It usually refers to the region below the lower costal margin on the back. The pain mostly occurs on L4 and L5, or L5 and L1, which is usually called as lower back pain. For the treatment of low back pain, it has lacked the effective and objective measurement methods based on the functional and structural features of spinal muscles. This article discussed on the core stability and core strength, the identification and classification of core muscle group, the relation between core stabilizing muscle group and low back pain. It also discussed the characteristics and effects of training motion therapy in the improving of core strength. The core of human body was consisted of waist, pelvis and hip joint. Core stabilizing training can effectively stabilize the spine and transmit power. The question of how to train and improve the core strength to relieve low back pain and make effective evaluation according to its therapeutic results are the key points in the future study.

Clinical and Radiological Comparison of Posterolateral Fusion and Posterior Interbody Fusion Techniques for Multilevel Lumbar Spinal Stabilization In Manual Workers

STUDY DESIGN: Eighty-four patients who had been treated for degenerative spinal diseases between January 2006 and June 2009 were reviewed retrospectively. PURPOSE: We aimed to compare the clinical and radiologic findings of manual workers who underwent posterolateral fusion (PLF) or posterior interbody fusion (PLIF) involving fusion of 3 or more levels of the spine. OVERVIEW OF LITERATURE: Previous studies have concluded that there is no significant difference between the clinical outcome of PLF and PLIF techniques. METHODS: After standard decompression, 42 patients underwent PLF and the other 42 patients underwent PLIF. Radiologic findings, Oswestry disability index (ODI) scores, and visual analogue scale (VAS) scores were assessed preoperatively and at 6-month intervals postoperatively and return to work times/rates were assessed for 48 months. RESULTS: Patients who underwent PLF had significantly shorter surgical time and less blood loss. According to the 48-month clinical results, ODI and VAS scores were reduced significantly in the two groups, but the PLIF group showed better results than the PLF group at the last follow-up. Return to work rate was 63% in the PLF group and 87% in the PLIF group. Union rates were found to be 81% and 89%, respectively, after 24 months (p=0.154). CONCLUSIONS: PLIF is a preferable technique with respect to stability and correction, but the result does not depend on only the fusion rates. Discectomy and fusion mass localization should be considered for achieving clinical success with the fusion technique. Before performing PLIF, the association of the long operative time and high blood loss with mortality and morbidity should be taken into consideration, particularly in the elderly and disabled patients.

Free-hand placement of high thoracic pedicle screws with the aid of fluoroscopy: evaluation of positioning by CT scans in a four-year consecutive series / Colocação de parafusos pediculares na coluna torácica alta utilizando fluoroscopia: avaliação do posicionamento dos parafusos por tomografia computadorizada em uma série de casos durante quatro anos

OBJECTIVE: To evaluate the feasibility, safety and accuracy of pedicle screw placement in the upper thoracic spine using the free-hand technique with the aid of fluoroscopy; to analyze the methods used to verify correct screw positioning intra and postoperatively. METHOD: All patients with instability of the cervicothoracic or upper thoracic spine and at least one screw placed in the segment T1-T6 as part of a posterior construct entered the study. Only C-arm intraoperative fluoroscopy was used to guide screw placement. RESULTS: We obtained excellent positioning in 98.07 percent of the screws. CT scans precisely demonstrated pedicle wall and anterolateral body violations. There was no hardware failure, no neurological or vascular injury and no loss of alignment during the follow-up period. CONCLUSION: Pedicle screws can be safely placed in the upper thoracic spine when strict technical principles are followed. Only a CT scan can precisely demonstrate vertebral body and medial pedicle cortical violations.

