Unilateral microscopic approach for lumbar spinal stenosis decompression: a scoping review.

BACKGROUND: Microscopic unilateral laminotomy for bilateral decompression (ULBD) is a minimally invasive technique used in the treatment of lumbar spinal stenosis and could limit spinal instability and be associated with better clinical outcomes. However, there is ongoing debate regarding its utility compared to conventional laminectomy (CL). The primary objective was to collate and describe the current evidence base for ULBD, including perioperative parameters, functional outcomes, and complications. The secondary objective was to identify operative techniques. METHODS: A scoping review was conducted between January 1990 and August 2022 according to the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. Major databases were searched for full text English articles reporting on outcomes following microscopic unilateral laminotomy in patients with lumbar spinal stenosis. RESULTS: Seventeen articles met the inclusion criteria. Two studies were randomised controlled trials. Two studies were prospective data collection and the rest were retrospective analysis. Three studies compared ULBD with CL. ULBD preserves the osteoligamentous complex and may be associated with shorter operative time, less blood loss, and similar clinical outcomes when compared to CL. CONCLUSION: This review highlights that ULBD aims to minimise disruption to the normal posterior spinal anatomy and may have acceptable clinical outcomes. It also highlights that it is difficult to draw valid conclusions given there are limited data available as most studies identified were retrospective or did not have a comparator group.

The Effect of COVID-19 National Lockdown on the Time from Presentation to Surgery of Patients with Suspected Cauda Equina Syndrome: Two UK Tertiary Centers' Study.

OBJECTIVE: To investigate if COVID-19 UK lockdown measures resulted in a delay in the presentation and treatment of patients with cauda equina syndrome (CES). METHODS: This is a multicenter retrospective study of patients with surgically treated CES across 3 time periods: April-May 2020 (first lockdown), August-September 2020 (no-lockdown group), and January-February 2021 (second lockdown). Data regarding duration of symptoms, time from referral to admission, time from admission to surgery, and postoperative outcomes were collected. RESULTS: A total of 56 patients (male: 26, female: 30, mean age: 44.3 years) were included in the study (n = 14, n = 18, and n = 24 in the 3 time periods, respectively). There was no significant difference in duration of symptoms across the time periods (12.6 days vs. 8.2 days vs. 3.8 days) (P = 0.16). Nearly all the patients were admitted within 48 hours of referral (n = 55, 98.2%). The majority of patients were operated on within 48 hours: first lockdown (n = 12, 85.7%), no-lockdown (n = 16, 88.9%), and second lockdown (n = 21, 87.5%). The length of hospital stay was significantly shorter in the second lockdown (3.3 days) versus the other 2 time periods (4.4 days and 6.4 days) (P = 0.02). Thirteen complications were present, with dural tear being the most common (n = 6, 10.7%). Majority reported symptom improvement (n = 53, 94.6%), with a similar number discharged home (n = 54, 96.4%). CONCLUSION: Despite the pandemic, patients with CES were promptly admitted and operated on with good outcomes. Shorter duration of hospital stay could be attributed to adaptation of spinal services.

Dural tear repair surgery comparative analysis: a stitch in time saves nine.

PURPOSE: A dural tear is a common iatrogenic complication of spinal surgery associated with a several post-operative adverse events. Despite their common occurrence, guidelines on how best to repair the defect remain unclear. This study uses five post-operative outcomes to the compare repair methods used to treat 106 dural tears to determine which method is clinically favourable. METHODS: Data were retrospectively collected from Southampton General Hospital's online databases. 106 tears were identified and grouped per repair method. MANOVA was used to compare the following five outcomes: Length of stay, numbers of further admissions or revision surgeries, length of additional admissions, post-operative infection rate and dural tear associated neurological symptoms. Sub-analysis was conducted on patient demographics, primary vs non-primary closure and type of patch. Minimal clinically important difference (MCID) was calculated via the Delphi procedure. RESULTS: Age had a significant impact on patient outcomes and BMI displayed positive correlation with three-fifth of the predefined outcome measures. No significant difference was observed between repair groups; however, primary closure ± a patch achieved an MCID percentage improvement with regards to length of original stay, rate of additional admissions/surgeries and post-operative infection rate. Artificial over autologous patches resulted in shorter hospital stays, fewer readmissions, infections and neurological symptoms. CONCLUSION: This study reports primary closure ± dural patch as the most efficient repair method with regards to the five reported outcomes. This study provides limited evidence in favour of artificial over autologous patches and recommends that dural patches be used in conjunction with primary closure. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Spinal Fractures Incurred by Sports-Related Injuries.

