Anterior Spinal Cord Decompression Research Articles

Anterior Full-endoscopic Single-port Double Transcorporeal Spinal Cord Decompression for Noncontinuous Two-segment Cervical Spondylotic Myelopathy: A Technical Note.

In clinical practice, noncontinuous two-segment spinal cord cervical spondylosis is a particular form of cervical degenerative disease. Traditional anterior open surgery frequently comes with severe trauma, risks, and debatable treatment options. This study aimed to describe for the first time a novel minimally invasive technique, namely, anterior full-endoscopic single-port double transcorporeal spinal cord decompression for the treatment of patients with noncontinuous two-segment cervical spondylotic myelopathy. From February 2020 to May 2021, five patients with noncontinuous two-segment cervical spondylotic myelopathy were treated with anterior full-endoscopic single-port double transcorporeal spinal cord decompression. Two bone channels were established by the trephine through the vertebral body oblique upward and downward to the herniated disc osteophyte complex, and the full-endoscopic system could decompress the spinal cord through the channels. All cases were followed up for over 2 years. The modified Japanese Orthopaedic Association (mJOA) score and visual analogue scale (VAS) score before and after operation and during follow-up were used to evaluate the clinical effectiveness. Radiological examinations, including CT and MRI, were utilized to evaluate the efficacy of spinal cord decompression and bone channel repair. All operations were successfully completed and the average operation time was 185 min, with no operation-related complications. Compared with the preoperative evaluation, the mJOA score and VAS score were improved at each time point after operation and follow-up. Postoperative CT and MRI scans showed that the intervertebral disc-osteophyte complex was removed through the vertebral bone passage, and the spinal cord was fully decompressed. After 24 months of follow-up, CT and MRI scans showed that the bone channel was almost repaired and healed. Anterior full-endoscopic single-port double transcorporeal spinal cord decompression is an effective minimally invasive technique for noncontinuous two-segment cervical spondylosis. It provides precise and satisfactory spinal cord decompression under endoscopic visualization with minimum trauma.

“Worse than hell”: Complex Neuraxial Lesions Resulting in Tetraplegia and Blindness after Polytrauma - Case presentation

Background. Lesions of the vertebral artery (VA) may develop spontaneously or as a result of severe traumatic cervico-cephalic injuries. Most frequent VA injuries (VAI) result from blunt trauma to the spine or may be due to penetrating lesions. VAI plays a significant role in the broader context of cervical spine trauma by providing insights into the vascular aspects of spinal cord injury (SCI). Upper cervical spine fractures and accompanying subluxation, as well as transverse process fractures extending into the artery bone foramen, are associated with an elevated risk of VAI. Clinical case. A 63-year-old female patient with flaccid C4 AIS-A quadriplegia (global motor score 3/100), vertebral myelopathy, neurogenic bladder, sacral pressure sore, and blindness was transferred from the spinal neurosurgical department. The patient fell from the same level and suffered a mild brain concussion and, apparently, a minor cervical SCI on October 1, 2022. She was asymptomatic, then quickly became tetraplegic, and then blindness added on in a few days. She was operated on on October 7, 2022, for a C6 vertebral body fracture and a C5-6 dislocation. The surgical protocol consisted of anterior spinal cord decompression, dislocation reduction, and mixed anterior fusion with bone grafts and fixation screws. Following the traumatic event, a bilateral posterior cerebral artery (PCA) stroke subsequently produced blindness and partial optic atrophy in both eyes. Serial clinical and imaging examinations confirmed the diagnosis: a subacute bilateral occipital stroke and a chronic lacunar lesion in the right thalamus associated with a severe spinal cord lesion. Anticoagulation has partially improved the neurological outcomes of stroke in the PCA territory. Ethical considerations. The patient's next of kin has given written consent to the case study and to use the radiological images related to the case for academic purposes. The personal identity data was anonymized. The presentation of this clinical case has the approval of the ethics commission of TEHBA (no. 40205/01.09.2023). Discussion. The clinical example is notable for the concurrent development of two severely devastating neurological syndromes, quadriplegia, and blindness, which occurred after an initially minor cervical trauma and progressed gradually over a few days. VA lesions after cervical trauma are considered rare, and the diagnosis is difficult because the vast majority of individuals do not exhibit cerebral neurological symptoms (due to the collateral compensatory blood supply from the circle of Willis). Most of the patients with bilateral or dominant VA occlusions are symptomatic, with rapid (and possibly fatal) ischemic damage to the encephalon, cerebellum, or brainstem. The detection and tracking of evolutionary tendencies required a series of clinical tests, including fundoscopy, and imaging procedures, including native CT, MRI, and MR angiography scans of the brain and spine. Conclusions. Although VAI is a rare complication, in every polytrauma patient with head and neck trauma, VA damage should be suspected. Careful clinical and imaging monitoring through detailed serial imaging procedures must be performed for every person with severe cranio-cervical trauma. The clinical example emphasizes the importance of the interprofessional team's participation in the patient's care.