OBJETIVO: Avaliar a factibilidade, segurança e eficácia da colocação de parafusos pediculares na coluna torácia alta utilizando apenas a fluoroscopia; analisar os métodos intra e pós-operatórios de verficação do posicionamento de parafusos. MÉTODO: Todos os pacientes com instabilidade da coluna cervico-torácica ou torácica alta e pelo menos um parafuso colocado no segmento T1-T6 foram incluídos no estudo. Apenas fluoroscopia intra-operatória foi utilizada para guiar a colocação dos parafusos. RESULTADOS: Obtivemos excelente posicionamento em 98,07 por cento dos parafusos. TC axial mostrou precisamente violações pediculares e da parede anterolateral do corpo vertebral. Não houve falência do instrumental, lesões neurológicas ou vasculares, ou perda do alinhamento sagital no período de seguimento. CONCLUSÃO: Os parafusos pediculares podem ser colocados com segurança na coluna torácica alta desde que técnicas operatórias precisas sejam executadas. Somente a TC pode demonstrar precisamente violações do corpo vertebral e da parede pedicular.

Surgery of Spinal Stenosis in Elderly Patients: Bilateral Canal Widening through Unilateral Approach

OBJECTIVE: We report an outcome of surgical treatment of the elderly patients with spinal stenosis, managed by a bilateral narrowed spinal canal widening technique through unilateral approach. METHODS: The operations were performed in 16 patients who diagnosed with spinal stenosis. All individuals had been presented with low-back pain, neurogenic claudication or radiculopathy and unresponsive to conservative treatment over six months. We perfomed hemi-laminectomy at the appropriate levels on the most symptomatic side preserving the facet joint. And the ligamentum flavum, as well as the cortical bone on the ventral surface of the contralateral laminae were removed. The spinous process was left as possible as we can, and the contralateral side of the spinal canal was decompressed completely. RESULTS: The mean age of the patients was 71 years. The mean operation time was 73 minutes. Despite of old age, the patients were able to walk in three days after the surgery. The significant pain scale improvement(7.73 to 2.68) and widening of the spinal canal diameter(7.60+/-1.75 to 17.77+/-1.47mm) were noted after the operation. No patient was presented spinal instability on their follow-up period over 24 months. CONCLUSION: The bilateral canal widening technique through the unilateral approach, minimizes the damage to the inter-spinous ligament and the inter-spinous muscle, and saves the operation time because it is not necessary to use the instruments which prevent spinal instability, despite spinal canal was sufficiently enlarged.

PLIF using Cages at the Instability Level and Additional Transpedicular Instrumental Fusion in Multilevel Degenerative Lumbar Disease

OBJECTIVE: The purpose of this study was to evaluate the efficacy of PLIF using cages on the unstable level and additional instrumented posterolateral fusion in patients with multilevel lumbar degenerative disease with segmental instability. METHODS: Clinical and radiological outcomes including the rate of bony fusion and changes in disc height, translation, and angular displacement on PLIF level, and its complications were analyzed in 28 patients (male:female=8:20) who were observed for more than 2 years (mean 30.6 months) between 1998 and 2000. RESULTS: The rate of successful fusion was 93% (26 patients). Clinical outcomes according to Prolos's classification were revealed with excellent in 10 patients (36%), good in 14 patients (50%), fair in 3 patients (10%), and poor in 1 patient (4%). The mean disc height on the PLIF level (35 levels including 6 patients with 2 levels PLIF) was changed from 0.48+/-0.11, preoperatively to 0.66+/-0.08 at 2-year follow-up by Farfan method (P<0.05). Mean vertebral body translation was decreased from 7.52+/-2.74mm, to 1.07+/-1.33mm and mean angular displacement was corrected from 11.21+/-4.43 degree to 1.03+/-0.62 degree (P<0.05). Permanent complications were relatively minimal. CONCLUSION: Favorable outcomes were achieved in 86% with relatively low surgical morbidity rates. It can be concluded that PLIF using cages on unstable lumbar segment and additional instrumented posterolateral fusion method is an effective stabilizing method for the multilevel lumbar degenerative disease with segmental instability in spite of its technical demanding and long operation time.

