Sacral insufficiency fracture: a single-center experience of 185 patients with a minimum 5-year follow-up.

PURPOSE: Sacral insufficiency fracture (SIF) is a commonly underdiagnosed etiology of back pain, especially in the geriatric and osteoporotic population. In this clinical study, we present our experience of 185 patients who were diagnosed with SIF and managed either with conservative or surgical treatment with a minimum 5-year follow-up. MATERIALS AND METHOD: Patients who were diagnosed with SIF, managed either conservatively or surgically, and had a minimum 5-year follow-up medical record were included in this study. CT scans and MR imaging including coronal STIR sequence were obtained from all. Bone densitometry (DEXA) was performed to detect accompanying osteopenia or osteoporosis. Patients were treated either conservatively or surgically. VAS and ODI scores were evaluated prior to the treatment and 1st day, 10th day, 3rd month, and 1st year postoperatively. RESULTS: The mean age of 185 patients was 69.2 and the mean follow-up period was 7.23 years (range: 5-11 years). 46 (24.9%) patients had a previous spinal or spinopelvic surgery and spinal instrumentation was implemented in 22(11.89%) of them. The time interval between the fusion surgery and the diagnosis of SIF was approximately 9.48 weeks. The fracture line could be detected with the MRI in 164 patients and with the CT in 177 patients. The fracture was bilateral in 120 (64.8%) patients. 102 patients were treated conservatively, and 83 received sacroplasty. VAS and ODI scores showed better improvement in pain and functionality in the surgical management group than in the conservative management group. CONCLUSION: SIF should be considered in the differential diagnosis of back and pelvic pain, especially in elderly and osteoporotic patients. MRI with coronal STIR imaging should be a standard protocol for patients with a risk of SIF. Our results show that sacroplasty provides better and faster pain relief and recovery than conservative management.

"Skip" corpectomy technique in multilevel cervical spondylotic myelopathy and ossified posterior longitudinal ligament: Outcomes with over 10-years follow-up.

OBJECTIVE: Skip corpectomy is a surgical technique that includes C4 and C6 corpectomies and fusion via autografts and a cervical plate and is frequently performed in patients with CSM and OPLL. This study presents long-term clinical and radiological outcomes of 48 patients who underwent skip corpectomy with 10-year follow-up. METHODS: 48 patients who were diagnosed with CSM or OPLL were included. All patients underwent spinal canal decompression and fusion via skip corpectomy. Clinical assessment was performed using the JOA scoring system. The radiological assessment was performed using plain anteroposterior, lateral, and flexion-extension cervical spine radiographs; cervical spine MR imaging; and cervical spine CT scans. The spinal canal size, spinal cord occupation ratio, cervical lordosis, and T2 signal changes were evaluated preoperatively, and postoperatively. RESULTS: The mean follow-up period was 14.6 years (13-20 years). Preoperatively, the JOA score was 11.06 ± 3.09. The mean cervical lordosis was 2.08°±11.74 and the average SCOR was 62.1 ± 14.22. There was a significant improvement in SCOR in the early postoperative period. The average cervical lordosis increased to 13.81 ± 2.51 in the 2nd month and minimal loss of cervical lordosis was observed on the 10th year in two patients. Fusion was achieved in all patients, regardless of the graft type. None of the patients had implant failure and graft or hardware-related complications at the 10th-year follow-up. CONCLUSION: Skip corpectomy provides efficient decompression of the spinal cord and provides adequate sagittal alignment and fusion in patients with CSM and OPLL. Long-term radiological and clinical outcomes of the technique are favorable.

Circumferential Approach to Congenital Kyphoscoliosis with Hemivertebra: Adding on Rather than Resecting Could Be a Better Option in Older Adolescents.

OBJECTIVE: To present a new technique combining anterior release with allograft insertion and lateral fixation at the concave side of the curve, preserving the hemivertebra and posterior bilateral transpedicular fixation in patients with congenital kyphoscoliosis (CKS) who were not operated on until late adolescence, including long-term follow-up of patients, and a discussion of the literature on CKS with hemivertebra. METHODS: Two patients with CKS concomitant with hemivertebra underwent circumferential (anterior-posterior) instrumentation and fusion using a new technique. RESULTS: Patient 1 underwent a 2-stage operation, first anterior then posterior. Patient 2 was operated on circumferentially in 1 session. Both patients had >10 years of follow-up showing solid fusion of their operated spine segments. The patients were pain-free, and their body heights were comparable to healthy peers. CONCLUSIONS: In our circumferential approach, we successfully integrated the hemivertebrae in anterior fusions rather than resecting them in older adolescents with CKS. This technique decreased bleeding, shortened operative time, and promised potential benefits compared with the available techniques in the literature.

