Expandable Titanium Cage Research Articles

Metastatic epidural spinal cord compression

Up-to-date management for metastatic epidural spinal cord compression is based on appropriate scoring systems. In this case, separation surgery and stereotactic radiosurgery achieved an optimized outcome. A 75-year-old man had thoracic band-like pain, left lower limb weakness and difficulty ambulating for 6 weeks. Spinal images showed a T4 metastatic epidural spinal cord compression with a pathological fracture of T4 and T10 and L3 lytic lesions. There was no other neoplastic lesion. The metastasized T4 was decompressed by a posterolateral right costotransversectomy, vertebrectomy and insertion of an expandable titanium cage. The spinal sagittal alignment was restored with T1–T7 pedicle screw fixation. Post-operatively the pain and motor power improved significantly so that the patient was discharged home. Separation surgery and adjuvant stereotactic radiosurgery of the spine successfully improved tumor burden, pain control and overall prognosis.

Early versus delayed corpectomy in thoracic and lumbar spine trauma. A long-term clinical and radiological retrospective study

Summary and background dataMany authors have demonstrated the necessity of reconstruction of the anterior column in spinal trauma with vertebral body collapse or nonunion. There is no publication comparing the result depending on the time between trauma and anterior reconstruction of the vertebral body. ObjectiveTo compare long-term clinical and radiological results between early and late anterior vertebral body reconstruction with expandable cages in patients with thoracic and lumbar spine trauma. HypothesisAn early anterior reconstruction of thoracolumbar fractures provides better clinical and radiological outcomes than a delayed one. Materials and methodsA retrospective clinical study was carried out with 44 consecutive patients with injuries of the thoracic and lumbar spine treated operatively with combined posterior stabilization and anterior reconstruction with an expandable implant for vertebral body replacement. All patients were evaluated with EOS full-spine radiograph and CT-scan. The mean follow-up was 5.1 years. Clinical result was evaluated with ODI, SF12, VAS back pain, return to work and sport. Radiological result was evaluated with regional kyphosis angle (RKA) evolution, fusion rate and sagittal alignment. In Group A, twenty-nine patients underwent an early anterior reconstruction within 3 weeks after trauma. The indication of vertebral body reconstruction was placed after post-operative CT-scan for a Mc Cormack score≥7. In Group B, fifteen patients underwent a late anterior reconstruction after diagnosis of nonunion by the combination of pain and CT-scan after 1 year. ResultsClinical scores and scales were significantly better for patients operated early in Group A. Return to work and activities were significantly more important in Group A too. The mean RKA correction with posterior reduction was 9.3°. The secondary anterior approach permit to reduce 2.9° more. At last follow-up, the loss of reduction was 4.3°. There was no significant difference between groups for those results. No difference in fusion rate was observed between groups. There was no significant difference between groups in the sagittal alignment excepted for SVA that was higher for Group B while remaining under a normal value of 50mm. ConclusionEarly anterior vertebral body reconstruction for fractures gives better clinical results than delayed reconstruction for patients with diagnosis of nonunion in patients with thoracic and lumbar spine trauma. Moreover, the shorter the time from trauma to operation, the better the sagittal reduction of kyphosis. The use of expandable titanium cage is a good way to perform and maintain this reduction. Level of evidenceIV, retrospective study.

Multiple solitary plasmacytoma of the spine with compressive cervical myelopathy: A rare case report and review of literature

We present a case of multifocal plasmacytoma, one of the rarest hematological malignancies, with an unusual presentation of cervical myelopathy. A 60-year-old male presented with features of cervicalgia and radiculomyelopathy. There was a history of significant weight loss over 2 months with no sphincter involvement. Neurological examination showed spastic quadriparesis with extensor plantars. Radiological workup showed multiple lytic lesions from C3 to C6 with cord compression and myelomalacic changes. The patient underwent three-level corpectomy (C5–C7) with cord decompression. Reconstruction was done with an expandable titanium cage, and anterior cervical plating from C4 to T1 was done. The histopathology and immunohistochemistry markers enabled in clinching this rare diagnosis of multifocal plasmacytoma. It is essential to distinguish early between various entities among plasmacytoma as each one has a different clinical course and prognosis. Multiple solitary plasmacytoma presenting de novo with cord compression and myelopathy is an extremely rare presentation.