Progressive Quadriparesis following a Minor Trauma in a Patient with Klippel-Feil Syndrome: Case Report

Klippel-Feil syndrome is characterized by congenital fusion of cervical vertebrae with a wide range of associated anomaly. The authors present a 50-year-old Klippel-Feil syndrome patient with a minor trauma followed progressive quadriparesis. He had typical radiologic findings of type II Klippel-Feil syndrome and presented progressive myelopathy due to cord compression at foramen magnum level with cervical instability. The patient underwent craniocervical decompression and fusion. The authors reviewed the pertinent literatures and discussed this rare syndrome.

Clinical Analysis of Re-Operation after Thoracic and Lumbar Spinal Fusion Surgery

OBJECTIVE: The purpose of this study is to review retrospectively 28 patients with re-operation due to complications related to instrumentation from thoracic and lumbar spinal fusion surgery. METHODS: A total of 285 patients underwent spinal fusion surgery with instrumentation between 1996 and 2000. Of these, 11 men and 17 women(mean age 46 years, range 21 to 69 years) presented with complications related to instrumentation. Previous surgery was preformed for vertebral column instability secondary to fracture(4), spondylolisthesis(12), failed back surgery syndrome(7), osteomyelitis(1), herniated nuclus pulposus(4). All patients underwent repeated spinal surgery including removal of instrument, new instrument fixation, or I & D. The mean follow-up period after second operation was 19 months. RESULTS: The complications related instrumentation system include six interbody fusion system retropulsion, eight screw loosenings, five screw fractures, three screw malpositions, three osteomyelitis, and one donor site infection. After repeated surgery, eight became asymptomatic and did not require further treatment, but eleven showed persistent low back pain without neurological deficits and the remaining nine continued to have nerve root deficits. CONCLUSION: In conclusion, spinal fusion surgery with instrumentation offers an immediate postoperative stability of the thoracic and lumbar spine and enhances early fusion. However, it may be associated with few, but significant, complications which may permanantly. The proper selection of patients and meticulous surgical technique for surgery are probably the most important factors associated good outcomes and prevention of complications.

High Lumbar Disc Herniation Treated with A Modified Posterolateral Approach: Case Report

Generally, the posterolateral approach had been recommended in case of extraforaminal disc herniation or lateral stenosis but it has been speculated that this procedure may be feasible to posterolateral disc herniation at the high lumbar levels of the L1-L2 interspace. Topographically, a posterolateral approach should be able to access anteromedial side of the spinal canal without the risk of the bony instability and damage to the neural structures. During the past one year period, three patients with high lumbar discs at the L1-L2 level were treated by the modified posterolateral approach. This article describeds the details of this approach with pertinent literature review.

Tratamento da instabilidade degenerativa da coluna lombar com fixação transpedicular / Transpedicular lumbar fixation for degenerative lumbar instability. An analysis of 53 cases

Os autores apresentam um estudo retrospectivo dos resultados de 53 pacientes, com instabilidade degenerativa da coluna lombar e toracolombar, que foram tratados consecutivamente com fixaçãotranspedicular por via posterior usando material Socon e Spine System da Aesculap. A casuística é constituída por 27 homens e 26 mulheres, com média etária de 53,4 anos (27 a 81 anos). A média do acompanhamento foi de 15 meses. O procedimento foi feito nos casos de espondilolistesedegenerativa (25 casos), instabilidade pós-operatória (12 casos), escoliose degenerativa (7 casos), fraturas degenerativas (5 casos), canal estreito lombar (2 casos) e instabilidade segmentar (2 casos).A cirurgia consistiu em descompressão neural, fixação interna com instrumentação transpedicular e enxerto ósseo. Em 18 casos foi associado o cage metálico. Obtiveram-se 90% de resultados bons e satisfatórios pela escala de Stauffer e Coventry, com 96% de taxa de fusão e 4% de pseudo-artrose. As complicações incluíram quatro casos de radiculalgia pós-operatória em virtude do contato da raiz com o instrumental, dois de fístulas liquóricas com resolução espontânea, duas infecções (uma profunda e outra superficial) e dois casos de estenose acima do nível t ratado. Destes pacientes, sete (14%) necessi taram dereoperação. Não houve óbito nem quebra do instrumental. Os resul tados comprovaram que, apesar do cur to per íodo de acompanhamento, a fixação transpedicular é um bom método para instrumentação e tratamento das instabilidades degenerativas, oferecendo vantagens biomecânicas comparadas com outras formas de tratamento, permitindo montagens curtas, preservando segmentos adjacentes e a lordose fisiológica. A seleção apropriada dos pacientes para a cirurgia é provavelmente o fator mais importante associado com bons resultados.

