This study sought to determine the outcomes of posterior lumbar interbody fusion (PLIF), via a unilateral approach, in selected patients who presented with unilateral leg pain and segmental instability of the lumbar spine. Patients with a single level of a herniated disc disease in the lumbar spine, unilateral leg pain, chronic disabling lower back pain (LBP), and a failed conservative treatment, were considered for the procedure. A total of 41 patients underwent a single-level PLIF using two PEEK™ (Poly-Ether-Ether-Ketone) cages filled with iliac bone, via a unilateral approach. The patients comprised 21 women and 20 men with a mean age of 41 years (range: 22 to 63 years). Two cages were inserted using a unilateral medial facetectomy and a partial hemilaminectomy. At follow-up, the outcomes were assessed using the Prolo Scale. The success of the fusion was determined by dynamic lumbar radiography and/or computerized tomography scanning. All the patients safely underwent surgery without severe complications. During a mean follow-up period of 26 months, 1 patient underwent percutaneous pedicle screw fixation due to persistent LBP. A posterior displacement of the cage was found in one patient. At the last follow up, 90% of the patients demonstrated satisfactory results. An osseous fusion was present in 85% of the patients. A PLIF, via a unilateral approach, enables a solid union with satisfactory clinical results. This preserves part of the posterior elements of the lumbar spine in selected patients with single level instability and unilateral leg pain.
Posterior lumbar interbody fusion (PLIF); unilateral approach; instability
Standard treatment of asymptomatic spinal cord hemangioblastoma in von Hippel-Lindau (VHL) disease has yet to be established. The purpose of this study was to propose guidelines for the treatment of asymptomatic spinal cord hemangioblastomas in VHL disease.
Materials and Methods
VHL disease patients treated for spinal cord hemangioblastomas between 1999 and 2009 were included. All spinal cord hemangioblastomas were divided into three groups: Group 1, asymptomatic tumors at initial diagnosis followed with serial imaging studies; Group 2, asymptomatic tumors at initial diagnosis that were subsequently resected; and Group 3, symptomatic tumors at initial diagnosis, all of which were resected.
We identified 24 spinal cord hemangioblastomas in 12 patients. Groups 1, 2 and 3 comprised 13, 4 and 7 tumors, respectively. Group 1 exhibited a smaller tumor volume (257.1 mm3) and syrinx size (0.8 vertebral columns) than those of Group 2 (1304.5 mm3, 3.3 vertebral columns) and Group 3 (1787.4 mm3, 6.1 vertebral columns). No difference in tumor volume or syrinx size was observed between Groups 2 and 3. Five tumors in Group 1 were resected during follow-up because symptoms had developed or the tumor had significantly grown. Finally, among 17 asymptomatic tumors at the initial diagnosis, nine tumors were resected. Only one tumor of these nine tumors resulted in neurological deficits, while five of seven symptomatic tumors caused neurological deficits.
Selective resection of asymptomatic tumors before they cause neurological deficits might bring about better outcomes.
Hemangioblastoma; spinal cord; treatment planning; von Hippel-Lindau disease
In the field of spinal surgery, a few laboratory results or clinical cases about robotic spinal surgery have been reported. In vivo trials and development of related surgical instruments for spinal surgery are required before its clinical application. We investigated the use of the da Vinci® Surgical System in spinal surgery at the craniovertebral junction in a human cadaver to demonstrate the efficacy and pitfalls of robotic surgery.
Dissection of pharyngeal wall to the exposure of C1 and odontoid process was performed with full robotic procedure. Although assistance of another surgeon was necessary for drilling and removal of odontoid process due to the lack of appropriate end-effectors, successful robotic procedures for dural sutures and exposing spinal cord proved its safety and dexterity.
Robot-assisted odontoidectomy was successfully performed in a human cadaver using the da Vinci® Surgical System with few robotic arm collisions and minimal soft tissue damages. Da Vinci® Surgical System manifested more dexterous movement than human hands in the deep and narrow oral cavity. Furthermore, sutures with robotic procedure in the oral cavity demonstrated the advantage over conventional procedure.