Decompression with Lateral Pediculectomy and Circumferential Reconstruction for Unstable Thoracolumbar Burst Fractures: Surgical Techniques and Results in 18 Patients

To introduce our technique and results of retropleural/peritoneal lateral pediculectomy for the decompression of thoracolumbar fractures and reconstruction using an expandable titanium cage and circumferential fixation at a single stage. Eighteen patients who had single unstable, burst thoracolumbar fracture were treated by this technique between January 2014 and December 2016 (T12: n= 9, L1: n= 7, L2: n= 2). They were reviewed retrospectively in terms of radiologic outcomes (computed tomography [CT] scan and radiograph), clinical outcomes, and complications. The results were compared with another cohort of thoracolumbar fractures treated by posterior-only surgery. There were no radiologic complications implying pseudoarthrosis or instrument failure on the postoperative 6-month CT scan. There was also no neurologic deterioration or infection during the same period. Two patients (11.1%) of iatrogenic injury and 1 patient of trauma-related injury of the dura were secured without any delayed complications. Three patients (16.7%) with transient weakness in left hip flexion immediately after operation were observed and recovered within 2 weeks in all cases. Six patients (33.3%) complained of dysesthesia and/or hypoesthesia on the incision site. In this study, we suggest lateral pediculectomy as a distinct anatomic landmark to access and remove bony fragments effectively and safely in unstable thoracolumbar burst fractures. This provides a more straightforward access to the burst fragment and helps the surgeon to make better intraoperative decompression strategies. Moreover, this circumferential instrumentation with anterior support and fusion revealed better restoration of the thoracolumbar spine alignment compared with posterior-only surgery, with acceptable complications rates.

Anterior Lumbar Corpectomy with Expandable Titanium Cage Reconstruction: A Case Series of 42 Patients.

Burst fractures involve the anterior and middle columns with an intact posterior column. Deforming forces are magnified at areas of transition, making the thoracolumbar junction highly susceptible to injury. This is a retrospective review of 42 consecutive patients who underwent single-level anterior lumbar corpectomy using an obelisc expandable titanium cage and lateral fixation for traumatic lumbar burst fractures. Myelopathy and sensory dysfunction were the most frequent neurologic deficits initially, occurring in 16 (38%) and 15 (36%) patients, respectively, which both decreased to 5 (13%). At follow-up, 26 patients (68%) were able to ambulate independently. No patient had significant cage displacement or needed cage replacement. Subsidence was minimal in 32 of 39 patients (82%). There were no hardware infections or surgical site infections. Options for stabilization include posterior instrumentation and fusion, anterior corpectomy with interbody fusion, and combination procedures. We believe anterior stabilization is superior because the aim is structural restoration of anterior and middle columns. The aim of posterior fixation is to replace the posterior tension band, which is not affected. There are 3 major surgical components to consider. First is anterior versus posterior decompression of the spinal canal. Second is the choice of autograft or titanium graft. Third is whether to stabilize posteriorly or anterolateral. Anterior corpectomy with an expandable titanium cage and lateral rod fixation is safe and effective with minimal complications. It is a viable alternative to posterior decompression and instrumentation.

Instrumented Circumferential Fusion in Two Stages for Instable Lumbar Fracture: Long-Term Results of a Series of 74 Patients on Sagittal Balance and Functional Outcomes.