Three region spinal decompression in the same session: a case report.

BACKGROUND AND IMPORTANCE: Multiregional spinal stenosis [tandem spinal stenosis (TSS)] is not rare but operating on multiple regions at the same sitting is. Decompression of cervical and lumbar spine in the same session has a frequency of 5-25% all TSS cases, the most frequent one is TSS. Decompression in three different regions is so rare that there is only one case in the literature. We report the second. CLINICAL PRESENTATION: A 72-year-old man with pain in legs and arms, neurogenic claudication, progressive loss of balance, radiculopathy and myelopathy in lower and upper extremities whose cervical-thoracic and lumbar spinal stenosis were treated with decompressive surgery in the same session. Total time of surgery for three regions was 330 min. No complications were observed. The patient was mobilized on day 1 postoperative and was discharged from the hospital on day 3. By month 3, motor function had improved almost completely, and pyramidal findings have decreased. CONCLUSION: Multiregional spinal stenosis of three spinal regions at the same time is a rare case and these cases, surgery of three regions can be carried out in the same session respectively.

The relationship between bone canal diameter and facet tropism in cases of lumbar spinal stenosis.

Objectives: Lumbar spinal stenosis (LSS) is a condition that increases in frequency with the aging of the spine and has adverse effects on the quality of life of individuals. Facet tropism (FT) refers to the difference in the orientation of the facet joints relative to each other in the sagittal plane. This situation may be due to a developmental defect or different stimuli. In many biomechanical studies in the literature, the relationship between FT and lumbar degenerative disorders has been investigated. In this study, we aimed to investigate whether there is a relationship between anteroposterior bone canal diameter and FT in LSS cases. Materials and Methods: We retrospectively evaluated the CT and T2-weighted axial and sagittal magnetic resonance imaging of the lumbar region of 100 LSS patients who were operated on in our clinic between 2015 and 2017. For each patient, the facet joint angles, the degree of FT, and the AP diameter of the spinal canal were determined. Results: The cases were grouped according to FT types and no correlation was found between midsagittal bone spinal canal measurement and FT types. According to the results, no significant difference was found. Conclusion: As a result, because of there is no relationship between midsagittal bone canal diameter and FT, we thought that FT may be both a part of the degenerative process and a congenital origin.

Radiological and clinical comparisons of the patients with rheumatoid arthritis operated with rigid and dynamic instrumentation systems due to lumbar degenerative spinal diseases.

BACKGROUND: It is extremely difficult to treat spine disorders with stabilization in patients with rheumatoid arthritis. Because revision rates are significantly higher in rigid stabilization. To date, there is no data about patients with rheumatoid arthritis treated with dynamic stabilization. Our aim was to compare the radiological and clinical results of patients with rheumatoid arthritis who underwent lumbar rigid stabilization or dynamic stabilization with Polyetheretherketone rod (PEEK). METHODS: Patients with degenerative lumbar spine disease with rheumatoid arthritis who underwent dynamic stabilization between 2013 and 2015 and rigid stabilization between 2010 and 2012 were evaluated radiologically for adjacent segment disease, proximal junctional kyphosis, system problem (nonunion, screw loosening, instrumentation failure, pull out). It was also compared according to both the revision rates and the Visual Analog Scale and Oswestry Disability Index scores at the 12th month and 24th month. RESULTS: The difference of decrease in Visual Analog Scale and Oswestry Disability Index scores from preoperative to 12th month between patients who underwent dynamic stabilization and rigid stabilization was statistically insignificant. However, there was a significant difference of increase in Visual Analog Scale and Oswestry Disability Index scores between the 12th month and 24th month of patients who underwent rigid stabilization, compared with patients with dynamic stabilization. In patients with dynamic stabilization, the problems of instrumentation were seen less frequently. Revision rates were high in patients with rigid stabilization when compared the patients with dynamic stabilization. CONCLUSION: Radiological and clinical outcomes in patients with rheumatoid arthritis operated with dynamic stabilization are more significant when compared to rigid stabilization. These patients have lower pain and disability scores in their follow up periods. Revision rates are lower in patients with dynamic stabilization.

