Journal of neurosurgery. Spine
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current lumbar total disc replacement (TDR) devices require an anterior approach for implantation. This approach has inherent limitations, including risks to abdominal structures and the need for resection of the anterior longitudinal ligament (ALL). Placement of a TDR device from a true lateral (extreme lateral interbody fusion [XLIF]) approach is thought to offer a less invasive option to access the disc space, preserving the stabilizing ligaments and avoiding scarring of anterior vasculature. In this study, the authors attempted to quantify the clinical and radiographic outcomes of a lateral approach to lumbar TDR from a prospective, single-center experience. ⋯ long-term results of a laterally placed TDR device demonstrate maintenance of pain relief and functional improvement. The benefits of this technique-minimal morbidity, avoiding mobilization of the great vessels, preserving the ALL, biomechanically stable orientation, and broader revision options-suggest a promising new direction for TDR procedures.
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treatment of lumbar spinal stenosis (LSS) in chronically ill or debilitated patients is challenging. The percutaneous remodeling of ligamentum flavum and lamina (PRLL) technique is a novel method for decompression of the hypertrophic ligamentum flavum component of LSS that is performed using a fluoroscopically guided percutaneous approach, local anesthesia, and minimal sedation. ⋯ this pilot series points to a potential new therapeutic option for LSS in high-risk surgical patients.
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pelvic incidence (PI) directly regulates lumbar lordosis and is a key determinant of sagittal spinal balance in normal and diseased states. Pelvic incidence is defined as the angle between the line perpendicular to the S-1 endplate at its midpoint and the line connecting this point to a line bisecting the center of the femoral heads. It reflects an anatomical value that increases with growth during childhood but remains constant in adulthood. It is not altered by changes in patient position or after traditional lumbosacral spinal surgery. There are only 2 reports of PI being altered in adults, both in cases of sacral fractures resulting in lumbopelvic dissociation and sacroiliac (SI) joint instability. En bloc sacral amputation and sacrectomy are surgical techniques used for resection of certain bony malignancies of the sacrum. High, mid, and low sacral amputations result in preservation of some or the entire SI joint. Total sacrectomy results in complete disruption of the SI joint. The purpose of this study was to determine if PI is altered as a result of total or subtotal sacral resection. ⋯ the PI is altered during total sacrectomy due to complete disarticulation of the SI joint and discontinuity of the spine and pelvis, but it is not changed if any of the joint is preserved. Changes in PI influence spinopelvic balance and may have postoperative clinical importance. Thus, the authors encourage attention to spinopelvic alignment during lumbopelvic reconstruction and fixation after tumor resection. Long-term studies are needed to evaluate the impact of the change in PI on sagittal balance, pain, and ambulation after total sacrectomy.
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The authors report the case of a patient with os odontoideum, myelopathy secondary to atlantoaxial instability, and bilaterally persistent first intersegmental artery at the craniovertebral junction. Instead of occipitocervical fusion, C1-2 posterior fusion was performed using a polyaxial screw/rod system. The information obtained from 3D CT angiography studies may highlight the potential risk of vertebral artery injury in advance and reduce the risk of an intraoperative vertebral artery injury. In addition, C-1 lateral mass screw placement may be a safe procedure for cases of atlantoaxial subluxation in which there are persistent C-1 intersegmental arteries.
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surgical correction of symptomatic cervical or cervicothoracic kyphosis involves the potential for significant neurological complications. Intraoperative monitoring has been shown to reduce the risk of neurological injury in scoliosis surgery, but it has not been well evaluated during surgery for cervical or cervicothoracic kyphosis. In this article, the authors review a cohort of patients who underwent kyphosis correction with multimodal intraoperative monitoring (MIOM). ⋯ in contrast to sensitivity and PPV, specificity and NPV were generally high in all 3 monitoring modalities. Both false-positive and false-negative results occurred. Transcranial MEP monitoring was the most useful modality and appeared to allow successful intervention in certain cases. Larger, prospective comparative studies are necessary to determine whether MIOM truly decreases the rate of neurological complications and is therefore worth the added economic cost and intraoperative time.