Handheld Osteotome Laminectomy in Cadavers and a Case Study.

Laminectomy is a commonly performed surgery to decompress the spinal canal to relieve spinal canal stenosis secondary to a variety of etiologies such as degenerative spinal changes, fractures, tumors, vascular lesions, and infections. Advances in technologies have allowed for more precise osteotomies and offer more protection to nearby structures; however, these technologies may not always be available at some facilities. To the best of the authors' knowledge, we describe an innovative technique to perform laminectomy using a handheld osteotome, which is widely available and at low cost. Our experience with cadavers and a case study shows that the technique appears to be safe and effective and may have the potential to reduce the procedure length of a laminectomy.

Impact of Chronic DMARD Therapy in Patients With Rheumatoid Arthritis Undergoing Surgery of the Craniovertebral Junction: A Multi-center Retrospective Study.

STUDY DESIGN: A multi-centered retrospective review from five institutions. OBJECTIVE: The aim of this study was to determine whether continuing or withholding disease-modifying antirheumatoid drugs (DMARDs) in the perioperative period affect outcomes in rheumatoid arthritis (RA) patients undergoing arthrodesis at the craniovertebral junction SUMMARY OF BACKGROUND DATA.: RA is a chronic systemic inflammatory disease that affects the cervical spine and is treated with DMARDs. Some advocate withholding DMARDs in the perioperative period due to concern for the cytotoxic effects of these medications. However, the impact of DMARDs in the perioperative period is not well understood. METHODS: A multicenter retrospective study from five affiliated institutions was performed. Adult patients with RA on chronic DMARDs undergoing posterior arthrodesis of the craniovertebral junction (occipital-cervical or atlanto-axial arthrodesis) were identified. Patients were stratified based on whether DMARD therapy was continued (C group) or discontinued (DC group) in the perioperative period. The primary outcome was the need for reoperation and reason for reoperation. RESULTS: Thirty-nine patients met inclusion criteria, 19 in C group and 20 in DC group. Average follow-up time was 42 months. Four patients (three in DC group and one in C group) required reoperation. Two patients from the DC group required readmission secondary to RA flare-up. CONCLUSION: Our cohort of RA patients who underwent occipital-cervical and C1/C2 posterior arthrodesis showed no significant differences in surgical complications when DMARD therapy was continued or discontinued in the perioperative period. The decision to continue or discontinue DMARD therapy in the perioperative period is at the discretion of the treating physician, but we encourage physicians to counsel patients regarding this theoretical risk and their tolerance of the medications as well as the risk of RA flare-up. Factors such as overall health, disease burden, nutrition, bone quality, smoking status, and other comorbid conditions are likely to have a larger influence on perioperative complications. LEVEL OF EVIDENCE: 3.

The relationship between cervical lordosis and Nurick scores in patients undergoing circumferential vs. posterior alone cervical decompression, instrumentation and fusion for treatment of cervical spondylotic myelopathy.

The loss of regional cervical sagittal alignment and the progressive development of cervical kyphosis is a factor in the advancement of myelopathy. Adequate decompression of the spinal canal along with reestablishment of cervical lordosis are desired objective with regard to the surgical treatment of patients with cervical spondylotic myelopathy. A retrospective chart review was conducted in which patients who underwent either a combined anterior/posterior instrumentation and decompression or a posterior alone instrumentation and decompression for the treatment of CSM at our institution were identified. Any patient undergoing operative intervention for trauma, infection or tumors were excluded. Similarly, patients undergoing posterior instrumentation with constructs extending beyond the level of C2-C7 were similarly excluded from this study. A total of 67 patients met the inclusion criteria for this study. A total of 32 patients underwent posterior alone surgery and the remaining 35 underwent combined anterior/posterior procedure. Radiographic evaluation of patient's preoperative and postoperative cervical lordosis as measured by the C2-C7 Cobb angle was performed. Each patient's preoperative and postoperative functional disability as enumerated by the Nurick score was also recorded. Statistical analysis was conducted to determine if there was a significant relationship between improvement in cervical lordosis and improvement in patient's clinical outcomes as enumerated by the Nurick Score in patients undergoing posterior alone versus combined anterior/posterior decompression, instrumentation and fusion of the cervical spine.

Unusual Metastasis of Papillary Thyroid Cancer to the Thoracic Spine: A Case Report, New Surgical Management Proposal, and Review of the Literature.

