New minimally-invasive approach in adult for Chiari I malformation.

BACKGROUND: Chiari I malformation is defined by tonsillar herniation through the foramen magnum. There is no consensus on the treatment of Chiari malformation. A simple follow-up is recommended for asymptomatic cases. The classic approach is the midline sub-occipital craniotomy. METHODS: For four years, we operated on six patients with Chiari malformation I using our endoscopic minimally invasive sub-occipital approach. We compared the results with six other patients operated by the classical sub-occipital approach. RESULTS: Patients operated by endoscopic approach had shorter hospital stays, and wounds healed faster and smoother. Mid-term results were similar in the two groups. CONCLUSION: This paper proposes a new endoscopic Minimally invasive paramedian sub-occipital approach for Chiari malformation I. Although the number of cases is limited, the results look promising. We need to gather more cases to have significant numbers to perform a global comparison between the two approaches and assess the advantages and disadvantages of each technique.

Noninfectious skin fistulization as a delayed complication of lumbar interlaminar device implantation: a report of two cases.

INTRODUCTION: Delayed wound healing is one reason for readmission after spine surgery. The main cause of delayed wound healing is infection. Infection rates after initial instrumented spine surgery reportedly range from 0.7% to 11.9%. However, there are noninfectious reasons for wound problems as well. MATERIALS AND METHODS: This report presents 2 cases of noninfectious fistulization, 1 which occurred 11 months and 1 which occurred 2 years after surgery for implantation of a lumbar interlaminar device. RESULTS: Although no sign of infection was found in either patient, in both cases it was necessary to remove the interlaminar device. CONCLUSIONS: These 2 cases of delayed noninfectious fistulization following instrumented spine surgery are the first seen by the authors of the current report, and as of the time of this writing, no such cases have been documented in the medical literature.

A comparison between different suture techniques in lumbar spine surgery.

As a result of solicited muscles, strong friction, and tensile force on cutaneous tissue, the difference in closure procedure and management strategies and complications of surgical incision healing is a real challenge in lumbar spine surgery. We performed a retrospective study to compare different types of wound closure in lumbar spine surgery. 4383 patients were included in this study. Wound dehiscence was more common in the intracutaneous suture group than in the far- near-near-far suture group. Delayed wound healing occurred more in the far-near near-far suture group than intracutaneous suture group. Also, the far-near near-far interrupted point suture group showed a higher ratio of delayed wound healing compared with crossover suture. The superficial wound infection rate was roughly the same in all types of sutures with an average value of 0.79% with 0.81% SD. This is a preliminary study to compare different types of operative wounds showing the pros and cons related to each option.

Modified anterior retropharyngeal approach for C2-C3 disc herniation.

Background: C2-C3 disc herniations are rare, but occur more frequent in the elderly population. As the classical anterior Cloward approach to these lesions is not optimal, we propose an alternative modified retropharyngeal approach to these disc herniations that were successfully utilized in two patients. Methods: Two patients with C2-C3 disc herniations underwent anterior cervical surgery utilizing the modified retropharyngeal approach. Results: Surgery was successful is two cases with C2-C3 disc herniation and no patient sustained a perioperative complication. Conclusion: Our modified anterior retropharyngeal approach for C2-C3 disc herniations resulted in good outcomes without perioperative complications.

Minimally Invasive Surgical Approach for Treatment of Chronic Subdural Hematoma, Outcome in 1079 Patients.

AIM: To present the authors' experience in treatment of chronic subdural hematoma (CSDH) by a minimally surgical percutaneous approach. MATERIAL AND METHODS: We relate our experience of mini-invasive evacuation of chronic subdural hematoma. Between May 2006 and December 2017, 1079 patients have been operated for percutaneous evacuation of chronic subdural hematoma. Prior to operation, the volume of hematoma was measured quantitatively by using a software for CT scan. RESULTS: From May 2006 to December 2017, 1079 patients underwent mini-invasive percutaneous evacuation (MIPE). Of the 1079 patients, 994 (92.12%) became asymptomatic or improved clinically. Six weeks later, the scan revealed the hematoma had wholly disappeared in 699 (64.78%) of the cases. We had one postoperative abscess. CONCLUSION: Treatment of CSDH using our MIPE technique is a safe method with satisfactory outcome and a good therapeutic alternative to the craniostomy.

A comparison of sciatica in young subjects and elderly person.

