Spinal neurenteric cysts: experience with 9 cases via an anterior cervical approach

Excision of an asymptomatic cervical intradural neurenteric cyst through the anterior approach: a study of two cases and a review of the literature

A recurrent intradural cervical neurenteric cyst operated on using an anterior approach: a case report

Neurenteric cysts are rare and account for only 0.7%-1.3% of all spinal tumors. Spinal neurenteric cysts are associated with spina bifida, split-cord malformations, and Klippel-Feil syndrome, a rare congenital disorder characterized by fusion of two or more cervical vertebrae. Klippel-Feil syndrome is rarely accompanied by neurenteric cysts. In this case report, we describe a cervicothoracic junction neurenteric cyst associated with Klippel-Feil syndrome in a 30-year-old man who presented with a 2-month history of neck pain with radiation of pain into both arms and a 1-month history of weakness in the left arm. Magnetic resonance imaging (MRI) of the spine revealed an expansive intradural extramedullary cystic lesion anterior to the spinal cord at the cervicothoracic junction. The neurenteric cyst was removed using an anterior approach, accompanied by C5-C6 corpectomy. The patient's condition improved postoperatively, and he was discharged after postoperative MRI. Spinal neurenteric cysts should be considered in the differential diagnosis in cases of vertebral developmental abnormalities concurrent with intraspinal cysts.

Study Design Case report.Objective The purpose of this work is to report the case of a giant cell tumor involving the second cervical vertebra in a pediatric patient. Surgical management included a combined posterior and anterior cervical approach. There has been no recurrence in 2 years of follow-up.Case Report A 13-year-old girl presented with scoliosis with incidentally lytic lesion involving the second cervical vertebra. The radiologic investigations and biopsy result indicated a giant cell tumor of the bone. A combined posterior and anterior cervical approach was performed to resect the lesion, reconstruct the spine, and restore stability. Two years of follow-up revealed no recurrence of the lesion with stable reconstruction of the spine.Results The lesion was surgically managed for excision and spinal fusion by combining a posterior occipitocervical arthrodesis with an anterior retropharyngeal cervical approach. The final histopathology result confirmed a giant cell tumor of the bone.Conclusions Giant cell tumor involving the second cervical vertebra is uncommon; this tumor can be managed surgically by using a combined posterior and anterior cervical retropharyngeal approach. The presented case was unique in terms of the tumor location, patient age, and surgical management.

Complications of Cervical Endoscopic Spinal Surgery: A Systematic Review and Narrative Analysis

ABSTRACTBackground:The parameter of T1 slope (T1S) minus C2-7 cervical lordosis (CL) is relevant to the surgical management of cervical degenerative diseases (CDD), but whether it contributes to cervical approaches decision-making has not been reported in the literature prior.Purpose:The purpose of this study was to investigate surgical approach optimization based on T1S minus C2-7 CL in the perioperative management of CDD.Materials and Methods:Three hundred sixty-six patients diagnosed with CDD were enrolled from 2018 to 2023. Grouped based on T1S-CL, a value of T1S-CL <20° defined as a matching group, and a value of T1S-CL >20° comprised a matching group. All patients underwent only cervical anterior or posterior approach surgery. Clinical indexes of the Japanese Orthopedic Association (JOA) score, Visual Analog Scale (VAS) and neck disability index (NDI), and radiologic parameters of T1S, CL, and sagittal vertical axis (C2-7 SVA) were recorded and analyzed.Results:Before surgery, there were significant differences in factors between the two groups for CL, T1S, and T1S-CL (P < 0.05). Postoperatively, clinical indexes and radiological parameters changed significantly (P < 0.001) in each group. There are significant correlations indicated between T1S and CL (P < 0.05) except for one in a mismatching group of posterior approach (P > 0.05) postoperatively. There are significant correlations indicated between T1S-CL and T1S, CL (P < 0.05) in two groups of anterior approaches except for posterior approaches (P > 0.05).Conclusion:T1S-CL-based surgical approaches indicate that cervical anterior approaches are superior to posterior paths in improving and optimizing sagittal alignment. Posterior approaches may impair alignment in situations of T1S-CL <20°, and deteriorate malalignment established with conditions of T1S-CL >20°.