To report the radiologic and functional results of a multicenter, prospective case series of patients with comminuted lumbar fractures treated with 2-stage circumferential arthrodesis. A multicenter prospective case series of 74 patients with comminuted lumbar fractures was analyzed. The strategy entailed initial posterior osteosynthesis, followed by physical replacement with an expandable titanium cage filled with autologous bone via retroperitoneal lumbotomy. The mechanism of lesion formation and epidemiologic characteristics were recorded. Clinical and quality-of-life analyses (visual analog scale [VAS], Oswesty Disability Index [ODI], Short Form 12 [SF-12]) were performed over a minimum observation period of 1 year. Radiologic parameters, including deformity measurements, were recorded at each evaluation. Fusion was analyzed by means of a 1-year monitoring scan. The mean patient age was 38.1 years, and median duration of follow-up was 2.1 years (interquartile range, 1.3-2.9). The distribution of fractures according to the Magerl classification scheme was as follows: A, 64.8%; B, 16.7%; C, 18.5%. At the last follow-up, fusion was considered certain in 57 cases (77%). The mean VAS score was 2.1 ± 1.3, mean ODI was 14.7 ± 8.0, mean SF-12 Physical Component Summary score was 43.2 ± 9.3, and mean SF-12 Mental Component Summary score was 50.8±5.9. Correction of the regional sagittal deformity was significant during the postoperative period, with a mean increase in lordosis of 9.0° (P < 0.0001). The loss of mean correction at the last follow-up (-2.9°) was not significant. Circumferential arthrodesis, including posterior osteosynthesis and physical replacement with an expandable cage and autologous graft, is applicable to the treatment of comminuted lumbar fractures. A high rate of fusion was obtained with significant and long-lasting correction of the sagittal deformity. Functional scores measured at 1 year suggest mild disability. The ODI, SF-12, and VAS scores were positively correlated with fusion at the last follow-up.

Cervical reconstruction techniques. After adequate selection of the patient report of a series of 34 patients treated with winged expandable cages.

After single or multilevel cervical corpectomy for the treatment of different diseases, many surgical options have been proposed over the years. As a single device, a winged expandable titanium cage (WETC) has been developed. We report the use of this device and our clinical results at 24months of follow-up in a prospective series of 34 patients who underwent single or multilevel corpectomy for the treatment of cervical spondylosis. Thirty-four consecutive patients underwent single or multilevel cervical corpectomy followed by the insertion of a WETC for the treatment of cervical spondylosis at Department of Neurology and Psychiatry "Sapienza" University of Rome, Italy, from May 2011 to May 2013. Patients affected by cervical spondylosis with cervical lordosis >0° were included. Patients affected by cervical lordosis <0°, osteoporosis, or other cervical diseases were excluded. The mean postsurgical Nurick's grade was significantly lower than the mean presurgical Nurick's grade (mean=0.98 for postsurgical Nurick's grade and mean=2.42 for presurgical Nurick's grade). Four patients (11.7%) presented subsidence respectively of 1, 2, 2, and 3mm at 24months of radiological follow-up. Postoperative complications occurred in five patients (14.7%). Our case series at 24months of follow-up demonstrates that the use of a WETC obtains good clinical results after single or multiple corpectomy in patients not affected by osteoporosis who do not require cervical lordosis correction. During the insertion of the device, an adequate preparation of the end plates is suggested and their over distraction should be avoided.

Complications associated with cervical vertebral body replacement with expandable titanium cages

Our aim was to analyze complications and risk factors for cervical vertebral body replacement (VBR) with expandable titanium cages (ETC). Fifty patients; 22 women and 28 men, mean age 61years, undergoing cervical VBR from 2010 to 2015 were analyzed. Complications were stratified by hardware-association (HA). Univariate and multivariate logistic regression was used to identify independent risk factors. Single, two and three level corpectomies were performed in 32, 15 and 3 patients respectively. A circumferential approach was necessary in 16 cases. At mean follow-up (7.3 months) 66% of patients had recovered. Radiological data showed a significant distraction (2.60mm, p<0.0001) and lordosis (5°, p=0.001). Twenty-three patients experienced 42 complications; 18 HA, 24 non-HA and 24% needed revision surgery. The number of corpectomy levels and surgical approach significantly correlated with the risk of complications (p=0.001), especially non-HA complications (p=0.002). On multivariate analysis, only the number of corpectomy levels (p<0.02, odds ratio 5.48, 95% CI 1.31–22.91) was a significant predictor of complications. We conclude that ETC are efficacious devices for cervical spine VBR, however, when used for more than 1 level, the corpectomy complication rate significantly increases.