Papillary thyroid carcinoma (PTC) is significantly more common than follicular thyroid carcinoma (FTC), yet FTC has a much higher tendency to metastasize to the spinal column. We present a rare case of a metastatic thoracic spinal column lesion originating from the PTC. Thyroid carcinoma is known to be highly vascular with a significant tendency to hemorrhage during surgical resection. This increased tendency to hemorrhage leads to unanticipated intraoperative risks when the type of cancer is not diagnosed before surgical resection. Complications related to intraoperative bleeding can be prevented by visualization using angiography and preoperative embolization. The type of cancer is ideally diagnosed before tumor resection either by the standard metastatic workup or histologically after the biopsy. However, limitations exist in these methods, therefore, hypervascular tumors such as metastatic thyroid cancer can go undiagnosed until after surgical resection. In addition to our case report, we present a review of the literature regarding diagnostic and treatment strategies for hypervascular thyroid tumors and propose a new algorithm for the surgical management of spinal tumors with an unknown origin for optimization of preoperative and perioperative care.

Are External Cervical Orthoses Necessary after Anterior Cervical Discectomy and Fusion: A Review of the Literature.

INTRODUCTION & BACKGROUND: The use of external cervical orthosis (ECO) after anterior cervical discectomy and fusion (ACDF) varies from physician to physician due to an absence of clear guidelines. Our purpose is to evaluate and present evidence answering the question, "Does ECO after ACDF improve fusion rates?" through a literature review of current evidence for and against ECO after ACDF.  REVIEW: A PubMed database search was conducted using specific ECO and ACDF related keywords. Our search yielded a total of 1,267 abstracts and seven relevant articles. In summary, one study provided low quality of evidence results supporting the conclusion that external bracing is not associated with improved fusion rates after ACDF.  The remaining six studies provide very low quality of evidence results; two studies concluded that external bracing after cervical procedures is not associated with improved fusion rates, one study concluded that external bracing after cervical procedures is associated with improved fusion rates, and the remaining three studies lacked sufficient evidence to draw an association between external bracing after ACDF and improved fusion rates. CONCLUSION: We recommend against the routine use of ECO after ACDF due to a lack of improved fusion rates associated with external bracing after surgery.

Comparison Between Gearshift And Drill Techniques For Pedicle Screw Placement By Resident Surgeons.

BACKGROUND: Various techniques have been described for pedicle screw placement with established clinical and radiological success. Suboptimal screw trajectories can compromise bony purchase and, worse yet, cause neurological and vascular injuries. Thus, it is of paramount importance to achieve maximum accuracy of screw placement. Our objective is to evaluate the accuracy of pedicle screw placement in the thoracolumbar spine by resident surgeons. Two popular techniques, gearshift versus drill, were compared. METHODS: This is a a cadaveric surgical technique comparison study. Six resident surgeons instrumented the spine from T1 to S1 using both gearshift and drill techniques. Each pedicle was randomly assigned to either of the techniques. Pedicle screws were placed freehand without radiographic guidance. Violations (medial, lateral, anterior, superior and inferior) were recorded by studying the computerized tomographic scans of instrumented cadavers by blinded observers. Critical perforations were defined as greater than 2mm breach of the pedicle wall. RESULTS: A total of 100 vertebrae (200 pedicles) were instrumented in the six cadavers. 103 pedicles were breached (51.5% of total pedicles). Lateral violations were the most encountered (65% of violations, 67 total, 48 critical, 19 noncritical) followed by medial (24%, 25 total, 13 critical, 12 noncritical), and the rest were anterior (3%), superior (4%) and inferior (4%). There was no overall difference in violations comparing the gearshift technique (49.5%, 51 total, 37 critical, 14 noncritical) with drill technique (50.5%, 52 total, 33 critical, 19 noncritical). Analyzing the breaches at individual vertebra indicated most violations at T6 (11), T5 (10), followed by T3 (9) and T4 (9), decreasing towards the lumbosacral vertebrae. CONCLUSION: The results of this study suggest that the gearshift and drill techniques for placement of pedicle screws in the thoracolumbar spine fare similarly with regards to risk of breach when applied by resident surgeons.

Functional radiography in examination of spondylolisthesis.

OBJECTIVE: Despite the predominant use of standing flexion-extension radiography for quantifying instability in isthmic and degenerative spondylolisthesis, other functional radio-graphic techniques have been presented in the literature. CONCLUSION: The current evidence reported in the literature is insufficient to influence how the results of these other functional radiographic techniques should affect clinical management; however, it does raise doubts regarding the accuracy and reliability of standing flexion-extension radiography in this setting. Based on the currently available evidence and until randomized studies are performed to assess the efficacy of functional radiographic techniques in directing clinical decision making, positioning schemes other than traditional standing flexion-extension may be considered as options in the evaluation of patients with symptomatic isthmic and degenerative spondylolisthesis in which standard flexion-extension radiographs fail to show pathologic instability.

Minimally invasive extracavitary approach for thoracic discectomy and interbody fusion: 1-year clinical and radiographic outcomes in 13 patients compared with a cohort of traditional anterior transthoracic approaches.