BACKGROUND: Sciatica is a common symptom for many people with degenerative lumbar spine diseases. It is by far the most common symptom of disc herniation. However, disc herniation is not the only cause of sciatica. Other degenerative lumbar spine diseases can provoke Sciatica. To date, few studies have analysed the cause of sciatica in particularly in elderly patients. MATERIAL AND METHODS: We analysed retrospectively records of patients aged between 35 and 55 (first group) and between 65 and 85 (second group) visited in our departments for sciatica between December 2009 and November 2018. RESULTS: In elderly patients, disc herniation from upper levels (L2-L3 and L3-L4) is more common than younger people. Sciatica as a result of exclusive disc herniation reduces with age. Foramen stenosis produces sciatica in elderly patients more than twice as high in younger patients. Statistically, more patients needed to surgery in elderly patients in comparison with younger population. CONCLUSION: Sciatica in elderly patients takes a different clinical aspect in comparison with younger population. The clinical picture associates pain less severe but more persistent, more resistant to treatment. It is caused in less than 50% by disc herniation.

Cervicothoracic junction disc herniation: Our experience, technical remarks, and outcome.

BACKGROUND: C7-D1 disc herniation is rare in comparison with other cervical levels. The incidence rates are between 3.5% and 8%. The cervicothoracic junction disc herniation can be operated posteriorly or anteriorly. The anterior approach can be challenging because of the difficulty of access resulted from the manubrium. In this article, we present our experience about cervicothoracic junction disc herniation (C7-T1) surgery. MATERIALS AND METHODS: Between January 2008 and December 2017, 21 patients have been operated for solitary C7-T1 disc herniation. We operated 12 male patients and 9 female patients. Eight patients have been operated by the anterior approach, and 13 patients underwent surgery by the posterior approach. The mean symptoms duration was 11.4 months. RESULTS: All patients had C8 cervicobrachial neuralgia. Other clinical presentations were numbness, tingling sensation, and weakness. All patients improved after surgery. We had no significant complication. CONCLUSION: We did not find a great difference between the clinical features of cervicothoracic herniated disc and other cervical levels. The anterior approach seems more difficult to carry out in particularly in large patients with the short neck. The posterior approach can be used for all types of patients except in the case of medial disc herniation.

Proposal of a new anatomical landmark to identify the disc space in endoscopic lumbar discectomy.

INTRODUCTION: In endoscopic lumbar discectomy for posterolateral disc herniation, we determined some anatomical landmarks for improved disc space access. These landmarks are based on the beginning of the insertion of the ligamentum flavum (LF) to vertebral lamina. MATERIALS AND METHODS: In 978 patients operated by posterolateral disc herniation, we measured prospectively the distance between the beginning of the insertion of the LF and space disc rostrally. RESULTS: The distance between the beginning of the insertion of the LF and space disc was broader at the level of L3-L4, with an average of 14 mm. At L4-L5, the average distance was 13.5. At L5-S1, the average distance was 12 mm. CONCLUSION: Knowing the accurate distance between the insertion of LF and disc space contributes to reducing the average duration of the surgical procedure to avoid empirical search of disc space by a surgeon and avoiding unnecessary and excessive LF and bone removal.

Interlaminar lumbar device implantation in treatment of Baastrup disease (kissing spine).

BACKGROUND: Baastrup disease (BD) is characterized by the degenerative changes of spinous processes and interspinous soft tissues. It is more common among aged persons. This disorder is a relatively common cause of low back pain. Its incidence is underestimated. A few studies have investigated BD epidemiology and proposed treatment efficacy. The aim of this paper is to establish impact and outcome evaluations of managing the patients with Baastrup disease who have been treated by implementing of floating interlaminar device (FID). MATERIALS AND METHODS: Between January 2015 and September 2017, 47 patients have been operated by implementing of FID for BD in our Department of Neurosurgery. RESULTS: Of the 47 patients, 20 were female and 27 were male with an average age of 51.78. On average, we followed the cases up to 11 months. The most frequent level of disorder was L4"L5 followed by L3"L4 level. The condition of 45 patients improved after surgery according to Oswestry low back pain score and 39 patients could return to their work. CONCLUSION: The results from our study corroborate that implementing of FID is a good alternative treatment for patient chronic low back pain due to BD This technique contributes to improving a better living situation for the patients given the correct indications.

Late appearance of low back pain relating to Modic change after lumbar discectomy.