Anterior spinal cord decompression via a posterolateral approach for the treatment of ossification of the posterior longitudinal ligament in the thoracic spine: A prospective cohort study

Anterior spinal cord decompression via a posterolateral approach for the treatment of ossification of the posterior longitudinal ligament in the thoracic spine: A prospective cohort study

Quality of life indicators in assessing the results of various surgical treatment methods for cervical myelopathy

Quality of life indicators are widely used to determine the efficiency of various medical therapies for cervical myelopathy; however, but these have been insufficiently studied in assessing the results of surgical treatment for this pathology. In addition, the results of surgical treatment for cervical myelopathy are observed to be unsatisfactory in 15–20% of cases, which indicates the need to develop new techniques and to improve existing ones for its correction. Direct electrical stimulation of the spinal cord may become one of the promising areas. Objective: to comparatively analyze the efficiency of various surgical treatments for cervical myelopathy, by assessing the quality of life indicators in the patients. Patients and methods. The investigation enrolled 92 patients with cervical myelopathy: 29 (49.2%) patients underwent posterior spinal cord decompression via laminectomy; in 17 of them, that was supplemented with the electrodes placed on the posterior columns of the spinal cord for its postoperative direct electrical stimulation; 63 (50.8%) patients underwent anterior spinal cord decompression, 12 of them had electrodes placed on the anterior horns of the spinal cord. Results and discussion. After posterior spinal cord decompression with laminectomy, there were increases in physical functioning from 36.7±2.1 to 49.6±3.1 arbitrary units (arb. unit) (p<0.05) and in role physical functioning from 39.4±2.6 to 51.3±2.6 arb. unit (p<0.05) and a decrease in pain sensations from 51.6±2.6 to 30.2±0.8 arb. unit (p<0.05). Electric stimulation of the spinal cord caused increases in physical functioning from 40.3±3.6 to 61.3±2.8 arb. unit (p<0.05) and in role physical functioning from 36.7±1.6 to 69.4±1.6 arb. unit (p<0.05) and a reduction in pain sensations from 49.8±2.4 to 21.0±1.2 arb. unit (p<0.05). The similar trend as also observed in anterior spinal cord decompression concurrent with corporodesis at the cervical level after direct electrical stimulation of the spinal cord. Physical functioning increased from 42.0±3.1 to 57.6±1.4 arb. unit (by 26.4%; p<0.05) and mental health improved (only by 14.3%). After isolated anterior spinal cord decompression with corporodesis, physical functioning was 48.4±0.9 arb. unit by the end of the third month follow-up (p<0.05); following that in combination with electrical stimulation, physical functioning was 57.6±1.4 arb. unit (p<0.05). The posttreatment levels of viability, social functioning, role emotional functioning, and mental health were significantly lower in patients with a disease duration of more than 6 years than in those with that of less than 3 years. Conclusion. Posterior and anterior spinal cord decompression with laminectomy for cervical myelopathy increases the indicators of physical functioning and role physical functioning and reduces pain sensations. The additional use of electrical stimulation of the spinal cord allows one to increase role physical functioning.