A Novel Technique to Reconstruct Anterior Cervical Spine after Total Removal of C2 and C3 Vertebrae

Introduction Reconstruction of C2 body in cases who need removal of C2 body and Axis is a challenging issue, due to difficult approach and small area for instrumentation and grafting, especially in pediatric age group. Material and Methods Our patient underwent a two-stage surgery. During the first operation via a posterior approach, a subtotal resection of a C2 bony mass was performed. C3 was also subtotally resected due to tumor extension. Posterior fixation of C1–C5 was performed by C1 sublaminar hooks and C4 and C5 lateral mass screws. Ten days later, a total resection of the residual bony mass was performed through an anterior approach (between the sternocleidomastoid muscle and carotid sheath). Reconstruction of C1–C3 was performed with C1 anterior sublaminar wiring and an expandable titanium cage. Results Successful reconstruction of C2–C3 vertebral bodies was achieved. At 2-year follow-up, the child was symptom-free. Imaging studies revealed no recurrence of tumor or instability. Conclusion A novel technique for reconstruction of C2–C3 vertebral bodies is demonstrated for the youngest case (a 6-year-old boy) of osteoblastoma in the literature. We recommend this approach for cervical spine reconstruction in patients who have an intact C1 arc and resected lower bodies.

Corpectomy and Vertebral Body Reconstruction with Expandable Cage Placement and Osteosynthesis via the single stage Posterior Approach: a Retrospective Series of 34 Patients with Thoracic and Lumbar Spine Vertebral Body Tumors

Metastatic disease of the spine requires a multidisciplinary and comprehensive approach to patient care, especially, for patients in a lot of pain with neurological deficit or spinal instability requiring surgical stabilization. The purpose of the study is to report our experience on 34 patients who underwent spinal metastasis resection. We used a single-stage posterior approach with vertebral body reconstruction by an expandable titanium cage and a posterior instrumentation. The parameters assessed were neurologic status, OMS score, angle of sagittal deformity, and morbidity. Between January 2011 and June 2014 we performed a monocentric consecutive case review of 34 patients with vertebral body tumor. All of them underwent a single-stage vertebrectomy with circumferential reconstruction and an arthrodesis by posterior approach. 34 patients underwent a single stage surgery by posterior approach, including 30 thoracic lesions and 4 lumbar lesions. Pre operatively, sixteen patients presented a neurologic impairment. The mean follow-up was 13.7 months [1-32 m]. No neurologic impairment was observed in the 34 cases. At the last term of follow-up, neurologic status was improved in 23 cases. OMS score was improved in 23 cases (67.6 %), and worsened in one case. Before surgery, the average of visual analogic scale was 8.94/10 [7-10] and decreased to 2.62/10 [1-5] after surgery. Single posterior approach surgery significantly reduced the average sagittal deformity to 10.0° (0.01-19.96; P = 0.013, Mann-Whitney test). Our outcomes suggest that it will be more efficient to perform an aggressive approach in spinal metastatic treatment in order to improve quality of life.

Minimally Invasive Muscle Sparing Posterior-Only Approach for Lumbar Circumferential Decompression and Stabilization to Treat Spine Metastasis—Technical Report

Palliative tumor resection and subsequent stabilization are important for maximizing function and quality of life for patients suffering from spinal metastases. However, traditional operative techniques for spinal metastases with vertebral body destruction involve extensive soft tissue dissection. In the lumbar spine, open 2-staged spine procedures are routinely required with an anterior retroperitoneal approach for corpectomy and cage insertion and posterior decompression and stabilization with pedicle screws and rods. Both stages require extensive soft tissue dissection that results in significant surgical morbidity, long recovery time, and subsequent delay in initiating postoperative chemoradiotherapy, as well as initially hampering patients' overall quality of life. A minimally invasive approach is desirable for achieving spinal stability, pain control, functional recovery, rapid initiation of adjuvant therapies, and overall patient satisfaction, especially in patients whose medical and surgical therapies are aimed at palliation rather than cure. A 59-year-old man with renal cell carcinoma and a known L1 vertebral body metastasis presented with severe progressive low back pain and was found to have a pathologic L1 vertebral body fracture with focal kyphosis. Here, we describe a minimally invasive muscle-sparing, posterior-only approach for L1 transpedicular hemicorpectomy and expandable cage placement, L1 laminectomy, and T11-L3 posterior instrumented stabilization. The surgical corridor was achieved through the Wiltse muscle plane between the multifidus and longissimus muscles so that minimal muscle detachment was required to achieve transpedicular access to the anterior and middle spinal columns. The L1 nerve root was completely skeletonized to allow adequate lumbar hemicorpectomy, tumor resection, and expandable titanium cage insertion. Lastly, percutaneous pedicle screws and rods were inserted from T11 to L3 for stabilization. The patient tolerated the procedure well with no complications and less than 200 mL estimated blood loss. Postoperative computed tomography revealed restoration of intervertebral height and adequate tumor resection with excellent placement of the expandable cage and posterior construct. The patient was discharged on postoperative day 4 and had nearly no back pain 3 weeks after surgery. Adjuvant therapies were started soon after. At the 6-month follow-up, the patient required minimal narcotic pain medication. Computed tomography scan demonstrated stable hardware with no evidence of failure. A minimally invasive muscle-sparing, posterior-only approach is a promising surgical strategy for 360-degree decompression and stabilization for the treatment of lumbar spinal metastases with minimized blood loss, muscle detachment and postoperative pain, and fast postoperative recovery and initiation of adjuvant therapy.