BACKGROUND: In practice of neurosurgery, we find that a wide number of patients referred for refractory low back pain have a history of lumbar discectomy. In a large number of them, magnetic resonance imaging (MRI) studies detect Modic changes (MCs). The aim of this study is to determine the relationship between emergence of MC and low back after lumbar discectomy. MATERIALS AND METHODS: Three hundred and fifty-eight patients with a medical history of discectomy had a MC at the level of the operated disc without any other discopathy. They have been selected from among the 1154 patients operated for lumbar disc herniation over 5 years. RESULTS: Two hundred and fourteen patients (67.30%) had not presented MCs on preoperative MRI. CONCLUSION: Our study awakens a strong presumption about the relationship between emergence of MC after lumbar discectomy.

Lumbar disk herniation: How far should efforts go to minimally invasive procedure?

BACKGROUND: Minimally invasive surgery (MIS) of lumbar disk herniation allows avoiding less of a mess in crossing structures, reducing muscular and cutaneous scarring, postoperative pain, lengthy recovery times, and the rate of infection. The aim of this study is to explain our experience in MIS of disc herniation. We compare the outcome of three different surgical techniques used for the treatment of lumbar disc herniation. MATERIALS AND METHODS: A total of 1147 patients have been operated from July 2008 to December 2015 for lumbar disk herniation by posterior endoscopic approach. Three hundred and seventy-nine patients underwent discectomy and herniectomy (DH), 557 patients have been operated by herniectomy (H), and 211 patients underwent only bone decompression (BD). RESULTS: The results show 80.10%, 82.06%, and 84.02% excellent outcome, respectively, in BD, DH, and BD techniques. CONCLUSION: Analysis of the data demonstrates that the results obtained are equivalent and comparable in different used techniques for the treatment of disc herniation, we do not need to perform discectomy in all cases in a systematic way.

Preliminary results of anterior cervical arthroplasty by porous alumina ceramic cage for cervical disc herniation surgery.

OBJECTIVE: Anterior cervical arthroplasty (ACA) is the gold standard surgery in severe or unresponsive cases of cervical disc herniation, uncarthrosis, and foraminal stenosis. The aim of this study is to establish the impact and outcome evaluations of managing the patients operated for cervical arthroplasty by the intersomatic porous alumina ceramic cervical cages (PACC). The authors describe their experience in the area to allow the comparison of effectiveness of ceramic cages versus other interbody fusion cages. MATERIALS AND METHODS: Between April 2015 and September 2018, we operated 118 for ACA by using PACC. Among them, 52 were female and 66 were male, with an average age of 46.78 years. RESULTS: The mean symptoms duration was 14.1 months. The most frequent level of the disorder was C5-C6 followed by C6-C7 level. Mean follow-up was 3.3 years. The Neck Disability Index (NDI) and the visual analog scale (VAS) were used to evaluate the patients status. No significant differences were observed between our results and literature data regarding operative time, duration of hospitalization, and NDI; however, we observed a shorter period and higher rate of bony fusion. CONCLUSION: The results from the present study corroborate that implementing of PACC is a good alternative treatment for the patient operated by ACA for cervical disc herniation or foraminal cervical stenosis.

Subcutaneous peripheral neurostimulation for the treatment of severe chronic poststernotomy neuralgia.

OBJECTIVE: Poststernotomy pain frequently develops after sternotomy in thoracic and cardiovascular surgery, and may affect patients' quality of life. In some cases of severe poststernotomy neuralgia, pharmacologic therapy does not provide adequate relief. CASE REPORT: We report on a 42- year-old woman who underwent sternotomy for aortic and mitral valve replacement. She developed severe chronic poststernotomy neuralgia that was refractory to medical treatment. After local anesthesia markedly but only transiently alleviated pain, we considered the option of subcutaneous peripheral neurostimulation (SPNS). Plate electrodes were implanted bilaterally in the parasternal region at the site of maximal pain. After a period of test stimulation, the electrodes were connected to a dual-channel implantable pulse generator. SPNS induced paresthesias in the painful area. Revision surgery was necessary twice because of electrode migration. Chronic SPNS markedly alleviated pain (visual-analog scale, VAS, 9/10 preoperatively, 2/10 postoperatively) and allodynia (VAS 9/10 preoperatively, 2/10 postoperatively) at the last available follow-up, 15 months postoperatively. CONCLUSIONS: SPNS may be a viable treatment option in patients with severe chronic poststernotomy neuralgia.