Category: Lumbar Decompression

Minimally invasive corpectomy and posterior stabilization for lumbar burst fracture.

Minimally invasive corpectomy and posterior stabilization for lumbar burst fracture.

Spine J. 2011 Jul 28;

Authors: Eck JC

BACKGROUND CONTEXT: Surgical indications for lumbar burst fracture remain controversial. Potential indications for surgery include 50% canal compromise, 50% loss of vertebral height, 30° of kyphosis, and posterior element fracture or disruption of the posterior ligamentous complex. Different surgical approaches are available depending on fracture characteristics. It is possible that a minimally invasive approach could allow for a safe and effective treatment with fewer comorbidities than the traditional open technique. PURPOSE: This is a report of an L3 burst fracture treated with a minimally invasive approach for anterior corpectomy and posterior pedicle screw fixation. STUDY DESIGN: Case report. PATIENT SAMPLE: Patient with L3 burst fracture. OUTCOME MEASURES: Radiographs and computed tomography scans to evaluate for fusion and evaluation of pain and neurologic function. METHODS: A 30-year-old male was involved in a head-on motor vehicle collision. Initial imaging revealed an L3 burst fracture with 60% canal compromise, 50% loss of vertebral body height, a large anteriorly displaced fragment consisting of 40% of the vertebral body depth, and a facet fracture. Surgical decompression and stabilization were recommended for this patient because of radiographic signs of instability. After medical clearance and consent, the patient underwent a minimally invasive L3 corpectomy and L2-L4 interbody fusion through a direct lateral approach with placement of a titanium mesh cage filled with local autograft and allograft bone matrix. The patient then underwent a percutaneous stabilization with pedicle screw fixation from L2 to L4. RESULTS: The patient was ambulating on the first postoperative day, and pain was controlled with oral analgesics. Intraoperative blood loss was less than 100 cc. He was discharged to a rehabilitation facility on the second postoperative day. Postoperatively, he complained of some left lower extremity pain and numbness. The pain completely resolved by the 6-month follow-up visit. The numbness in the anterolateral left thigh was improved but not completely resolved at 12 months. He continued to have full strength in all extremities. CONCLUSION: The traditional approach to an anterior lumbar corpectomy and posterior pedicle screw fixation involves significant postoperative pain and frequent ileus. This minimally invasive approach allowed for early mobilization, resumption of diet, and discharge from the hospital on postoperative day two.

PMID: 21803000 [PubMed – as supplied by publisher]

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[Investigation of Pseudolocalizing Signs in the Lumbar Region: Analysis of L5 Monoradiculopathy due to Upper Lumbar Compressive Lesions].

[Investigation of Pseudolocalizing Signs in the Lumbar Region: Analysis of L5 Monoradiculopathy due to Upper Lumbar Compressive Lesions].

No Shinkei Geka. 2011 Aug;39(8):743-53

Authors: Ikeda H, Hanakita J, Takahashi T, Kitahama Y, Kuraishi K, Watanabe M, Uesaka T, Takeshima Y, Kitagawa M, Murata D

Background and Purpose: Pseudolocalizing signs in lumbar spinal disease seems to be rarely encountered. To our knowledge, only six cases which caused L5 monoradiculopathy due to upper lumbar lesions have been described. We retrospectively reviewed patients with similar signs in our center, and we discussed the pathogenesis of such interesting neurological signs depending on our own and reported cases. Results: Between January, 2005 and August, 2010, 1,229 patients with lumbar degenerative disease underwent spinal decompression surgery, 3 of which (0.24%) presented with L5 monoradiculopathy due to upper compressive lesions in lumbar spinal disease. Discussion and Conclusion: As pathological mechanisms, 2 hypotheses are speculated: Direct compression at the epiconus level or circulatory disturbance at the nerve root itself. If the level of the conus medullaris is situated at the lower lumbar level, such as L2 level, a compressive lesion at the L1-2 level, for example lumbar disc herniation, can compress the L5 nerve root resulting in L5 nerve palsy. However, the affected level below the cauda equina doesn’t seem to compress only the L5 nerve root directly, because the cauda equina is mobile enough to avoid the compression. Another speculated mechanism is the so-called circulatory disturbance. When the cauda equina is remarkably compressed at the upper level, less severe compressive change may cause selective monoradiculopathy at the lower lumbar level. Based upon the presented analyses, we adopt the circulatory mechanism in our cases as the causative factor in lumbar pseudolocalizing signs.