Distractive flexion injuries (DFI) of subaxial cervical spine are common after motor car accident or falling from height. The ideal surgical approaches to DFI are still unclear. A retrospective comparative study of surgical approaches for DFI of sub-axial cervical spine involved 60 patients throughout the years 2014 to 2016 at Al-Azhar University Hospitals. All patients were undergoing initial routine resuscitative measures, full general and neurological examinations. Neurologic function was assessed according to modified Frankel’s grading. All patients were received cervical plain antero-posterior, lateral and oblique X-ray, CT with 3D and MRI of cervical spine. Severity of DFI injury was assessed according to Allen and Ferguson’s classification. The most common level involved was C5-6 and most common grade was grade 3. The patients operated through anterior approach were 36 patients and through the posterior approach were 24 patients. Restoring cervical alignment was achieved in 29 patients (80.56%). The mean time of bone fusion was 5.454 months in anterior approach while it was 9.876 months in posterior approach. The extend of bone fusion was good in 30 patients (83.33%) after anterior approach and in 8 patients (33.33%) after posterior approach, while poor fusion was observed in 6 patients (16.67%) after anterior approach and 16 patients (66.67%) after posterior approach. We can conclude that anterior cervical approach is better in DFI stage 3 and 4 where there are associated ruptured intervertebral disc. Posterior approach is better in DFI stage 1 and 2 with or with presence of posterior compressing lesion.

Cervical fractures in patients with ankylosing spondylitis can have devastating neurological consequences. Currently, several surgical approaches are commonly used to treat these fractures: anterior, posterior, and anterior-posterior. The relative rarity of these fractures has limited the ability of surgeons to objectively determine the merits of each. The authors present an updated systematic review and meta-analysis investigating the utility of anterior surgical approaches relative to posterior and anterior-posterior approaches. After a comprehensive literature search of the PubMed, Cochrane, and Embase databases, 7 clinical studies were included in the final qualitative and 6 in the final quantitative analyses. Of these studies, 6 compared anterior approaches with anterior-posterior and posterior approaches, while 1 investigated only an anterior approach. Odds ratios and 95% confidence intervals were calculated where appropriate. A meta-analysis of postoperative neurological improvement revealed no statistically significant differences in gross rates of neurological improvement between anterior and posterior approaches (OR 0.40, 95% CI 0.10-1.59; p = 0.19). However, when analyzing the mean change in neurological function, patients who underwent anterior approaches had a significantly lower mean change in postoperative neurological function relative to patients who underwent posterior approaches (mean difference [MD] -0.60, 95% CI -0.76 to -0.45; p < 0.00001). An identical trend was seen between anterior and anterior-posterior approaches; there were no statistically significant differences in gross rates of neurological improvement (OR 3.05, 95% CI 0.84-11.15; p = 0.09). However, patients who underwent anterior approaches experienced a lower mean change in neurological function relative to anterior-posterior approaches (MD -0.46, 95% CI -0.60 to -0.32; p < 0.00001). There were no significant differences in complication rates between anterior approaches, posterior approaches, or anterior-posterior approaches, although complication rates trended lower in patients who underwent anterior approaches. The results of this review and meta-analysis demonstrated the varying benefits of anterior approaches relative to posterior and anterior-posterior approaches in treatment of cervical fractures associated with ankylosing spondylitis. While reports demonstrated lower degrees of neurological improvement in anterior approaches, they may benefit patients with less-severe injuries if lower complication rates are desired.

Purpose: Application of the anterior sub-axial cervical approach to the axial spine or the high thoracic spine has been previously described. Evaluation methods to determine the feasibility of these approaches were also described but alternative method was utilized in the current study. We describe our experience expanding the boundaries of anterior cervical approach utilizing a novel algorithm for approach selection.Materials and methods: A retrospective analysis of patients’ files and imaging data of all anterior cervical approach to treat pathologies above C2–3 disc space or below C7–D1 disc space. The decision to proceed with standard approach was based on CT or MRI scans and the pre-operative cervical range of motion. Post-operative course and surgical complications will be discussed.Results: During a two year period 13 patients had undergone anterior cervical approach to the axial spine (3 patients) or the thoracic spine (10 patients). Ten patients were treated for tumour resection, one for trauma, one for myelopathy and the last for infective osteomyelitis with epidural abscess. Three patients were previously operated in another hospital via the posterior approach with remaining compressive mass necessitating anterior decompression. Complications were recorded in 30% of the patients.Conclusions: Approach to the axial or the high thoracic spine is more challenging and harbors approach-related complication. Pre-operative evaluation of patients imaging allows harnessing the standard approach for treatment of extreme levels with relative safety and efficiency. Spine surgeons’ awareness to this technique may increase surgical efficacy while reducing the complication rates.

