ABSTRACT
BACKGROUND: Biomechanical resistance and surgical morbidity of spinal posterior pedicle screw fixation depend on the intraosseous position of the implants. Upper thoracic pedicle screws are particularly demanding given their convergence and thin character. We present our experience as military surgeons of freehand placement of upper thoracic pedicle screws supported solely by anteroposterior, i.e., frontal x-ray fluoroscopy. METHODS: A single-center retrospective analysis was performed at Sainte-Anne Military Teaching Hospital between 2017 and 2024 of patients in whom upper thoracic pedicle screw (T1-T5) were placed with anteroposterior fluoroscopy guidance only. RESULTS: Analysis included 23 patients (mean age 59; male/female ratio 3.6; 16 traumatic lesions and 7 neoplastic lesions) in whom 15 cervicothoracic junction fixation and 8 upper thoracic spine surgeries were performed. Of 124 screws inserted (T1-T5), 85% (106/124) were graded 0 (Gertzbein-Robbins scale), whereas 14.5% (18/124) displayed some degree of misplacement (grades 1-3). All T1 screws (22/22) were accurately placed compared with 83% (20/24) of T2 screws, 88% (30/34) of T3 screws, 85% (17/20) of T4 screws, and 71% (17/24) of T5 screws, with no clinical complications. There were 3 surgical revisions (1 asymptomatic misplaced screw, 2 mechanical failures in trauma). Finally, 92.7% (51/55) of the screws inserted during working hours were accurately placed compared with 79.7% (55/69) inserted during after-hours surgeries (P = 0.039). CONCLUSIONS: Clinically, placement of upper thoracic pedicle screws supported solely by anteroposterior fluoroscopy appears to be safe. The surgical technique is simple enough to be used in settings with limited resources, such as a mobile field surgical team.
ABSTRACT
BACKGROUND: Some young patients with preserved functional status suffering from aggressive isolated neoplastic disease of the thoracic spine may be eligible from curative en-bloc vertebrectomy surgical treatment. METHOD: Long-segment posterior pedicle screw fixation is performed. Complete excision of the posterior arch and of ribs posterior aspect is performed. Finger blunt dissection is performed between vertebral body, pleura, and aorta allowing to place a soft abdominal valve and then Gigli saws surrounding the anterior aspect of the spine, in order to saw the upper and the lower discs. Unilateral temporary rod is placed. The vertebral body is dislodged from posterior ligament and then removed by circling laterally around spinal cord. An expandable vertebral implant is placed. CONCLUSION: Posterior en-bloc thoracic vertebrectomy is a highly technical yet achievable procedure which carries a curative intent for isolated neoplastic spine lesions.
Subject(s)
Spinal Neoplasms , Thoracic Vertebrae , Humans , Thoracic Vertebrae/surgery , Thoracic Vertebrae/diagnostic imaging , Spinal Neoplasms/surgery , Spinal Neoplasms/diagnostic imaging , Pedicle Screws , Treatment OutcomeABSTRACT
Combined deficit of the four lower cranial nerves (CN IX, X, XI, and XII) was originally described by French physicians Collet (1915) and Sicard (1917) during World War I. To date though, this rare neurological clinical picture lacks systematic evidence regarding its epidemiology, clinical presentation, treatment strategies, and outcome. We conducted a systematic review and meta-analysis concerning Collet-Sicard syndrome (CSS) on Medline database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The research yielded 84 articles among which 73 individual case reports were eventually retained. Mean age was 53.7 (± 16) years old and the male-to-female ratio was 1.8/1. CSS was firstly caused by tumors (38.4%), following by vascular etiologies (28.8%), trauma (16.4%), and infection (6.8%), among others. Temporary enteral nutrition was required for 17 patients (23.3%). The four CN presented significant chances of complete or partial recovery: 52.1% for CN IX ( p < 0.001), 46.6% for CN X and CN XII ( p < 0.001), and 39.7% for CN XI ( p = 0.002). Tumoral causes presented significantly lower chances of favorable CN recovery (7.1%) compared to infection (60%), vascular (52.4%), and trauma (41.7%) ( p < 0.001). Older age (> 53 years old) was not associated with a dismal CN prognostic ( p = 0.763). Most patients (71.2%) presented a favorable outcome (Glasgow Outcome Scale score ≥ 4). All the patients who died (6.8%) suffered from skull base tumors. CSS is a rare condition requiring prompt clinical and radiologic diagnostic and multidisciplinary management. Vascular or infectious-related CSS seem to present a rather good prognostic, closely followed by trauma, whereas tumoral-related CSS seem to suffer from a more dismal prognostic.