PMID: 21799224 [PubMed – in process]

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Tubercular spinal epidural abscess involving the dorsal-lumbar-sacral region without osseous involvement.

Tubercular spinal epidural abscess involving the dorsal-lumbar-sacral region without osseous involvement.

J Infect Dev Ctries. 2011;5(7):544-9

Authors: Arora S, Kumar R

Musculoskeletal tuberculosis is known for its ability to present in various forms and guises at different sites. Tubercular spinal epidural abscess (SEA) is an uncommon infectious entity. Its presence without associated osseous involvement may be considered an extremely rare scenario. We present a rare case of tubercular SEA in an immune-competent 35-year-old male patient. The patient presented with acute cauda equina syndrome and was shown to have multisegmental SEA extending from D5 to S2 vertebral level without any evidence of vertebral involvement on MRI. The patient made an uneventful recovery following surgical decompression and antitubercular chemotherapy. The diagnosis was confirmed by histopathological demonstration of Mycobacterium tuberculosis in drained pus. Such presentation of tubercular SEA has not been reported previously in the English language based medical literature to the best of our knowledge.

PMID: 21795824 [PubMed – in process]

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To fuse or not to fuse in lumbar degenerative spondylolisthesis: do baseline symptoms help provide the answer?

To fuse or not to fuse in lumbar degenerative spondylolisthesis: do baseline symptoms help provide the answer?

Eur Spine J. 2011 Jul 24;

Authors: Kleinstueck FS, Fekete TF, Mannion AF, Grob D, Porchet F, Mutter U, Jeszenszky D

INTRODUCTION: Clinical symptoms in lumbar degenerative spondylolisthesis (LDS) vary from predominantly radiating pain to severe mechanical low back pain. We examined whether the outcome of surgery for LDS varied depending on the predominant baseline symptom and the treatment administered [decompression with fusion (D&F) or decompression alone (D)]. METHODS: 213 consecutive patients (69 ± 9 years; 155f, 58 m) participated. Inclusion criteria were LDS, maximum three affected levels, no previous surgery at the affected level, and D (N = 56) or D&F (N = 157) as the operative procedure. Pre-op and at 12 months’ follow-up (FU), patients completed the multidimensional Core Outcome Measures Index (COMI) including 0-10 leg-pain (LP) and LBP scales. At 12 months’ FU, patients rated global outcome which was then dichotomised into “good” and “poor”. RESULTS: Pre-operatively, LBP and COMI scores were significantly worse (p < 0.05) in the D&F group than in the D group. The improvement in COMI at 12 months’ FU was significantly greater for D&F than for D (p < 0.001) and was not influenced by the patient’s declared “main problem” at baseline (back pain, leg pain, or neurological disturbances) (p > 0.05). There was a higher proportion (p = 0.01) of “good” outcomes at 12 months’ FU in D&F (86%) than in D (70%). Multiple regression analysis, controlling for possible confounders, revealed treatment group to be the only significant predictor of outcome (adding fusion = better outcome). DISCUSSION: Our study indicated that LDS patients showed better patient-based outcome with instrumented fusion and decompression than with decompression alone, regardless of baseline symptoms. This may be due to the fact that the underlying slippage as the cause of the stenosis is better addressed with fusion.

PMID: 21786174 [PubMed – as supplied by publisher]

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Complications of open compared to minimally invasive lumbar spine decompression.