Presenting cadaveric study proved the probability of robot-assisted transoral approach. However, the development of robotic instruments specific to spinal surgery must first precede its clinical application.
Cervical; Robotics; Odontoid process; Craniovertebral junction; Transoral surgery
Resection of retroperitoneal tumors is usually perfomed using the anterior retroperitoneal approach. Our report presents an innovative method utilizing a robotic surgical system. A 50-yr-old male patient visited our hospital due to a known paravertebral mass. Magnetic resonance imaging showed a well-encapsulated mass slightly abutting the abdominal aorta and left psoas muscle at the L4-L5 level. The tumor seemed to be originated from the prevertebral sympathetic plexus or lumbosacral trunk and contained traversing vessels around the tumor capsule. A full-time robotic transperitoneal tumor resection was performed. Three trocars were used for the robotic camera and working arms. The da Vinci Surgical System® provided delicate dissection in the small space and the tumor was completely removed without damage to the surrounding organs and great vessels. This case demonstrates the feasibility of robotic resection in retroperitoneal space. Robotic surgery offered less invasiveness in contrast to conventional open surgery.
Paraspinal; Neurilemmoma; Robotic; Retroperitoneal Space
A retrospective review of medical records and
imaging studies. To investigate characteristic clinical features and surgical outcomes of spinal cord tumors (SCTs) of the thoracolumbar junction (TLJ). The spinal cord transitions to the cauda equina in the TLJ. The TLJ contains the upper and lower motor neurons of the spinal cord and cauda equina. As a result, the clinical features of lesions in the TLJ vary, and these anatomical characteristics may affect surgical outcome.
Materials and Methods
diagnosis, clinical features, neurological signs, and surgical outcomes were investigated in 76 patients surgically treated at our institute for SCTs arising from T11 to L2. The patients were divided into epiconus (T11-12, n = 18) and conus groups (L1-2, n = 58).
Patients in the
epiconus group had hyperactive deep tendon reflexes (DTRs), while those in the conus group had hypoactive DTRs (p < 0.05). Nine patients were misdiagnosed with intervertebral disc diseases (IVDs) before correct diagnoses were made. It was impossible to definitively determine the exact cause of symptoms in four patients who had both SCTs and IVDs.
Among SCTs of the TLJ, the
epiconus group displayed upper motor neuron syndrome and the conus group displayed lower motor neuron syndrome. SCTs of the TLJ were frequently misdiagnosed as IVDs due to symptomatic similarities. SCTs of the TLJ should be included in differential diagnosis of back and leg pain, and it is highly recommended that routine lumbar magnetic resonance imaging include the TLJ.
Spinal cord neoplasms; thoracolumbar junction; conus medullaris; cauda equina
We have experienced 23 patients who had underwent cervical disc replacement with Mobi-C disc prosthesis and analyzed their radiological results to evaluate its efficacy.
Patients and Methods
This study was performed on 23 patients with degenerative cervical disc disease who underwent CDR with Mobi-C disc prosthesis from March 2006 to June 2006.
The age of the study population ranged from 31 to 62 years with mean of 43 years, and 16 male and 7 female cases. Regarding axial pain, the average preoperative VAS score was 6.47 ± 1.4, while at final follow-up it was 1.4 ± 0.7 (p < 0.001). The preoperatively VAS score for radiculopathy was 6.7 ± 0.7 compared with an average score of 0 ± 0 at the final follow-up (p < 0.001). At postoperative 6th month, Odom's criteria were excellent, good, or fair for all 23 patients (100%). 7 patients (30.4%) were classified as excellent, 15 patients (65.2%) as good, and 1 patients (4.4%) as fair. Prolo economic and functional rating scale was average 8.9 ± 0.7 at postoperative 6th month. ROM in C2-7, ROM of FSU, and ROM in upper adjacent level were well preserved after CDR.
This report would be the first document about the CDR with Mobi-C disc prosthesis in the treatment of degenerative cervical disc disease. CDR with Mobi-C disc prosthesis provided a favorable clinical and radiological outcome in this study. However, Long-term follow-up studies are required to prove its efficacy and ability to prevent adjacent segment disease.