The authors present the results of the treatment of 53 consecutive patients with lumbar and thoraco-lumbar spine degenerative instability by a posterior transpedicular fixation using Socon and Spine Aesculap instrumentation systems. The mean follow-up was 15 months. Surgery was performed for degenerative spondilolisthesis (25 cases), post-surgical instability (12 cases), degenerative scoliosis (7 cases), degenerative fractures (5 cases), lumbar spine stenosis (2 cases) and segmental instability (2 cases). There were 27 men and 26 women, aging from 27 to 81 years (mean 53,4), all of them complained of back pain.The surgical procedure consisted in neural decompression, transpedicular fixation and instrumentation and bone graft. In eighteen cases we associated the use of a metallic cage. The results were good or fair in 90% of the cases (according to the Stauffer and Coventry?s scale), with 96% of fusion rate and 4% of pseudarthrosis. Complications included: four cases of radiculopaty due the contact of the nerve roots with the instrumentation system; two cases of CSF leak, both clearing spontaneously; two cases of infection (one superficial, the other deep) and two cases of stenosis above the level of instrumentation. Seven (14%) of these complication cases required reoperation. There were no deaths in this series and no problems with the instrumentation device itself. We concluded that, despite the short follow-up period, the transpedicular fixation is a good methodfor treatment of degenerative instability, with biomechanical advantages if compared with other modalities of treatment. It allows short instrumentation, sparing adjacent segments and the physiological lordosis is preserved. Careful selection of the patients for surgery is probably themost important factor associated with good outcome.

A Case of Juxtafacet Cyst of the Lumbar Spine Accompanied by Spinal Instability

A 37-year old man presented with radiating pain and hypesthesia of the right leg for one year, without a history of trauma. Clinical and radiological evaluation showed that he had bilateral L5 spondylolysis, spondylolisthesis L5 on S1, and a 1cm sized round epidural mass compressing the right L5 nerve root ventral to the right L5-S1 facet joint. After L5 total laminectomy and facetectomy, followed by excision of the juxtafacet cyst, L5-S1 pedicle screw fixation and L5-S1 intertransverse bone graft fusion were successfully performed. Rare reports of juxtafacet cysts have stated that they were often accompanied by spondylolisthesis and degenerative spinal changes, and associated with trauma and spinal instability. The authors believe that since spinal instability may be one of the causes of juxtafacet cysts, the removal of these may lead to spinal fusion.