Complications of open compared to minimally invasive lumbar spine decompression.

J Clin Neurosci. 2011 Jul 18;

Authors: Shih P, Wong AP, Smith TR, Lee AI, Fessler RG

Minimally invasive modalities have demonstrated efficacy in the treatment of neurogenic claudication. Direct comparisons, however, between complication rates of these newer techniques with open surgical techniques for lumbar decompression are lacking. This single-institution study examined neurogenic claudicants between August 2007 and June 2009. A total of 26 patients received open surgical decompression, and 23 patients microendoscopic decompression. Baseline demographic characteristics, peri-operative morbidity and mortality, length of hospital stay, and final disposition following hospitalization were recorded. Morbidity was divided into major and minor categories as defined by degree of requisite intervention and adverse impact on hospital stay. Average age, number of surgical levels, and pre-operative American Society of Anesthesiologists Physical Status Index scores were similar in each group (p>0.05). While minimally invasive surgery may be associated with slightly longer operative times, there is decreased blood loss, shorter hospital stays, and likely decreased requirements for ancillary support services upon discharge.

PMID: 21775145 [PubMed – as supplied by publisher]

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Anaphylaxis secondary to levobupivacaine.

Anaphylaxis secondary to levobupivacaine.

Anaesthesia. 2011 Jul 19;

Authors: Gupta A, Fennelly M, Ramesh V, Agyare K

We describe the case of a 25-year-old woman presented for elective lumbar decompression and microdiscectomy who, towards the end of her surgery, developed clinical signs of anaphylaxis. Skin testing later confirmed sensitisation to levobupivacaine and possibly MediShield, an anti-adhesion gel used following microdiscectomy. This case is the first confirmed case report of anaphylaxis in response to levobupivacaine. It also highlights the possibility that multiple agents may simultaneously trigger a life-threatening reaction. Anaesthetists should remain alert to the use of potentially allergenic agents employed by surgeons.

PMID: 21770908 [PubMed – as supplied by publisher]

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Local bone graft harvesting and volumes in posterolateral lumbar fusion: a technical report.

Local bone graft harvesting and volumes in posterolateral lumbar fusion: a technical report.

Spine J. 2011 Jun;11(6):540-4

Authors: Carragee EJ, Comer GC, Smith MW

In lumbar surgery, local bone graft is often harvested and used in posterolateral fusion procedures. The volume of local bone graft available for posterolateral fusion has not been determined in North American patients. Some authors have described this as minimal, but others have suggested the volume was sufficient to be reliably used as a stand-alone bone graft substitute for single-level fusion.

PMID: 21729803 [PubMed – in process]

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Rationale, design and clinical performance of the Superion(®) Interspinous Spacer: a minimally invasive implant for treatment of lumbar spinal stenosis.

Rationale, design and clinical performance of the Superion(®) Interspinous Spacer: a minimally invasive implant for treatment of lumbar spinal stenosis.

Expert Rev Med Devices. 2011 Jul;8(4):419-26

Authors: Loguidice V, Bini W, Shabat S, Miller LE, Block JE

Lumbar spinal stenosis is a progressive degenerative condition that manifests as low back pain with neurogenic claudication as a cardinal clinical feature. Although mild radicular symptoms can often be successfully treated with conservative care, management of lumbar spinal stenosis grows increasingly difficult as symptoms worsen. No satisfactory nonsurgical treatments exist to manage moderate radicular symptoms and, therefore, these patients are faced with the decision of continuing ineffective conservative options or opting to undergo invasive decompressive spine surgery. The Superion(®) Interspinous Spacer (Vertiflex, Inc., CA, USA) was developed specifically to fill the therapeutic void between conservative care and surgical decompression. The Superion device is a titanium implant that is delivered percutaneously and deployed between the spinous processes at the symptomatic vertebral levels. The Superion device improves radicular symptoms by limiting spinal extension and, consequently, minimizing impingement of neural and vascular elements. This article describes the rationale for and the design of the Superion device and summarizes initial clinical results with this novel, minimally invasive interspinous spacer.