ABSTRACT
Unstable trauma lesion of the spinopelvic junction, including U-shaped sacral fractures and Tile C pelvic ring disruptions, require surgical stabilization in order to realign the bone arches of the pelvis thus reducing the upcoming orthopaedic impairment during sitting, standing, and walking positions, decompress the nerves roots of the cauda equina in a view of reducing neurological impairment, and allow early weight bearing. Even though posterior open modified triangular spinopelvic fixation is particularly efficient for treating unstable trauma lesions of the spinopelvic junction, it may not be sufficient alone in order to prevent long-term counter-nutation, i.e. rotation and anteflexion deformity of the anterior pelvis under load bearing conditions. Such progressive deformation is caused by either the slight rotation of the iliac connectors within the head of iliac screws for spinopelvic constructs, or the slight rotation of sacral cancellous bone around transsacral screws in case of percutaneous procedure. Regardless of the posterior surgical technique that is used, complementary anterior pelvic fixation appears mandatory in order to prevent such deformation over time, which can lead to pelvic asymmetry and then gait imbalance.
Subject(s)
Fracture Fixation, Internal , Pelvic Bones , Sacrum , Spinal Fractures , Humans , Sacrum/surgery , Pelvic Bones/surgery , Pelvic Bones/injuries , Fracture Fixation, Internal/methods , Spinal Fractures/surgery , Weight-Bearing/physiology , Bone Screws , Pelvis/surgerySubject(s)
Laminectomy , Lumbar Vertebrae , Pedicle Screws , Spinal Fractures , Thoracic Vertebrae , Humans , Spinal Fractures/surgery , Spinal Fractures/complications , Laminectomy/methods , Thoracic Vertebrae/surgery , Lumbar Vertebrae/surgery , Kyphoplasty/methods , Male , Spinal Stenosis/surgery , Titanium , Fracture Fixation, Internal/methods , Plastic Surgery Procedures/methods , AdultABSTRACT
Unstable traumas of the spinopelvic junction, which include displaced U-shaped sacral fractures (Roy-Camille type 2 and type 3) and Tile C vertical shear pelvic ring disruptions, occur in severe traumas patients following high speed traffic accident or fall from a height. These unstable traumas of the spinopelvic junction jeopardize one's ability to stand and to walk by disrupting the biomechanical arches of the pelvis, and may also cause cauda equina syndrome. Historically, such patients were treated with bed rest and could suffer a life-long burden of orthopedic and neurological disability. Since Schildhauer pioneer work back in 2003, triangular spinopelvic fixation, whether it is performed in a percutaneous fashion or by open reduction and internal fixation, allows to realign bone fragments of the spinopelvic junction and to resume walking within three weeks. Nevertheless, such procedure remains highly technical and it not encountered very often, even for spine surgeons working in high-volume level 1 trauma centers. Hence, this visual technical note aims to provide a few tips to guide less experience surgeons to complete this procedure safely.
Subject(s)
Bone Screws , Fracture Fixation, Internal , Pelvic Bones , Sacrum , Spinal Fractures , Humans , Sacrum/surgery , Sacrum/injuries , Fracture Fixation, Internal/methods , Fluoroscopy/methods , Pelvic Bones/injuries , Pelvic Bones/surgery , Spinal Fractures/surgery , Ilium/surgery , Fractures, Bone/surgery , Pelvis/surgerySubject(s)
Fracture Fixation, Internal , Lumbar Vertebrae , Pelvic Bones , Sacrum , Spinal Fractures , Humans , Sacrum/injuries , Sacrum/surgery , Sacrum/diagnostic imaging , Fracture Fixation, Internal/methods , Spinal Fractures/surgery , Spinal Fractures/diagnostic imaging , Pelvic Bones/injuries , Pelvic Bones/surgery , Pelvic Bones/diagnostic imaging , Lumbar Vertebrae/surgery , Lumbar Vertebrae/injuries , Bone Screws , Treatment OutcomeABSTRACT
BACKGROUND: Symptomatic spinal epidural hematoma (SSEH) is one of the most feared complications and source of litigation in spine surgery. Its occurrence rises up to 2% in minimally invasive spine surgery. In parts of the world where the population is aging, more fragile patients are expected to undergo degenerative spine surgery. Management of the SSEH includes emergent spine MRI, though some experts advocate for direct second-look surgery without imaging. Then, an urgent revision surgery under general anesthesia for hematoma evacuation is warranted. We report the case of a threatening SSEH in an 88-year-old patient after lumbar spine stenosis surgery. In order to spare a second general anesthesia for this fragile patient, we opted for a percutaneous ultra-sound guided drainage of the hematoma under local anesthesia as a first line treatment. The procedure was successful, we report an instant relief of his neurological deficit while performing the procedure. CONCLUSION: Ultra-sound guided percutaneous drainage of hyperacute SSEH successfully avoided a revision surgery. It spared a second general anesthesia in a fragile patient. This procedure could be an alternative first-line treatment of SSEH for fragile patients.