Clinical and radiological outcomes after correction of degenerative lumbar scoliosis with dynamic stabilization (with the help of a rigid rod); and describing an alternative technique.

Sharing clinical and radiological results in patients with degenerative lumbar scoliosis (DLS) treated surgically with dynamic system and describing an alternative technique for scoliosis correction. Between 2013 and 2018, 48 patients with flexible degenerative lumbar scoliosis (DLS) were operated with dynamic stabilization with Polyetheretherketone Rod (PEEK rod) after rigid rod application. Preoperative and postoperative scoliosis angles (standing and supine) were statistically compared. Preoperative and postoperative low back pain (LBP) Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores were compared. In addition, preoperative C7 Sagittal Vertical Axis (SVA) values and lumbar lordosis angles were compared with postoperative values. The mean follow-up period of the patients was 48.3 months (range 30-76), the mean age was 67.08 (range 49-84). While the average Cobb angle of all patients was 9.65 in preoperative supine position, the average Cobb angle with standing position was 19.73. The mean standing Cobb angle of the patients after surgery was 3.52. The mean Cobb angle in the supine position after surgery was 3.02. The difference between the preoperative and postoperative patients' Cobb angles in standing and supine position were statistically significant (p:0,000, p:0,000, respectively). The differences of VAS and ODI scores between preoperative and postoperative period were statistically significantly (p:0,000, p:0,000; respectively). Especially in patients with flexible LDS, the technique we have defined and dynamic stabilization with PEEK rod provides significant correction. There was no loss of correction in our patients during postoperative follow-up period. PEEK rod is insufficient for lordosis increase and correction of SVA values.

Any Instrument in a Surgeon's Hand can be Fatal: Unusual Iliac Artery Injury in Lumbar Spinal Deformity Surgery.

BACKGROUND: Vascular complications, which we rarely encounter during lumbosacral stabilization surgeries, can be life-threatening if they are not treated quickly. These arterial injuries occur during screw insertion. Our presentation with the common iliac artery injury during the decortication process in transverse processes with the "pedicle awl" will be the first case in the literature to our knowledge. CASE DESCRIPTION: Lumbosacral decompression and stabilization surgery was performed in a 57-year-old patient with L1-S1 spinal stenosis and scoliosis. After the stabilization process was completed, while decorticating the transverse processes with the pedicle awl, the tool fell to the paravertebral region, and then active arterial hemorrhage was observed at the surgical site. Hemostasis was achieved in the surgical field, but a rapid progressive drop was observed in the patient's blood pressure. The surgery was quickly terminated, and the patient was turned to the supine position. Vascular surgeons opened the abdomen with a midline laparotomy, and approximately 2600 mL hematoma was evacuated from the retroperitoneum. The 5-mm defect in the left common iliac artery was repaired by primary suturing. The patient had no problem in postoperative follow-up and was discharged on the 10th postoperative day. CONCLUSIONS: In these complications that we rarely encounter in lumbosacral stabilization surgeries, perioperative findings should be well evaluated, and rapid intervention should be made in cases in which vascular injury is considered. One must remember that every tool used during surgery can be dangerous even in an experienced hand.

Vertebroplasty with Decompression for Epidural Extending Vertebral Hemangiomas: An Alternative Technique.

AIM: To document the effectiveness of an alternative surgical technique with concurrent vertebroplasty and decompression without instrumentation for patients with vertebral hemangioma presenting with neural compression symptoms. MATERIAL AND METHODS: This study is a technical note and a retrospective clinical evaluation. We analyzed the data of 8 patients operated with our alternative surgical technique for vertebral hemangiomas with epidural extension and neural compression, between 2013 and 2018. The preoperative, postoperative 1st month and postoperative 12th-month Visual Analogue Scale (VAS) scores were assessed and compared. RESULTS: Five of the patients had lumbar and 3 had thoracic hemangiomas. The difference between preoperative and 1st and 12thmonth Visual Analogue Scale scores were statistically significant. None of the patients received additional intervention, stabilization, or needed a blood transfusion. CONCLUSION: This technique is a safe and minimally invasive approach for vertebral hemangiomas with epidural extension allowing decompression of the spinal cord without massive hemorrhage.