Can Intraoperative Spinal Cord Monitoring Reliably Help Prevent Paraplegia During Posterior Vertebral Column Resection Surgery?

Study DesignRetrospective case series. ObjectiveAnalyze patients who underwent posterior vertebral column resection (PVCR) above the conus medullaris with intraoperative spinal cord monitoring (SCM) data loss. Summary of Background DataPVCR is a powerful technique for treating severe spinal deformity but carries a high risk for major spinal cord deficits. MethodsWe assessed clinical, radiographic, and electrophysiologic monitoring and operative records of 90 consecutive adult and pediatric patients (mean age, 24.8 years; range, 7.5–76.8) who underwent PVCR above the conus medullaris for severe spinal deformity performed from 2002 to 2010 by one surgeon at one institution. ResultsFifteen of 90 patients (16.7%) (10 male/5 female; mean age, 15 years) lost SCM (n = 13) or had data degradation meeting warning criteria (n = 2). Diagnoses were kyphoscoliosis (n = 8), angular kyphosis (n = 3), global kyphosis (n = 2), and severe scoliosis (n = 2). Seven were revisions. The average pre-/postoperative scolioses were 99° (range, 32°–152°) and 43° (range, 6°–76°), respectively. The average pre-/postoperative kyphoses were +100° (range, 60°–170°) and +54° (range, 28°–100°), respectively. SCM fluctuated during osteotomy on nine occasions, stabilizing with elevation of blood pressure in addition to anterior spinal cord decompression in four, correction of subluxation in one, and traction reduction in one. Seven patients had SCM changes during rod compression. Three required partial release of correction, two larger cage insertion, one subluxation correction, and one pedicle screw removal. One experienced changes during rod placement/removal, and another, as a result of hypothermia. Data returned in all after prompt intervention (mean, 10.1 minutes; range, 1–60) and all awoke with intact lower extremity function. ConclusionThe prevalence of SCM changes during PVCR above the conus medullaris was 16.7%, mostly during osteotomy and rod/screw compression. Data returned with prompt intervention and all had intact lower extremity motor function postoperatively. These SCM “saves” strongly emphasize the importance of multimodality neurophysiologic monitoring during high-risk cases, minimizing postoperative complications.

Progressive Quadriplegia from Kyposis in Pediatric Patient after Laminectomy for Cervical Intramedullary Tumor Excision: Case Report and Literature Review in Short

Cervical spinal deformities with progressive neurological deficit after laminectomy is relatively uncommon. But, it can happen more commonly after resection of intramedullary spinal cord lesions than other spinal lesion. Postlaminectomy cervical spinal deformity is most common in children with an immature skeletal system. Many factors such as the extent of laminectomy and facetectomy, number of laminae removed, location of laminectomy, preoperative loss of lordosis, postoperative radiation therapy, etc. can precipitate such deformities. We report a pediatric patient with who underwent successful complete removal of long segment cervical intramedullary spinal tumor. Postoperatively he developed progressive kyphosis in cervical spine with progressive neurological deficit. We went for second operation (anterior cervical spinal cord decompression by two segments corpectomy followed by iliac crest strut graft fusion and stabilization). Postoperatively patient recovered well. He had loss of cervical spinal lordosis with mild kyphosis before first operation. Such a case report in the literature is relatively uncommon. Here, we also go for short review of literature on this topic.