PMID: 21728727 [PubMed – in process]

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Perioperative complications and adverse events after lumbar spinal surgery: evaluation of 1012 operations at a single center.

Perioperative complications and adverse events after lumbar spinal surgery: evaluation of 1012 operations at a single center.

J Orthop Sci. 2011 Jul 2;

Authors: Imagama S, Kawakami N, Tsuji T, Ohara T, Matsubara Y, Kanemura T, Goto M, Katayama Y, Ishiguro N

BACKGROUND: Lumbar surgery and associated complications are increasing as society is aging. However, definitions of complications after lumbar surgery have not been established and previous reports have varied in the definition of, and focus on, intraoperative or major postoperative complications. We analyzed the frequency and severity of perioperative complications and all minor adverse events in lumbar surgery at a single center. METHODS: We retrospectively reviewed all lumbar surgery, including decompression surgery with or without fusion, at Meijo Hospital over a 10-year period. Perioperative complications and all surgery-related adverse events until 1 month postoperatively were reviewed for 1012 operations on 918 patients (average age 54 years old). The incidence of intraoperative complications was compared between junior (<10 years experience of spine surgery) and senior (?10 years experience) surgeons. RESULTS: Perioperative complications and adverse events occurred in 159 operations (15.7%) on 127 patients (13.8%). There were a variety of perioperative adverse events, including digestive problems. Of the 159 complications and events, 24 (2.4%) were intraoperative and 135 (13.3%) were postoperative. Incidence of intraoperative complications was not significantly higher for junior surgeons; however, the operations performed by senior surgeons were significantly more invasive. Complications were more frequent in elderly patients (p < 0.01) and in operations that were longer (p < 0.0001), had greater estimated blood loss (p < 0.0001), and involved use of spinal instrumentation (p < 0.0001). Psychotic symptoms occurred significantly more often in older patients (p < 0.001). CONCLUSION: The absence of a relationship between the experience of the surgeon and incidence of intraoperative complications may be because of the greater effect of invasive surgery. Although age and invasiveness were associated with more perioperative adverse events, we do not conclude that major surgery should be avoided for elderly patients. In contrast, careful focus on the surgical indication and procedure is required for these patients.

PMID: 21725670 [PubMed – as supplied by publisher]

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Lumbar ligamentum flavum hematoma treated with endoscopy.

Lumbar ligamentum flavum hematoma treated with endoscopy.

Orthopedics. 2011 Jul;34(7):e324-7

Authors: Ohba T, Ebata S, Ando T, Ichikawa J, Clinton D, Haro H

Hematoma of the ligamentum flavum is a rare cause of neural compression, for which treatment has consisted of excising the hematoma via open surgical approaches, including total laminectomy or bilateral partial laminectomy. This article presents the first report of a microscope-assisted endoscopic decompression to resect a hematoma of the ligamentum flavum.A 52-year-old man presented with back and leg pain, as well as difficulty initiating micturation. Magnetic resonance imaging demonstrated an epidural mass at L5/S1 that was continuous with the facet joint. Visualization was obtained via an endoscope, and a reddish tan-brown solid mass was found beneath the ligamentum flavum. Thorough decompression of the cauda equine and nerve roots was undertaken. The patient’s radicular leg pain and bladder function improved soon after the decompression. Histological examination of the ligamentum flavum revealed a consolidated hematoma with granulomatous change.A review of the English literature revealed 29 cases of hematoma in the lumbar ligamentum flavum. Surgical decompression in these patients was accomplished with a standard open approach through hemilaminectomy (n=11), total laminectomy (n=10), or laminectomy followed by posterior fixation (n=3). The literature review did not identify any case of hematoma of the lumbar ligamentum flavum that was treated endoscopically. We expect our case may expand the indications for the endoscope in spine surgery.

PMID: 21717999 [PubMed – in process]

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