OBJECT: Open transthoracic approaches, considered the standard in treating thoracic disc herniation (TDH), are associated with significant comorbidities. The authors describe a minimally invasive lateral extracavitary tubular approach for discectomy and fusion (MIECTDF) to treat TDH. METHODS: In 13 patients (5 men, 8 women; mean age 51.8 years) with myelopathy and 15 noncalcified TDHs, the authors achieved a far-lateral trajectory by dilating percutaneously to a 20-mm working portal docked at the transverse process-facet junction, which then provided a corridor for a near-total discectomy, bilateral laminotomies, and interbody arthrodesis requiring minimal cord retraction. A cohort of 11 demographically comparable patients treated via transthoracic approaches was used as control. RESULTS: Preoperative Frankel grades were B in 1 patient, C in 4, D in 5, and E in 3, whereas at mean of 10 months, 11 had Grade E function and 2 had Grade D function. Mean surgical metrics were operating room time 93.75 minutes, blood loss 33 ml, and hospital stay 3.1 days. Complications included 4 transient paresthesias, 1 CSF leak, 1 abdominal wall weakness, and 3 nonwound infections. One-year follow-up MR imaging revealed full decompression in all cases and no cage migration. Mean visual analog scales scores preoperative, at 6 weeks, 3 months, and 1 year were 5.6, 4.5, 3.2, and 1.2, respectively. No differences existed in preoperative clinical and radiographic profile of the study and control groups. Compared with controls, the MIECTDF group achieved superior scores in all metrics (p < 0.01) except for equivalent 1-year neurological outcomes. CONCLUSIONS: Compared with transthoracic procedures, MIECTDF effectively decompressed the spinal canal, yielding identical 1-year radiographic and clinical outcomes to those seen in controls, while producing superior clinical scores in the interim. Thus, MIECTDF is the authors' treatment of choice for TDH.

Minimally invasive operative management for lumbar spinal stenosis: overview of early and long-term outcomes.

Standard open posterior decompression is well established and familiar to virtually all spine surgeons. However, this traditional surgical treatment of lumbar spinal stenosis (LSS) is often associated with significant postoperative pain, disability, and dysfunction. This article reviews the use of a minimally invasive microendoscopic approach for bilateral decompression of lumbar stenosis by way of a unilateral approach. This technique has been shown to provide symptomatic relief equivalent to that of open discectomy, with significant reductions in operative blood loss, postoperative pain, hospital stay, and narcotic usage. Furthermore, the article explains the rationale, indications, and surgical techniques for minimally-invasive LSS surgery and presents the authors' 4-year outcomes data.

Treatment of lumbar spinal stenosis with a total posterior arthroplasty prosthesis: implant description, surgical technique, and a prospective report on 29 patients.

OBJECT: Total disc replacement is an alternative to lumbar fusion, but patients with spinal stenosis, spondylolisthesis, and facet arthropathy are often excluded from this procedure because increased adjacent-segment motion can exacerbate dorsal spondylotic changes. In such cases of degenerative spondylolisthesis with stenosis, decompression and fusion remain the gold standard of treatment. To avoid attendant loss of motion at the treated segment, the TOPS system is a novel total posterior arthroplasty prosthesis that allows for an alternative dynamic, multiaxial, three-column stabilization and motion preservation. The purpose of this study is to report preliminary surgical data and clinical outcomes in patients treated with the TOPS lumbar total posterior arthroplasty system. METHODS: Twenty-nine patients were enrolled in a nonrandomized, multicenter, prospective pilot study outside the US. All patients had spinal stenosis and/or spondylolisthesis at L4-5 due to facet arthropathy. Radiographs and scores on outcome measures including the visual analog scale (VAS) for pain, Oswestry Disability Index (ODI), Short Form-36, and Zurich Claudication Questionnaire were prospectively recorded before surgery and at 6-week, 3-month, 6-month, and 1-year intervals after surgery. Prior to instrumentation, a bilateral total facetectomy and laminectomy at L4-5 or L3-4 was performed via a standard midline posterior approach. After decompression, the TOPS screws were inserted into four pedicles to achieve maximal purchase with triangulating bicortical trajectories. An appropriately sized TOPS arthroplasty implant was then applied. The mean surgical time was 3.1 hours, and patients' clinical status improved significantly following treatment with the TOPS device. The mean ODI score decreased compared with baseline by 41% at 1 year, and the 100-mm VAS score declined by 76 mm over the same time period. Radiographic analysis showed that lumbar motion was maintained, disc height was preserved, and no evidence of screw loosening was found. No device malfunctions or migrations and no device-related adverse events were reported during the study. CONCLUSIONS: The TOPS total posterior arthroplasty system represents a novel, dynamic, posterior arthroplasty device that provides multiaxial stability in flexion, extension, rotation, and lateral bending after total facetectomy and neural decompression. The surgical data indicate that it can be safely applied via a traditional approach with low surgical morbidity and excellent 1-year functional and radiographic outcomes in patients with degenerative spondylolisthesis accompanied by stenosis and back pain.