Surgical treatment of thoracic disc disease via minimally invasive lateral transthoracic trans/retropleural approach: analysis of 33 patients

Thoracic disc herniations are associated with serious neurological consequences if not treated appropriately. Although a number of techniques have been described, there is no consensus about the best surgical approach. In this study, the authors report their experience in the operative management of patients with thoracic disc herniations using minimally invasive lateral transthoracic trans/retropleural approach. A series of 33 consecutive patients with thoracic disc herniations who underwent anterior spinal cord decompression followed by instrumented fusion through lateral approach is being reported. Demographic and radiographic data, perioperative complications, and clinical outcomes were reviewed. Forty disc levels in 33 patients (18F/15M; mean age, 52.9) were treated. Twenty-three patients presented with myelopathy (69%), 31 had radiculopathy (94%), and 31 had axial pain (94%). Among patients with myelopathy, 14 (42.4%) had bladder and/or bowel dysfunction. In the last eight cases (24%), the approach was retropleural instead of transpleural. Patients were followed up for 18.2months on average. The mean length of hospital stay was 5days. None of the patients developed neurological deterioration postoperatively. Among 23 patients who had myelopathy signs, 21 (91%) had improved postoperatively. The mean preoperative visual analog scale pain score, Oswestry Disability Index score, SF-36 PCS, and mental component summary scores were 7.5, 42.4, 29.6, and 37.5 which improved to 3.5, 33.2, 35.5, and 52.6, respectively. Perioperative complications occurred in six patients (18.1%), all of which resolved uneventfully. Minimally invasive lateral transthoracic trans/retropleural approach is a safe and efficacious technique for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional approaches.

Abord mini-invasif de la charnière thoracolombaire du rachis par voie extrapleurale, rétropéritonéale. Étude prospective sur 40 cas

Study designProspective study. Background and purposeThe anterior spinal cord decompression and spinal interbody fusion is considered an effective therapeutic procedure for thoracolumbar spine junction (TLSJ) (T11 to L2) fractures and tumors. However, it is also known to be associated with considerable surgery-related trauma. The purpose of this study was to show that neural elements decompression and anterior reconstruction at the TLSJ can be performed via a minimally invasive extrapleural retroperitonal approach (MIERA). MethodsThe authors studied prospectively the hospital records and radiological data obtained in 40 patients (mean age: 43.6 years, range: 16–74 years) who all underwent first a posterior fixation followed by a thoracic (T11 or T12) or lumbar (L1 or L2) corpectomy and spinal fusion via a MIERA. ResultsThe MIERA provided excellent exposure to facilitate complete decompression and anterior reconstruction in all patients, as verified on follow-up radiographic studies. More than 2years follow-up record is available for 24 patients, a one year follow-up record for 14 others, and six months follow-up for the last two ones. Radiography demonstrated anatomically correct reconstruction in all patients, as well as a solid fusion or a stable compound union in the 24patients for whom a minimum of 2years follow-up records was available. ConclusionsThe MIERA allows the surgeon to perform anterior thoracolumbar spine surgery via a less invasive approach. The authors demonstrate the efficacy and safety of this technique and its potential to reduce perioperative morbidity compared with conventional retroperitoneal lumbar spine surgery or thoracophrenolombotomy.

Anterior thoracic foraminotomy through mini-thoracotomy for the treatment of giant thoracic disc herniations