Neurenteric cysts are rare congenital lesions from heterotopic endodermal tissue, often presenting with radiculopathy or myelopathy in young adults. Gross-total resection is curative; however, the surgical approach remains widely debated for cervicothoracic cases. While the posterior approach is common, the anterior approach has had success in adults. The authors present the first pediatric case of anterior corpectomy with gross-total resection of a cervicothoracic neurenteric cyst alongside an extensive literature review. A 10-year-old male, who had undergone a previous cyst resection via a posterior approach at an outside institution, presented with back pain, paraplegia, and urinary incontinence. Magnetic resonance imaging of the spine revealed a ventral hyperintense cyst at C7-T1 consistent with a neurenteric cyst. An anterior approach involving C7 and T1 corpectomies was performed, including intradural exploration leading to complete cyst resection. This was followed by the placement of an expandable cage and anterior and posterior fixation with arthrodesis for stabilization. The patient's symptoms completely resolved after surgery, and there has been no recurrence. The anterior approach is a viable option for cervicothoracic neurenteric cyst resection in the pediatric population and can aid in gross-total resection by providing better lesion visualization. More studies are needed on long-term outcomes of the anterior approach in pediatric populations. https://thejns.org/doi/10.3171/CASE24120.

To compare the diagnostic performance of shoulder magnetic resonance arthrography (MRA) with the anterior trans-subscapularis versus posterior injection approach to diagnose subscapularis tendon (SCT) tears. One hundred and sixty-seven arthroscopically confirmed patients (84 anterior and 83 posterior approaches) were included. Two readers retrospectively scored SCT tears. Proportions of correctly graded tears between MR arthrography and arthroscopy were calculated. Retrospective error analysis was performed. The sensitivity and specificity were 80% (24/30) and 72% (39/54) by reader 1, 73% (22/30) and 76% (41/54) by reader 2 in the anterior approach, and 86% (30/35) and 79% (38/48) by reader 1, 80% (28/35) and 88% (42/48) by reader 2 in the posterior approach, respectively. There were no significant differences in sensitivity and specificity between the two groups. Proportions of correctly graded tears of both readers were 48% and 36% in the anterior approach, and 70 % and 68% in the posterior approach, respectively. The intratendinous collection of contrast material was not statistically significantly different between anterior (n = 8) and posterior (n = 3) approach group. For the MRA diagnosis of SCT tears, there was no significant difference between the anterior trans-subscapularis and the posterior approach. • Anterior trans-subscapularis and posterior approaches showed no significant difference for SCT tears • Intratendinous collection of gadolinium is more frequent in anterior trans-subscapularis approach • Extent of SCT tears tends to be overestimated in anterior trans-subscapularis approach • Posterior approach should be considered for diagnosing SCT tear.

Introduction: Spinal cord injury (SCI) is a devastating and disabling condition that predominantly affecting younger population. Several management protocols have been suggested to improve outcome of acute traumatic SCI including conservative and operative treatment. For the operative treatment, surgical decompression in SCI could be achieved by posterior, posterolateral and anterior approaches. This systematic review aim to compared the approaches in performing decompression in spinal cord injury. Methods: We conduct study from their inception dates to January 2021 with operative treatment of SCI with anterior and posterior approach as the inclusion criteria. Boolean method and PRISMA guideline was used to optimize the search and finding the study. All of the author assessed the quality of study. Results: A total of 4 studies were included in this systematic review. Three studies reported no significant difference between two approach while one study described anterior approach Is more effective than posterior approach. Discussion: There is still much debate about the approach to be used in patients with spinal cord injuries. Three studies mentioned neither the anterior approach nor the posterior approach had significant differences in managing SCI operatively. One study reported neurological recovery was found to be better in patients operated with the anterior approach. Conclusion: The effectiveness between the use of anterior and posterior approaches in patients with spinal cord injury that both had the same clinical outcome. The location of the difference is only in the posterior approach where there is a significant amount of blood loss also has a much longer hospital stay than the anterior approac Keywords: Spinal Cord Injury, SCI, Surgical Approach, Anterior Approaches, Posterior Approaches.