Spinal anesthesia in surgical treatment of lumbar spine tumors.

OBJECTIVE: This study aims to show the feasibility of spinal anesthesia in lumbar spinal tumor surgery; share our data and experience. PATIENTS AND METHODS: A retrospective review of 14 patients with high risk for general anesthesia due to severe comorbidities was carried out. Patients who underwent surgeries under spinal anesthesia for lumbar vertebral column or spinal cord tumors at a single center between 2007-2019 were evaluated. The final pathological diagnosis, operation time, and surgical procedures were analyzed. Also, preoperative and postoperative advantages and disadvantages were determined. A comparison was performed with other 184 patients who were operated for spinal tumors in the same period under general anesthesia. RESULTS: Maximum operation time was found 220 min, and the average operation time was 166 min. The most primary diagnosis was vertebral column metastasis. The mean age was 65.5 years. None of the patients required general anesthesia during surgery; however, two patients needed additional spinal anesthesia preoperatively, which was performed by the surgeon. Lumbar decompression and fusion were the most performed procedures. CONCLUSION: Spinal anesthesia is a feasible and useful method of anesthesia in lumbar spinal tumor surgery for especially elderly patients with American Society of Anesthesiologists (ASA) 3 or 4 score and high risk of general anesthesia.

Acute spinal epidural hematoma: A case report and review of the literature.

Spinal epidural hematoma (SEH) is a rare but a significant cause of spinal cord compression and neurologic deficits. Its etiology is usually unknown and requires emergency intervention. The present study aims to review the clinical significance, treatment strategies and clinical outcomes of traumatic SEH with a rare case presentation. Our patient was a 42-year-old female who presented with back pain and loss of sensation and strength in the legs. The patient did not have any disease and did not use anticoagulant drugs. The patient developed numbness in her legs half an hour after having a traditional back walking massage due to occasional back pain. She was paraplegic and anesthetic when seen in our clinic. Thoracic computed tomography (CT) and magnetic resonance imaging (MRI) revealed posterior epidural hemorrhage at Th3-Th4 levels. In the 12th hour, the hematoma was evacuated by an emergency decompressive hemilaminectomy. At the postoperative 24th hour, the patient had symptomatic improvement, and in the sixth month, the patient was mobilized with support. SEH is a rare condition that should be considered in patients with sudden onset of back pain and extremity weakness. Although the gold standard diagnostic tool is MRI, CT is often sufficient to avoid delayed surgery. Immediate surgical decompression (laminectomy/hemilaminectomy) should be performed in cases diagnosed with SEH with neurological deficits.

Polymethylmetacrylate Cement Augmentation of the Coccyx (Coccygeoplasty) for Fracture: A Case Report

Background: Coccydynia is a painful condition of the sacrococcygeal region, with symptoms associated with sitting and rising from a seated position. It is frequently related to trauma and idiopathic causes, and the pain is mostly chronic. Percutaneous vertebroplasty and sacroplasty are the methods that are widely used for treating compression fractures and sacral insufficiency fractures, respectively. However, the success of polymethylmethacrylate injection in the treatment of osteoporotic coccyx fractures and coccydynia is still unknown. Case Report: A 68-year-old man was admitted to our clinic with complaints of pain in the sacrococcygeal and perianal regions. In the imaging studies, a fracture line in the fifth sacral and first coccygeal segments was observed as evidenced by a bony edema. Since the patient's pain did not improve with conservative methods, we treated him with coccygeoplasty. No complication was encountered. The day after the operation, he was discharged from the hospital with complete pain relief. The patient confirmed having no pain on the third postoperative month and so did not need any analgesics. Conclusion: Coccyceoplasty may be a good treatment option for retractable pain in patients with acute or subacute osteoporotic coccygeal fractures and coccydinia with edema.

Traumatic Sequestrated Thoracic Disc Herniation; A Case Report.