A retrospective review of a case series. Giant thoracic disc herniations remain a surgical challenge and historically have been associated with significant complications. While neurological outcomes have improved with the abandonment of decompressive laminectomy, the attempt to minimize surgical complications and associated morbidities continues through less-invasive approaches. With the current study, we describe a surgical technique to treat giant thoracic disc herniations while minimizing approach-related morbidity. Demographic and radiographic data; clinical outcome and perioperative complications were retrospectively analysed for patients with single-level giant thoracic disc herniations who underwent mini-thoracotomy and selective microsurgical anterior spinal cord decompression without instrumented fusion. Between 2007 and 2012, 7 consecutive patients with giant thoracic disc herniations were treated (average age of 53 years; range 45-66 years). The average canal encroachment was 73.2 % (range 40-92 %) with 5 grossly calcified discs of which 3 had transdural components. All patients had gradual myelopathic progression. The average Nurick grade was 3.5 (range 2-5). All patients were successfully treated with anterior microsurgical decompression without instrumentation. Uninstrumented fusion with rib graft was performed only in one patient with advanced degenerative changes. Average time of surgery was 337.8 min (range 220-450 min). The average length of hospital stay was 7.4 days (range 6-11 days). The average neurological status at follow-up (average 23.5 months; range 9-36 months) using the modified Nurick grading scale was 1.28. No vertebral collapse or loss of spinal alignment developed. There were no neurological complications. One patient developed an acute headache and diplopia, 10 days after surgery, following sneezing associated with a post-operative thoracic cerebrospinal fluid leakage requiring revision. Two patients suffered an approach-related complication in form of intercostal neuralgia; one was persistent. Anterior decompression using a mini-transthoracic approach provides sufficient exposure for microsurgical decompression of giant thoracic disc herniations without disrupting the stability of the spine. Microsurgical decompression without instrumentation does not appear to lead to vertebral collapse or spinal malalignment.

Evaluation of Role of Anterior Debridement and Decompression of Spinal Cord and Instrumentation in Treatment of Tubercular Spondylitis

Study DesignProspective study with simple randomization.PurposeTo evaluate the results of anterior spinal instrumentation, debridement and decompression of cord and compare it with results of a similar procedure done without the use of anterior instrumentation.Overview of LiteratureUse of anterior spinal instrumentation in treatment of tubercular spondylitis is still an infrequently followed modality of treatment and data regarding its usefulness are still emerging.MethodsThirty-two patients of tubercular paraplegia with involvement of dorsal and dorso-lumbar vertebrae were operated with anterior spinal cord decompression, autofibular strut grafting with anterior instrumentation in 18 patients and no implant in 14 patients. Results were compared on the basis of improvement in Frankel grade, correction of local kyphosis, decrease in canal compromise and further progression of kyphosis.ResultsThe mean local kyphosis correction in the immediate postoperative period was 24.1° in the instrumented group and was 6.1° in the non instrumented group. The mean late loss of correction of local kyphosis at 3 years follow-up was 1.7° in the instrumented and 6.7° in the non instrumented group. The mean improvement in canal compression was 39.5% in the instrumented group and 34.8% in the non instrumented group.ConclusionsIn treatment of tubercular spondylitis by anterior debridement and decompression of the spinal cord and autofibular strut grafting, the use of instrumentation has no relation with the improvement in neurological status, however the correction of local kyphosis and prevention of further progression of local kyphosis was better with the use anterior spinal instrumentation.

Management of brown-sequard syndrome in cervical disc diseases

To raise the awareness of the appropriate management of unusual clinical presentation of cervical disc herniation. Seven patients with Brown-Sequard syndrome due to cervical disc herniation presented with Brown-Sequard syndrome had been treated surgically as one of them treated with anterior cervical discectomy and three patients treated by anterior cervical discectomy and fusion while three of them have been treated by posterior laminectomy. Patients were 7 three of them were female and four were males and the mean age of our patients is 45.28 ± 16.49 years ranged between 32 and 72 years. History of spinodegenerative disease in the form of chronic neck pain with or without brachialgia was found in 6/7 patients (85.7%) while history of trauma was found in 5/7 patients (71.4%). Most common affected level is C5-C6 disc Outcome after surgical treatment revealed complete recovery in 4/7 patients (57.1%) while incomplete recovery in 2 patients (28.6%) and no improvement in one patient (14.3%). Brown-Sequard syndrome is a rare presentation of cervical disc herniation but accurate diagnosis, and early anterior spinal cord decompression lead to complete recovery of these cases.