Spinal neurenteric cysts are uncommon congenital lesions, furthermore solitary neurenteric cysts of the upper cervical spine are very rare. A 15-year-old boy having an intraspinal neurenteric cyst located at cervical spine presented with symptoms of neck pain and both shoulders pain for 2 months. Cervical spine magnetic resonance (MR) imaging demonstrated an intradural extramedullary cystic mass at the C1-3 level without enhancement after gadolinium injection. There was no associated malformation on the MR imaging, computed tomography, and radiography. Hemilaminectomy at the C1-3 levels was performed and the lesion was completely removed through a posterior approach. Histological examination showed the cystic wall lined with ciliated pseudostratified columnar epithelium containing mucinous contents. Neurenteric cyst should be considered in the diagnosis of spinal solitary cystic mass.

This meta-analysis aims to evaluate the therapeutic efficacy of anterior versus posterior surgical approaches for multisegment cervical spondylotic myelopathy (MCSM). Eligible studies published between the period of January 2001 and April 2022 and comparing the anterior and posterior surgical approaches for treating cervical spondylotic myelopathy were retrieved from the PubMed, Web of Science, Embase, and Cochrane databases. A total of 17 articles were selected based on the inclusion and exclusion criteria. This meta-analysis failed to show any significant difference in the duration of surgery, the hospitalization time, or the improvement in the Japanese Orthopedic Association score between the anterior and posterior approaches. The anterior approach, however, exhibited increased efficacy in the improvement of the neck disability index, reduction in the visual analog scale for cervical pain, and improvement in the cervical curvature compared with the posterior approach. Bleeding was also less with the anterior surgical approach. The posterior approach provided a significantly higher range of motion of the cervical spine and showed fewer postoperative complications compared with the anterior approach. While both the surgical approaches have good clinical outcomes and show postoperative neurological function improvement, the meta-analysis shows that both anterior and posterior approaches have certain merits and shortcomings. A meta-analysis of a larger number of randomized controlled trials with longer follow-up can conclusively determine which of the surgical approaches is more beneficial in the treatment of MCSM.

Commentary The article by Hoskins et al. provides robust data regarding the relative incidence of early revision of primary total hip arthroplasties (THAs) performed through posterior, lateral, and anterior approaches. Although this study has the usual limitations inherent in data from joint registries, it provides both young and experienced arthroplasty surgeons thoughtful consideration of the results of these procedures. The conclusions that the anterior approach has the highest incidence of major femoral complications (fracture and failure of fixation) of the 3 approaches, the anterior approach has a lower incidence of infection when compared with the posterior approach, and the posterior approach has the highest incidence of dislocation are in general agreement with the current body of literature. However, the overall cumulative percent revision was statistically similar among all approaches. These conclusions should be tempered by realization of the inherent limitations in this study. For instance, the body mass index (BMI) of the posterior approach group was higher than that of the anterior group, suggesting (not inappropriate) bias of selection between the 2 groups, as obesity is a known risk factor (along with its attendant comorbidities, such as diabetes) for wound complications and infection1. Similarly, this study could not tabulate the prevalence of prolonged limp in the lateral approach group (a recognized complication of this approach), as only complications that required a return to the operating room were recorded2. What are the important conclusions to be derived from this work, beyond the statistical tabulation of the early complications of these 3 approaches? The first, and perhaps most important, is that all 3 approaches—and particularly the anterior and posterior approaches—have potential early complications. Surgical technique counts! Second, the surgeon should select the approach to primary THA based on training and experience. Obviously, the approach that offers the most flexibility in exposure would be an excellent basis on which to make this selection. Third, the surgeon should not be attracted by the siren song of “muscle sparing” and “no postoperative restrictions” attached particularly to the anterior approach. Unfortunately, mass marketing of the anterior approach (a Google search for “hip replacement and anterior approach” returned 7,730,000 hits as of August 11, 2020) by both industry and individual practitioners has resulted in patients searching for an approach, rather than a surgeon, lulled into thinking that this approach converts a major procedure into a minor inconvenience. We, as surgeons, must be prepared to admit that there is a learning curve associated with the anterior approach and that embracing this approach may require substantial commitment to proper training and careful patient selection as well as careful surgical technique, particularly with regard to femoral preparation3. We should not overpromise or we will underdeliver as compared with our patients’ expectations. These data are still evolving. Recent publications such as that of Aggarwal et al. have shown a lower incidence of complications with the posterior approach (although they reported on a substantially smaller study cohort), and the posterior approach remains the most popular among multiple joint registries4-7. However, as experience, instrumentation, and prosthetic design evolve, the anterior approach with its potential advantages may supervene the alternatives. For now, the surgeon is urged to become highly proficient in the 3 options (if individual case volume allows) and select the best for the individual patient based on current knowledge and surgeon experience.