BACKGROUND: Sports-related injuries are the third commonest cause of spine fractures. Spinal fractures incurred as a result of partaking in sport by their nature are different from those associated with frailty and road traffic accidents. The patient demographics and nature of fractures associated with sports activities are not well documented. We aim to describe the management and outcome of patients with a sports-related spine fracture in a single U.K. major trauma center in a 6-year time period. METHODS: Patients with sports-related spinal fractures were identified from the Trauma Audit and Research Network database at a U.K. major trauma center between January 2011 and December 2016. Patient notes were retrospectively reviewed for demographics, injury severity score, treatment, complications, and outcomes. RESULTS: In the study period, 122 patients were admitted with a sports-related spinal fracture, sustaining a total of 230 fractures. Of these, 48 (20.9%) were in the cervical, 79 (34.3%) in the thoracic, and 103 (44.8%) in the lumbar regions. The sports most commonly associated with spinal fractures were horse riding (n = 55), cycling (n = 36), and boating (n = 10). Of the 230 fractures, 32 (13.9%) were associated with neurologic injury. Forty-five of the 230 fractures (19.6%) were managed surgically, and the remainder were managed conservatively. CONCLUSIONS: Within our population, sports most commonly associated with spinal fractures were horse riding, cycling, and boating. The majority of cases were managed nonoperatively. Further research is required to establish evidence-based guidelines on the management of sports-related spinal fractures.

Differences in management of isolated spinal fractures between neurosurgery and orthopaedics: a 6-year retrospective study.

INTRODUCTION: The acute management of spinal fractures is traditionally split between neurosurgeons and orthopaedic surgeons and the specialities have varying approaches to management. This study investigates differences between neurosurgeons and spinal orthopaedic surgeons in the management of spinal fractures at a single trauma centre in the United Kingdom. METHODS: A retrospective study at a single trauma centre of patients identified using the Trauma Audit and Research Network (TARN). Case notes and radiological investigations were reviewed for demographics, fracture classification, clinical management and outcomes. Polytrauma cases and patients managed by non-neurosurgical/orthopaedic specialties were excluded. RESULTS: A total of 465 patients were included in this study (neurosurgery n = 266, orthopaedics n = 199). There were no significant differences between groups for age, gender, Charlson co-morbidity score or distribution of fractures using the AO spine classification. Patients admitted and managed under the orthopaedic surgeons were more likely to undergo a surgical procedure when compared to those admitted under the neurosurgeons (n = 71; 35.7% vs n = 71; 26.8%, p = 0.042, OR 1.56 95%CI 1.056 to 2.31). The median overall length of stay was 8 days and there was no significant difference between teams; however, the neurosurgical cohort were more likely to be admitted to an intensive care unit (24.3% vs 16.2%, p = 0.04). CONCLUSION: This study is the first in the United Kingdom to compare neurosurgical and orthopaedic teams in their management of spinal fractures. It demonstrates that differences may exist both in operating rates and outcomes.

Posterior fossa ICP monitoring: a tale of two compartments.

AIM: Measuring the intracranial pressure (ICP) of the infra-tentorial, posterior fossa compartment has long been avoided due to a lack of precedent and interpretability, as well as concern of damage to the underlying vital structures. In cases of posterior fossa insults however, the supra-tentorial compartment ICPs can be falsely reassuring. We aimed to measure the posterior fossa ICP in such a case and analyse the resulting data. METHODS: We present a case of posterior fossa ICP monitoring and discuss its safety profile, rationale and possible indications. RESULTS: Our comparison of the supra and infra-tentorial ICPs showed that there was a statistically significant difference in the two compartments. The infra-tentorial compartment had ICPs averaging 11.02 ± 2.24 mmHg whilst the supra-tentorial compartment averaged 4.94 ± 1.80 mmHg in the first 72 hours post-op (p < .01 on paired t-testing). After 72 hours, the pressures seemed to equilibrate and were 4.71 ± 2.6 and 3.88 ± 2.89 for the infra and supra-tentorial compartments respectively. CONCLUSION: We propose that where a patient with a posterior fossa insult exhibits signs and symptoms consistent with raised ICP but the supra-tentorial readings are normal, posterior fossa ICP monitoring can be considered.