Cervical; arthroplasty; Mobi-C disc prosthesis
We performed 65 cases of posterior fusion surgery for cervical and/or high thoracic lesions using a polyaxial screw-rod system.
Patients and Methods
A total of 486 screws were implanted in 65 patients.
Fixation of the screws was carried out over an average of 2.9 spinal segments. Upon evaluation by postoperative CT scans, twelve (2.5%) screws had suboptimal trajectories but two of these revealed radiculopathy in one patient and required screw repositioning. No vascular sequelae resulted. There has been no segmental motion in any of the cases to date. As for other complications, there was one case of dural tearing and two cases of lateral mass fractures. There were no infections or other wound healing problems or hardware failures. No patients had neurological deterioration after surgery. There were statistically significant improvements in the mean Neck Disability Index (NDI) scores and Visual Analogue Scale (VAS) scores in the preoperative and late postoperative follow-up evaluations. Although further studies are required to establish the long-term results of fusion rates and clinical outcomes.
We cautiously suggest that the posterior polyaxial screw-rod system can be safely used as a primary or additional fusion method in this risky region. The successful and safe use of this method is dependent on a precise preoperative surgical plan and tactics for ensuring safe screw fixation.
Cervical; thoracic; fixation; posterior fusion; screw-rod system
We report a series of epidural hematomas which cause neurologic deterioration after spinal surgery, and have taken risk factors and prognostic factors into consideration. We retrospectively reviewed the database of 3720 cases of spine operation in a single institute over 7 years (1998 April-2005 July). Nine patients who demonstrated neurologic deterioration after surgery and required surgical decompression were identified. Factors postulated to increase the postoperative epidural hematoma and to improve neurologic outcome were investigated. The incidence of postoperative epidural hematoma was 0.24%. Operation sites were cervical 3 cases, thoracic 2 cases, and lumbar 4 cases. Their original diagnoses were tumor 3 cases, cervical stenosis 2 cases, lumbar stenosis 3 cases and herniated lumbar disc 1case. The symptoms of epidural hematomas were neurologic deterioration and pain. After decompression, clinical outcome revealed complete recovery in 3 cases (33.3%), incomplete recovery in 5 cases (55.6%) and no change in 1 case (11.1%). Factors increasing the risk of postoperative epidural hematoma were coagulopathy from medical illness or anticoagulation therapy (4 cases, 44.4%) and highly vascularized tumor (3 cases, 33.3%). The time interval to evacuation of complete recovery group (29.3 hours) was shorter than incomplete recovery group (66.3 hours). Patients with coagulopathy and highly vascularized tumor were more vulnerable to spinal epidural hematoma. The postoperative outcome was related to the preoperative neurological deficit and the time interval to the decompression.
Clinical outcome; risk factor; postoperative; spinal epidural hematoma; spine surgery
The purpose of this study was to evaluate the clinical feasibility, benefits, and limitations of CT fluoroscopy (CTF)-guided percutaneous vertebroplasty (PVP). PVP under the guidance of CTF without additional guidance by conventional C-arm fluoroscopy was performed in a total of 29 vertebral bodies in 21 patients with vertebral compression fractures. While monitoring sectional CTF images, the needle was advanced from the skin to the target vertebra. Contrast media and polymethylmethacrylate (PMMA) were injected into the target vertebra with careful monitoring of their distribution. After the procedure, an evaluation was conducted to determine whether extraosseous leakage of PMMA occurred and whether sufficient filling of PMMA had been achieved. Needle placement into the target vertebra was easily achieved with both the transpedicular and posterolateral approaches. Injection of PMMA and venous leakage of contrast media were carefully monitored in all patients, and early detection of PMMA leaking was achieved in 5 patients. Extraosseous leakage that had not been detected during the procedure was not found upon postoperative evaluation. Pain scales were significantly decreased after the procedure, and no obvious complications occurred following the procedure. CTF-guided PVP without the combined use of C-arm fluoroscopy was feasible and showed definite benefits. We believe that, in spite of some limitations, CTF-guided PVP provides an alternative technique appropriate in certain situations.
Compression fracture; osteoporosis; vertebroplasty; CT fluoroscopy