AIM: To present a case (3rd report in the literature, 1st case with sequestrated-extruded disc herniation) of thoracic disc herniation that was sequestrated only by ligamentous injury without thoracic osseous pathology. MATERIAL AND METHODS: We reviewed the diagnosis and treatment of a 25-year-old man presenting with paraplegia after a car accident. RESULTS: In this case, no pathology was seen on the X-ray and spinal computed tomography (CT), and the paraplegia of the patient was unexplained in the first examination. Subsequent spinal MRI revealed a T12-L1 cranial-migrated soft disc herniation, which was surgically treated and neurologically recovered within weeks after surgery. CONCLUSION: Traumatic thoracic disc herniations are extremely rare and can be seen without any obvious signs of trauma on X-ray and spinal CT. A spinal MRI scan helps with diagnosis, while rapid surgical treatment (decompression) supports excellent recovery.

Polyetheretherketone Rods in Lumbar Spine Degenerative Disease: Mid-term Results in a Patient Series Involving Radiological and Clinical Assessment.

AIM: To evaluate the satisfaction of patients operated due to degenerative lumbar spinal diseases with dynamic stabilization placing polyetheretherketone (PEEK) rods and to share their radiological and clinical results (mid-term) with visual analogue scale (VAS) and Oswestry disability index (ODI) scores. MATERIAL AND METHODS: The preoperative and postoperative low back pain, leg pain VAS and ODI scores of 172 patients who were operated for degenerative spinal diseases, were evaluated. Preoperative and postoperative lumbar lordosis were compared. The patients included to the study were evaluated postoperatively around the 2nd year with lumbar MRI by means of adjacent segment disease (ASD) and additional problems. RESULTS: A statistically but not radiologically-by means of sagittal profile reconstruction-significant increase in lumbar lordosis angle was achieved. Significant improvement was observed in the comparison of preoperative and postoperative period in the analysis of patients’ preoperative low back pain (p < 0.0001), and decompression-related leg pain VAS scores (p < 0.0001). Significant improvement was also observed in the ODI scores of the patients (p < 0.0001). Among 172 patients with dynamic stabilization, there were 10 patients who underwent reoperation (5.8%). CONCLUSION: Although it is statistically significant, it can be seen that the lumbar lordosis can not be corrected at significant degrees radiographically in the operations performed with the PEEK rod. Dynamic stabilization with PEEK rod is insufficient for sagittal correction, but the mid-term results reached satisfactory reoperation rates clinically outcomes. Rate of ASD is quite low in stabilization with PEEK rod.

Phantom Radicular Pain Treated with Lumbar Microdiscectomy: A Case Report.

Phantom limb pain in amputee patients is not well defined in the literature. Also, there is still no clear information on the definition and treatment of phantom radicular pain, in which amputee patients have radicular pain. This phenomenon, called phantom radiculitis or phantom radiculopathy, has been described in a limited number of cases. If a pathological condition that may cause radicular pain is present in amputee patients, the severity of phantom pain increases. Degenerative disc disease is the most common cause of phantom radicular pain. Spinal injection can be used to control this pain. Surgical treatment can be performed when adequate pain control cannot be achieved. The phantom radicular pain of the patient is expected to improve after surgical or medical treatment. The pain is expected to descend to previous levels if phantom pain was present previously. In this paper, we present and discuss a case of phantom radicular pain in the context of treatment with lumbar microdiscectomy.

Clinical Comparison Between Patients Operated for Unilateral Radiculopathy via a Contralateral (Facet-Sparing) and Ipsilateral Side Approach.