Cervical Spine Metastases: Our Experience

Introduction Metastases are the most frequent malignant lesions of the spine. Around 5 to 10% of the patients with a systemic tumor have got spinal metastases. More than 95% of spinal metastases are extradural lesions. The residual cases are intradural extramedullary lesions and only 0.5% are intramedullary lesions. Prostate, lung, breast, clear cell kidney tumors, lymphoma, myeloma, and gastric carcinoma are the most frequent primitive neoplasms to cause secondary lesions to the spine. The cervical spine is involved in 10% of the cases. In 80% of the cases, metastases are found to be in the lower cervical tract. Life expectancy in patients with lung carcinoma metastasis is approximately 6 months, 1.5/2 years in patients affected by breast, kidney, and prostate cancers. We reviewed our series of patients with spinal metastases operated between 1997 and 2013 with the aim to analyze the efficacy of the surgical treatment to recover the function and biomechanics of the vertebral column. We evaluated the prognosis in terms of duration and quality of residual life. Materials and Methods We included 36 patients (mean age 65 years). The patients were evaluated according to neurological status, Karnofsky score for the quality of life, and Denis score for pain. Indications for surgery were: pain resistant to pharmacological therapy, medullary compression, neurological deficits, and vertebral instability. Patients underwent CT and MR scan examinations of the cervical spine. In all patients, a total body CT scan was performed. All surgical procedures were performed with microsurgical techniques. In 25 cases, the surgical treatment contemplated an anterior approach: single corpectomy in 16 cases and double in 11 cases. In these cases, the vertebral body was replaced by an expandable titanium cage with PMMA filling and plating. In 6 cases, the treatment consisted of a 360-degree reconstruction. In the residual 5 cases, where the lesion was located in the superior cervical tract of the spine, we performed an occipital–cervical fusion through a posterior approach. Postoperative follow-up controls were run at 1, 3, 6, and 12 months. A cervical orthosis was worn by the patient for 40 days. Results During the follow-up time, 18 patients died because of the progression of the primitive tumor. In 36 patients treated with surgery, the histological examination documented a primitive lesion of the breast in 12 cases, of the lung in 10 cases, of the prostate in 5, of the kidney in 4, of the thyroid in 2, and of the testicle in 2. One patient affected by plasmacytoma was also observed. No intra- and perioperative complications arose. The neurological status was preserved intact in all cases with a sensible improvement in those patients affected by severe tetraparesis. We noticed a rise in the Karnofsky score, on an average from 70 to 85. Postoperative neuroimaging controls documented that the instrumentation was in the correct place. Conclusion Surgical treatment of spine metastases allows pain control, management of neurological conditions, and an overall improvement in the quality of residual life.