Subject(s)
Decompression, Surgical , Hematoma, Epidural, Spinal , Lumbar Vertebrae , Postoperative Complications , Spinal Stenosis , Humans , Hematoma, Epidural, Spinal/etiology , Hematoma, Epidural, Spinal/surgery , Spinal Stenosis/surgery , Male , Aged, 80 and over , Decompression, Surgical/methods , Lumbar Vertebrae/surgery , Drainage/methods , Ultrasonography, Interventional/methods , Magnetic Resonance ImagingABSTRACT
Neurosurgical approach to lesions located in the occipital lobes or in the posterior fossa require very specific and time-consuming patient installations, such as the park bench position, the prone position, or the sitting position. Nevertheless, each of these position present major drawbacks regarding specific installation-related adverse events and potentially serious neurosurgical complications such as venous air embolism, iatrogenic intracranial hypertension, and supratentorial remote hematoma just to cite a few. In order to provide neurosurgeons with a simpler, physiologically-respective, easily tolerated, less time-consuming, and less provider or specific adverse events patient installation, Ochiai (1979) introduced the supine modified park-bench / lateral decubitus position. Given that this patient position has not gained wide visibility among the neurosurgical community despite its obvious numerous advantages over its classic counterparts, we provide our experience using this installation for neurosurgical approach to lesions located in the occipital lobes and in the posterior fossa.
Subject(s)
Cranial Fossa, Posterior , Neurosurgical Procedures , Occipital Lobe , Patient Positioning , Humans , Occipital Lobe/surgery , Neurosurgical Procedures/methods , Patient Positioning/methods , Cranial Fossa, Posterior/surgery , Supine Position , Male , PostureSubject(s)
Cerebrospinal Fluid Leak , Postoperative Complications , Humans , Cerebrospinal Fluid Leak/etiology , Postoperative Complications/etiology , Pituitary Neoplasms/surgery , Male , Female , Sphenoid Bone/surgery , Middle Aged , Neurosurgical Procedures/adverse effects , Magnetic Resonance ImagingSubject(s)
Cauda Equina Syndrome , Hematoma, Subdural, Acute , Magnetic Resonance Imaging , Aged , Humans , Male , Cauda Equina Syndrome/surgery , Cauda Equina Syndrome/diagnosis , Hematoma, Subdural, Acute/surgery , Hematoma, Subdural, Acute/diagnosis , Hematoma, Subdural, Spinal/complications , Hematoma, Subdural, Spinal/surgery , Spinal Cord Compression/surgeryABSTRACT
In large-scale naval battles during World War II, sailors sometimes sustained serious lower limb injuries when explosion blast of sea mines was transmitted from underneath through the metal deck of the ships. Some of these sailors were thrown in the air due to the blast and sustained axial trauma of the spine when they landed on the hard deck, which was thus called a deck slap by Captain Joseph Barr in 1946, among others. Nowadays, this peculiar mechanism has shifted to the civilian setting. Tourists unaware of the danger may sustain spine compression fractures when they sit at the bow of speed boats while underway on a calm sea. When the craft unexpectedly crosses the wake of another ship, tourists are thrown a few feet in the air before suffering a hard landing on their buttocks. This historical vignette is presented as a preventive message to help to reduce this poorly known yet avoidable "summer wave of vertebral fractures."