Minimal Invasive Anterolateral Transthoracic Transpleural Approach

A retrospective review of a case series. To describe a novel surgical technique for a minimally disruptive lateral transthoracic transpleural approach to treat thoracic disc herniations. Thoracic disc herniation is a relatively uncommon spinal condition, and surgical treatment is indicated for patients with myelopathy or radiculopathy that failed to respond to conservative therapy. Presently there is no consensus about the best approach to address thoracic disc herniations. Using the novel retractor system (MaXcess), the authors describe a novel minimally disruptive approach that allows the surgeons to perform a standard anterior discectomy and fusion with instrumentation while minimizing approach-related morbidity. A series of 12 patients with single-level thoracic disc herniations who underwent anterior spinal cord decompression followed by instrumented fusion through a novel retractor system is being reported. Demographic and radiographic data, perioperative complications, and clinical outcomes were reviewed. Twelve patients were enrolled with an average age of 51 years (range, 23 to 67 y). The average follow-up was 28 months (range, 12 to 33 mo). The average length of hospital stay was 5 days (range, 2 to 12 d). The average preoperative visual analog scale pain score was 9 (range, 7 to 10), which later decreased to 3 (range, 0 to 5) at final follow-up. All patients with myelopathy and/or sphincter dysfunction had significant improvement of their symptoms. One patient had pleural effusion and 1 patient had intercostal neuralgia. Anterior decompression using a transthoracic transpleural approach provides excellent exposure and allows consistent decompression of thoracic disc herniations. This study demonstrated that a new minimally invasive, transthoracic transpleural decompression technique can be safely performed for single-level thoracic disc herniations. The early results showed that this technique allows less dissection, along with the advantages of conventional thoracotomy.

Minimally Invasive Extrapleural Retroperitoneal Approach to the Thoracolumbar Spine Junction: Clinicoradiologic Study of 29 Consecutive Cases

The anterior spinal cord decompression and spinal interbody fusion is considered an effective therapeutic procedure for thoracolumbar spine junction (T11 to L2) fractures and tumors. However, it is also known to be associated with considerable surgery-related trauma. The purpose of this study is to show that neural elements decompression and anterior reconstruction at the thoracolumbar spine junction can be conducted through a minimally invasive extrapleural retroperitonal approach (MIERA). Hospital records and radiologic data were obtained prospectively in 29 patients (mean age 43.6 years, range 16 to 74 y) who all underwent first a posterior fixation followed by a thoracic (T11 or T12) or lumbar (L1 or L2) corpectomy and spinal fusion through a MIERA. The MIERA provided excellent exposure to facilitate neural decompression and anterior reconstruction in all patients, as verified on follow-up radiographic studies. More than 1-year follow-up record is available for 23 patients, a 9-month follow-up record for 4 others, and 6-months follow-up for the last 3 ones. Radiography showed anatomically correct reconstruction in all patients, and a solid fusion or a stable compound union in the 20 patients for whom a minimum of 1-year follow-up records were available. The MIERA allows the surgeon to carry out anterior thoracolumbar junction spine surgery through a less invasive approach. The investigators report the safety efficacy of this technique and its reduced perioperative morbidity compared with conventional retroperitoneal lumbar spine surgery or thoraco-phreno-lombotomy.

General anesthesia for cesarean delivery followed by anterior and posterior spinal cord decompression of a parturient with symptomatic spinemetastasis due to breast cancer

Cesarean delivery of a parturient suffering from paraplegia followed by anterior corpectomy and posterior spinal cord decompression because of spine metastasis at T1 due to breast cancer was presented. General anesthesia was uneventfully completed after rapid sequence anesthesia induction with propofol, ketamine, and succinylcholine, which was maintained by isoflurane inhalation in 50% oxygen-air mixture until delivery of the newborn. After delivery, remifentanil infusion was added to isoflurane inhalation in approximately 33%/66% oxygen:air until skin closure of the latter operation. Consequently, satisfactory recovery of paraplegia resulting from spine metastasis and delivery of a healthy baby were provided by successful and uneventful management of sequential caesarean delivery and neurosurgical intervention requiring double different positioning successively under general anesthesia.