Spinal fractures incurred by a fall from standing height.

OBJECTIVE: Falls from standing are common, particularly amongst the aging population, due to declining mobility, proprioception and vision. They are often complicated by fragility fractures, including vertebral fractures, that are associated with significant morbidity and may represent a pre-terminal condition with high one-year mortality rates. PATIENTS AND METHODS: A retrospective review of the Trauma Audit and Research Network database for a major trauma centre was conducted for all patients admitted between January 2011 and December 2016. Patients with a spinal fracture and a confirmed fall from standing height were eligible for inclusion. Case notes were reviewed for demographics, Injury Severity Score, Charlson co-morbidity score, treatment, complications and outcomes. RESULTS: Of 1408 patients with a spine fracture admitted during the study period, 229 (16.3%) were confirmed to be secondary to a fall from standing height. The average age of this cohort was 76.6 ± 14.5 years and 134 (58.5%) cases were female. The average ISS score was 9.7 ± 5.4. The 229 patients sustained 283 fractures with a distribution of: cervical (n = 140), thoracic (n = 65) and lumbar (n = 78) spine. Fifty-six (24.5%) patients underwent surgical intervention. Forty-three patients (18.7%) died within 6 months of admission and all-cause mortality was significantly higher in patients with increasing age and Charlson co-morbidity score. CONCLUSION: Spinal fractures due to a fall from standing height represent one sixth of the fracture workload of the emergency spinal service at a major trauma centre. Whilst the majority of patients can be managed conservatively there are still considerable implications for hospital bed usage and patient mortality.

Spontaneous regression of a cystic hypoglossal schwannoma causing unilateral tongue atrophy.

A 60-year-old lady presented with intermittent headaches. Examination revealed striking marked unilateral tongue atrophy. Magnetic resonance imaging (MRI) revealed a cystic lesion in the hypoglossal canal and a provisional diagnosis of cystic hypoglossal schwannoma made. Annual surveillance scans showed stable appearances but surprisingly at 3 years they showed a significant reduction in the size of the lesion. Most patients with hypoglossal schwannomas present with ipsilateral hypoglossal nerve palsy; careful cranial nerve examination is vital in diagnosing such rare lesions. Little is known of their natural history, with most lesions undergoing surgery. This case highlights spontaneous regression following non-operative management.

Pilocytic astrocytoma originating at the cavernous sinus.

We report a case of histologically proven pilocytic astrocytoma arising within the cavernous sinus, confirmed radiographically and at operation. We discuss the implications in the context of previous reports of ectopic glioma origin. In particular, the possiblity of glioma development within glial cell islands in the peripheral segment of cranial nerves is explored.

Fibrin Sealant Injection: An Aid to Reduce Venous Bleeding during Jugular Bulb and Sigmoid Sinus Dissection in Glomus Jugulare (Jugulotympanic Paraganglioma) Surgery.

Glomus jugulare (jugulotympanic paraganglioma) surgery requires tumor dissection in the region of the jugular bulb, upper internal jugular vein, and sigmoid sinus. Despite ligation or external compression of the sigmoid sinus proximally and ligation of the internal jugular vein distally, troublesome venous bleeding can arise from the inferior petrosal sinus or condylar veins at the medial wall of the jugular bulb. Excessive packing in this area can place the integrity of the lower cranial nerves at risk. We report a technique in which Tisseel(®) fibrin sealant is injected into the ligated sigmoid sinus and internal jugular vein. This forms an internal cast around the tumor in the sigmoid-jugular complex and helps seal the inferior petrosal sinus and condylar veins. This allows for safer dissection with reduced venous bleeding. Our experience in five cases has shown this technique to be effective.

Visual recovery following optic nerve decompression for chronic compressive neuropathy.