AIM: To compare clinical outcomes of the patients operated from the contralateral or ipsilateral side for unilateral radiculopathy in spinal stenosis. MATERIAL AND METHODS: This was a retrospective study. Twenty patients were listed as Group 1 (Contralateral) with unilateral radiculopathy and spinal stenosis with/without lateral recess syndrome or foraminal stenosis. Decompression from opposite side of radiculopathy was performed to Group 1 patients. Decompression from the radiculopathy side was performed to the patients in Group 2 (Ipsilateral). Twenty eight patients were listed as Group 2. Back pain visual analogue scale (VAS) score and leg pain VAS score were assessed at preoperative, postoperative 1st month and postoperative 12th month. The results were compared statistically. RESULTS: Two patients were excluded because of reoperation at the 2nd month from the Group 2 to assessment 12th month VAS score. There was no significant difference between two groups at 1st month back pain VAS and leg pain VAS scores. There was no significant difference between two groups at 12th month back pain VAS and leg pain VAS scores. Dynamic stabilization was performed at 2nd month to two patients after the first operations for instability. So, there was no difference in clinical outcomes between the patients treated by contralateral approach and ipsilateral approach when instability did not occur. However, there is a risk of instability of the same side approach and surgery owing to shaving of the facet joint. CONCLUSION: In the contralateral approach, the recess of the contralateral side and foramen can be better seen than in the ipsilateral approach. So, this is a facet-sparing approach to spinal stenosis with/without lateral recess syndrome or foraminal stenosis with unilateral radiculopathy. The contralateral approach to unilateral radicular complaints is quite effective. With this approach, facet joints are protected from possible instability.

The Effect of Technological Devices on Cervical Lordosis.

PURPOSE: There is a need for cervical flexion and even cervical hyperflexion for the use of technological devices, especially mobile phones. We investigated the effect of this use on the cervical lordosis angle. MATERIAL AND METHODS: A group of 156 patients who applied with only neck pain between 2013-2016 and had no additional problems were included. Patients are specifically questioned about mobile phone, tablet, and other devices usage. The value obtained by multiplying the year of usage and the average usage (hour) in daily life was determined as the total usage value (an average hour per day x year: hy). Cervical lordosis angles were statistically compared with the total time of use. RESULTS: In the general ROC analysis, the cut-off value was found to be 20.5 hy. When the cut-off value is tested, the overall accuracy is very good with 72.4%. The true estimate of true risk and non-risk is quite high. The ROC analysis is statistically significant. CONCLUSION: The use of computing devices, especially mobile telephones, and the increase in the flexion of the cervical spine indicate that cervical vertebral problems will increase even in younger people in future. Also, to using with attention at this point, ergonomic devices must also be developed.

Classification of Radiological Changes in Burst Fractures.

AIM: Burst fractures can occur with different radiological images after high energy. We aimed to simplify radiological staging of burst fractures. METHODS: Eighty patients whom exposed spinal trauma and had burst fracture were evaluated concerning age, sex, fracture segment, neurological deficit, secondary organ injury and radiological changes that occurred. RESULTS: We performed a new classification in burst fractures at radiological images. CONCLUSIONS: According to this classification system, secondary organ injury and neurological deficit can be an indicator of energy exposure. If energy is high, the clinical status will be worse. Thus, we can get an idea about the likelihood of neurological deficit and secondary organ injuries. This classification has simplified the radiological staging of burst fractures and is a classification that gives a very accurate idea about the neurological condition.

Management of Obstructive Hydrocephalus in Pregnant Patient.

De novo obstructive hydrocephalus is a rare event during pregnancy. There are only case reports presented in literature. We aimed to discuss the pathophysiological basis and management options with an exemplary case presentation and review of the current literature. A 28-year-old G2P1 patient presented to our clinic with headache, vomiting, and deteriorated vision at the 8th week of gestation. She had no history of central nervous system infection or trauma. A brain magnetic resonance imaging was obtained. There was hydrocephalus due to cerebral aqueduct stenosis (Evan's index of 58%). She was managed conservatively with bed rest and diuretics; however, she got no relief. A ventriculoperitoneal shunt was inserted at the 13th week of gestation. At the 38th week, she had cesarean section (C/S) due to previous history of C/S in the first pregnancy and present cord entanglement of the fetus. C/S was conducted under epidural anesthesia after conforming she had no increased intra cranial pressure findings. Delivery was uneventful with a healthy newborn. Obstructive hydrocephalus is a very rare complication during pregnancy. Hydrocephalus becomes obvious and necessitates treatment, before the third trimester of pregnancy. Timely diagnosis, especially differentiation from preeclampsia, is a life-saving step. If no complication happens during intervention for hydrocephalus, spontaneous vaginal delivery is a safe way of delivery for both mother's and newborn's well-being. C/S should be saved for obstetrical indications and can be conducted under epidural anesthesia if intracranial pressure is kept under control. Interdisciplinary approach of neurosurgeons and anesthesiologists is pivotal for delicate care of the patient and the baby.