INTRACANAL METHOD FOR SPINAL CANAL WIDENINGIN COMPLICATED INJURIES OF THE THORACOLUMBAR SPINE AND THEIR CONSEQUENCES

Objective. To analyze results of surgical treatment of patients with complicated injury of thoracolumbar spine using effective techniques of anterior spinal cord decompression and the injured spine stabilization with the account for economic possibilities of the Kyrgyzstan health system. Material and Methods. The paper presents results of surgical treatment of 43 patients with complicated injuries of the spine who have undergone reconstructive surgery in thoracolumbar spine including widening of the spinal canal and supporting stabilization with bone autofraft. Results. The treatment results were assessed on the basis of clinical information and radiological findings and considered as good and satisfactory in 95.7% of cases. The method of anterior decompression with intracanal widening of the spinal canal has been proved effective in the treatment of thoracolumbar spine. Conclusion. In situation when the choice of optimal surgical method is limited by economic conditions the developed technique may be sufficiently effective in the treatment of complicated fractures of the thoracolumbar spine.

Abord ventral transcervicomanubrial du rachis thoracique supérieur : note technique à propos de six cas

Ventrolateral cervicotomy provides a narrowed working space for surgical management of upper thoracic spine. We report our experience about ventral upper thoracic spinal cord decompression with reconstruction and plating via the cervicomanubrial route. Six patients (24 to 75 years old) were operated on by the same operator (LN) by cervicomanubriotomy from 2002 to 2007 for upper thoracic spinal cord compression (one case of Pott's disease, three cases of metastases, one fracture, one invasive hemangio-epithelioma), with a good outcome in five patients. Lesions were located from the cervicothoracic junction down to the fourth thoracic vertebra (T4). In all cases, anterior spinal cord decompression, strut graft reconstruction (iliac bone in two cases, cement in four cases) and osteosynthesis were performed. In two cases, a second stage posterior decompression with fixation was performed. The approach begins by a left sided anterior cervicotomy, medial to the sternocleidomastoid muscle and lateral to the trachea and esophagus, associated with division of the infrahyoid muscles close to their insertion at the upper thoracic outlet followed by osteotomy of the manubrium sterni. Then, division of the thyropericardic fascia and thymus, control of the brachiocephalic vein, control of the thoracic lymphatic duct and the horizontal thoracic aorta are performed. The ventral part of fifth cervical vertebra body down to T4 is then exposed between the left primitive carotid artery laterally, the esophagus medially and the thoracic aorta caudally. Compared to total sternotomy without or with clavicle resection, cervicomanubriotomy seems to be a less aggressive, safe and reliable procedure.

The indications for lumbar and cervical disc replacement

Although cervical and lumbar disc replacements are in their spinal surgical infancy with regard to clinical application, the indications are already delineated. Lumbar disc arthroplasty is indicated for one- or two-level discogenic mechanical back pain primarily in the absence of radiculopathy. In contrast, cervical disc replacement can be readily applied in patients presenting with neurologic deficit, radiculopathy or myelopathy because the approach and anterior spinal cord decompression are identical for anterior cervical disc replacement and traditional Smith-Robinson cervical decompression. In addition, the application of more complex spinal osteotomies, revision of pseudarthroses and deformity correction are much more applicable to the cervical arthroplasty procedures. This is because even the most experienced vascular access surgeon has difficulty with the formidable revision through a repeat anterior lumbar procedure, whereas most experienced cervical spinal surgeons are familiar with repeat anterior cervical approaches. The end result is that surgeons will have more trepidation with multilevel lumbar arthroplasties, especially those presenting in conjunction with neurologic symptoms. At the current time radiculopathy is an exclusion criteria for the four prospective Investigational Device Exemption (IDE) Food and Drug Administration (FDA) studies on lumbar disc replacement, whereas cervical radiculopathy is an inclusion criteria for the major IDE FDA investigations of cervical arthroplasties.