PURPOSE: Visual failure due to optic nerve compression is a common indication for decompressive surgery. Most data only refer to the odds of improvement, deterioration or remaining the same. However, patients frequently wish to know more detail about the outcomes of surgery. Our aim was to assess the visual outcome from optic nerve decompression for visual failure in detail in order to help counsel patients pre-operatively. METHODS: Sixty-eight patients undergoing 71 operations to decompress 87 optic nerves between 1991 and 2007 were identified. Thirty-four decompressions were performed via a transzygomatic and 37 via a transbasal approach. Fifty-two patients had meningiomas, 3 pituitary adenomas, 3 craniopharyngiomas, 3 chordomas, 2 adenocarcinomas, 2 fibrous dysplasia, 1 schwannoma, 1 granular pituitary tumour and 1 olfactory neuroblastoma. Visual acuity and fields were recorded pre-operatively, immediately post-operatively, at first follow-up and at most recent follow-up. RESULTS: Forty-three eyes (49.4%) experienced an improvement in either acuity or fields. Twenty-four (27.5%) were unchanged and 20 (22.9%) deteriorated. Average improvement was 0.88 Snellen lines (logMAR 0.13). Improvement was seen between immediate post-operative acuity and first follow-up in 52%, but 22% suffered a late deterioration after 1 year. There was no relationship between age, duration of symptoms, pathology, approach or redo surgery and visual outcome. There was a complex relationship between pre-operative visual acuity and post-operative improvement and outcome. Better pre-operative acuity predicted better outcome and greater odds of improvement, although patients with poor pre-operative vision had a greater average magnitude of improvement. CONCLUSIONS: Patients experience significant benefit from optic nerve decompression irrespective of pre-operative visual status. Although early decompression is desirable, good results can still be obtained in patients with severe visual failure. Detailed data on visual outcome can help counsel patients pre-operatively to aid decision-making and set expectations.

Management of petrous endostosis in posterior fossa procedures for trigeminal neuralgia.

OBJECTIVE: Within a series of 440 consecutive patients who underwent posterior fossa procedures for trigeminal neuralgia (TN), the site of neurovascular conflict was obscured by petrous endostosis in 15 patients. The surgical management and clinical outcomes of these patients are presented. METHODS: We retrospectively analyzed the prospectively collected data of all patients with a diagnosis of TN from 1980 to 2005. Clinical presentation, preoperative imaging, intraoperative findings, surgical technique, and outcomes were recorded. A postal follow-up questionnaire and a visual analog scale of 100 points were used for outcome assessment and patient satisfaction. RESULTS: All 15 patients presented with typical TN, had preoperative imaging suggestive of vascular compression of the trigeminal nerve root, and underwent standard retromastoid craniotomy. The juxta-petrous portion of the trigeminal nerve root was obscured by petrous endostosis. The neurovascular conflict was revealed and dealt with after drilling of the endostosis in 11 patients, and four patients had endoscopic-assisted exploration of the region of the endostosis. A pontotrigeminal vein caused compression in most cases. Three patients had endoscopic-assisted division of the vein. All patients had immediate relief of pain and were 100% satisfied with the results of surgery after a mean follow-up period of 38.6 months. Four patients developed a cerebrospinal fluid leak, and five patients experienced postoperative headaches. CONCLUSION: Petrous endostosis is an uncommon finding in posterior fossa procedures for TN (3.4%). However, it can obscure the region of neurovascular conflict, which is venous compression in these cases. We have found that drilling away endostosis or using endoscopic-assisted microsurgery increases the chances of good outcome and avoids unnecessary rhizotomy. All magnetic resonance imaging scans should be inspected for evidence of petrous endostosis and, when present, a bone window computed tomographic scan should be performed to clarify the image and check for the presence of petrous air cells. If the endostosis is drilled, failure to detect and to seal these air cells thoroughly can result in postoperative cerebrospinal fluid rhinorrhea. Attention to these details will optimize the surgical results. However, the use of an angled endoscope avoids this problem and is now our preferred method.

Anterior transvertebral transposition of the spinal cord for the relief of paraplegia associated with congenital cervicothoracic kyphoscoliosis. Technical note.

The authors describe a technique for the relief of spinal cord compression associated with congenital kyphoscoliosis. A 13-year-old girl with congenital cervicothoracic kyphoscoliosis had undergone in situ fusion; spastic paraparesis and bladder disturbance developed postoperatively. Spinal cord detethering and posterolateral decompression temporarily arrested the neurological deterioration; however, the patient's condition then progressed to paraplegia with a partial sensory level at L-1. Imaging demonstrated persisting cord compression at the apex of the kyphotic curve. Transvertebral transposition of the spinal cord was performed using sagittal vertebrotomies, preserving the lateral aspects of the vertebral bodies, pedicles, and fusion mass. By 2 years postoperatively she had recovered normal sensation and good bladder function and was walking unaided. Transposition of the spinal cord may be used to relieve spinal cord compression associated with complex spinal deformities.