Geometric Analysis of Dural Compression in Non-traumatic Spinal Instability

We studied the extent of dural sac compression and the contributory factors involved during lumbar flexionextension motion in non-traumatic spinal instability patients. In a total of 79 patients, spinal instability at L4-L5 or L5-S1 had been clinically and radiologically diagnosed. Their lateral flexion-extension lumbar myelograms were reviewed and we selected 48 cases which had adequate lumbar mobility, and clear and unequivocal measuring points. Those patients were divived into four groups of 12, as follows: Group I: transient low back pain without radiologic abnormalities(Control); Group II: spinal instability without displacement(SIWD) had been clinically and radiologically diagnosed; Group III: symptomatic degenerative spondylolisthesis(DSL); Group IV: symptomatic isthmic spondylolisthesis(ISL). Using the OPTIMAS 5.2 image analyzing program, we measured dural AP distance(DD) at intervertebral disc level and dural area(DA) at each functional motion segment, as seen on flexion-extension lumbar myelograms. The results were as follows: (1) In the control group and SIWD group, the degree of dural sac compression was not significantly different. (2) In the DSL group, DD and DA at the L4-L5 level were markedly lower than in the control group(p<0.05). In the ISL group, DD was significantly higher(p<0.05), but DA was slightly lower than in the control group. In addition, DD and DA in the ISL group were significantly higher than in the DSL group. (3) At the L5-S1 level, these changes were variable and there were no significant trends. In conclusion, we discovered that in determining the extent of dural sac compression in spondylolisthesis, measuring both dural distance and dural area is more valuable than measuring either of these alone. This is because in this condition, anterior displacement of the vertebral body or posterior displacement of the mobile lamina plays an important role. We also found that the different mechanisms of dural sac compression seen in the DSL and ISL group, as well as the variable changes seen at the L5-S1 level, are due to anatomical characteristics.

Surgical Treatment of Unstable Thoracic and Lumbar Spine Disease Using TSRH Instrumentation

The authors present surgical experience with 33 patients who had incurred unstable thoracic or lumbar spine pathology(22 degenerative lumbar spine disease, 6 trauma, 3 tumor, 2 vertebral tuberculosis) and who were intraoperatively stabilized with the Texas Scottish Rite-Hospital(TSRH) universal instrumentation system over 20 months period. The 11 men and 22 women(mean age 45 years, range 23 to 71 years) presenting with signs or symptoms of neural compression underwent surgery consisting of neural decompression, internal fixation, and bone grafting. Spondylolisthesis were fused in situ without reduction. For thoracic and thoracolumbar junction pathology, multisegment fixations were performed. A 95% fusion rate was obtained with a mean follow-up period of 15 months. There were no cases of instrumentation failure. Major postoperative complications included 2 isolated nerve root deficits(one transient, one permanent) and 3 pulmonary embolism(one fatal). The construct design of the TSRH system offers some advantag es compared to other forms of interal fixation:simple assembly, rigid stability, safety, and ability to remove easily. This system provides a highly successful method to obtain arthrodesis for unstable thoracic or lumbar spine.

Clinical Analysis of Less Extensive Microsurgical Decompression for Lumbar Spinal Stenosis

The cases of twenty-eight patients with spinal stenosis treated by microscopic decompressive surgery from January 1991 to September 1995, were analysed in an attempt to define is clinical feature, and to evaluate the results of our modified operation technique of preventing postoperative spinal instability. The main age group of the patients were in the fifties and sixties. On plain X-ray, most lumbar spine of the patients showed degenerative change. Pain in lower back and legs were the most common symptom, and intermittent neurogenic claudication was presented in three quarters of the patients. Radiologically, the diagnosis was confirmed by either myelography, CT, and MRI or by their combination. The major etiologic factors were thickening of ligamentum flavum, hypertrophy of laminae or facet joints and associated herniated nucleus pulposus. Since a significant rate of postdecompressive instability had been reported by other authors, therefore we have decided to performed less extensive decompressive total laminectomy procedure. The outcome of our decompressive laminectomy was favorable. In patients with no preoperative instability, newly developed instability following the less extensive decompressive total laminectomy was none.

High Lumbar Disc Herniation Treated With an Anterolateral Approach: Case Report

Approaching to high lumbar level, the width of laminar decrease and conventional laminectomy for the management of L1-2 or L2-3 disc herniation may cause fracture of inferior articular facets of L1 or L2 vertebrae. We performed anterolateral approach to preserve posterior elements(destruction of which may cause later spinal instability), for the management of high lumbar disc herniation.