Radiolucent cage for cervical vertebral reconstruction: A prospective study of 17 cases with 2-year minimum follow-up

In cervical spondylotic myelopathy, extended anterior spinal cord decompression necessitates subsequent stable vertebral reconstruction. Reconstruction with an iliac crest graft and screw-plate fixation gives satisfactory clinical and radiological results, but they are often compromised by morbidity involving the bone harvest. The purpose of this study was to evaluate the contribution to cervical reconstruction of a biocompatible, radiolucent cage combined with screw-plate fixation, making use of bone harvested in situ. This prospective study was performed between July 2000 and March 2001 in eight women and nine men (mean age, 55 years) operated for cervical spondylotic myelopathy. Situated between levels C3 and C6, the cage was inserted after one corporectomy in ten patients, two corporectomies in five patients, and three corporectomies in two patients. The cage consisted of a polyester mesh impregnated with poly-L-lactic acid (PLLA) conferring temporary rigidity to the cage during bony fusion. Clinical and radiological follow-up (plain films, computed tomographic reconstruction in three cases) was performed at 2 months, 6 months, 12 months, 24 months and 36 months, postoperatively, with a mean follow-up of 30 months. Functional results were evaluated according to the Japanese Orthopaedic Association's scoring system. An independent surgeon assessed the radiological evidence of anterior cervical fusion using the grades proposed by Bridwell [6]. Every patient experienced neurological recovery. At last follow-up, radiological findings were consistent with grade I (complete fusion) in five cases, grade II (probable fusion) in ten cases, grade III (radiolucent halo in favor of non fusion) in one case, and grade IV (graft lysis) in one case with persistent neck pain. In three cases there was screw breakage (two grade II, one grade IV). None of these cases required surgical revision at latest follow-up. In extensive spinal cord decompression through an anterior approach, cervical reconstruction using the present type of cage can achieve clinical results comparable to conventional techniques. The rigidity of the cage meets biomechanical imperatives. Its radiolucency permits one to monitor the course of consolidation, contrary to metal cages. The cases of probable non-fusion and screw breakage were not accompanied by signs of instability on the flexion extension films. This cage meets the biologic and biomechanical imperatives of cervical reconstruction. It obviates complications involving bone harvest.

後方侵入脊髄前方除圧術の後背角の検討

Five years ago, we started treating patients with OPLL by anterior spinal cord decompression through posterior approach for the first time. In the four persons treated for OPLL etc. so far, the kyphotic angles of the concerned region have been appreciated at present.

Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life.

Eighty-six surgical interventions in 76 consecutive patients with symptomatic spinal metastases were reviewed retrospectively. To evaluate the postoperative outcome and quality of life of patients surgically treated for symptomatic spinal metastases. The standard surgical treatment for patients with symptomatic spinal metastases is anterior spinal cord decompression with stabilization. However, because therapy is only palliative, satisfactory quality of life and high patient acceptance are essential. The medical records of all patients were reviewed retrospectively. Furthermore, all surviving patients or the next of kin of deceased patients were interviewed by telephone, and the family doctors or the care-providing physicians of external institutions were contacted. First-choice surgical treatment was anterior spinal cord decompression with stabilization. Postoperative mean survival was 13.1 months, and mean time at home after spinal surgery was 11.1 months. Neurologic improvement with regard to Frankel classification was observed in 58% of the patients, and 93% were able to walk postoperatively. Pain relief was noted in 89%. Overall, 67% of the patients achieved moderate or good general health as shown by the Karnofsky Index, and 80% were satisfied or very satisfied with the surgical intervention. Moreover, 19% of the surgical interventions were associated with complications, local tumor recurrence developed in 22% of the patients, and paraplegia ultimately developed in 18% of patients. Surgical management of symptomatic spinal metastases, in particular anterior decompression, is of benefit in most metastatic lesions in terms of satisfactory postoperative outcome and quality of life. However, in patients with melanoma or lung carcinoma, the authors advocate spinal surgery only in very exceptional cases.