Thoracic lateral extracavitary corpectomy for anterior column reconstruction with expandable and static titanium cages: Clinical outcomes and surgical considerations in a consecutive case series

ObjectiveMany surgical interventions have emerged as effective means of restoring mechanical stability of the anterior column of the spine. The lateral extracavitary approach (LECA) allows for broad visualization and circumferential reconstruction of the spinal column. However, early reports demonstrated significant complication rates, protracted operative times, and prolonged hospitalizations. More recent reports have highlighted concerns for subsidence, particularly with expandable cages. Our work seeks to describe a single-surgeon consecutive series of patients undergoing LECA for thoracic corpectomy. Specifically, the objective was to explore the surgical considerations, clinical and radiographic outcomes, and complication profile of this approach. MethodsA retrospective study examined data from 17 consecutive patients in whom single or multi-level corpectomy was performed via a LECA by a single surgeon. Vertebral body replacement was achieved with either a static or expandable titanium cage. The Karnofsky Performance Scale (KPS) was utilized to assess patient functional status before and after surgery. Radiographic outcomes, particularly footplate-to-body ratio and subsidence, were assessed on CT imaging at 6 weeks after surgery and at follow-up of at least 6 months. ResultsThe majority of patients had post-operative KPS scores consistent with functional independence (≥70, 12/17 patients, 71%). Fourteen patients had improved or maintained function by last follow-up. In both groups, all patients had a favorable footplate-to-body ratio, and rates of subsidence were similar at both time points. Notably, the overall complication rate (24%) was significantly lower than that published in the literature, and no patient suffered a pneumothorax that required placement of a thoracostomy tube. ConclusionThe LECA approach for anterior column reconstruction with static or expandable cages is an important surgical consideration with favorable surgical parameters and complication rates. Further, use of expandable cages may allow for reconstruction over a larger segment without increased risk of subsidence.

Vertebral Body Reconstruction using Expandable Titanium Cages after Anterior Decompression for Cervical Spondylotic Myelopathy: A Review

Objective: Cervical spondylotic myelopathy is a progressive debilitating disease that favorably responds to surgical decompression. The objective of this study was to review the use of expandable titanium cages for reconstruction of the spine after cervical corpectomy. Methods: We searched PubMed and Google Scholar databases up to March 2013 to identify English articles reporting the use of expandable titanium cages in cervical spondylotic myelopathy (CSM). Identified articles were excluded if they lacked CSM cases, radiologic or clinical outcomes were not reported, and if only static cages cases were reported. Additional relevant references from these articles were also reviewed. Results: A total of six case series published from 2005 through 2012 with a combined total of 143 patients who underwent implantation of an expandable titanium cage and a mean follow-up of 21.4 months were identified and included for review. The combined fusion rate was 97%, and the mean correction of cervical lordosis reported for 125 patients was 10.1°. The combined complication rate was 10%, and the overall reported outcomes were favorable. Conclusions: The results of this review demonstrate that the use of expandable titanium cages is safe and effective after decompression in the treatment of cervical spondylotic myelopathy. The features of the expandable titanium cages allow for easier incorporation of the cage into a corpectomy defect relative to a static titanium mesh cage, adding structural support and restoring sagittal alignment.

Five-year clinical and radiological results of combined anteroposterior stabilization of thoracolumbar fractures

Despite promising early clinical results, the long-term outcome of the use of expandable titanium cages to reconstruct the anterior column after traumatic burst fractures is still unknown. The purpose of this prospective study was to assess the clinical and radiological outcomes of the use of expandable titanium cages 5 years postoperatively. Eighty patients with traumatic thoracolumbar burst fractures (T4-L5) underwent posterior stabilization followed by anterior corpectomy and reconstruction using expandable titanium cages with or without additional anterior plating. After 5 years, fusion was evaluated by means of plain radiographs and CT scans, and the patients' scores on the Oswestry Disability Index (ODI), their neurological status, and clinical results were assessed. Forty-five (56%) of the 80 patients could be examined after 5 years. There was a relatively high rate of complications related to thoracotomy (26%), but there were no complications directly related to the cages. Revision surgery was required in 1 case. The average postoperative loss of correction was only 2.4° due to minimal subsidence of the cages. No cage showed a radiolucent line or instability in flexion-extension views. Bony fusion, as assessed by CT scan, was achieved in 41 patients (91%). On clinical examination, 96% of all patients were ambulatory and showed minimal restriction of spinal range of motion; 71% did not need analgesic medication at all; and 67% were able to work. The average ODI score was 12. Thirty-one percent of patients complained of some kind of anterior approach-related complications. Combined anteroposterior stabilization of thoracolumbar burst fractures with expandable titanium cages is a relative safe procedure with satisfactory radiological and clinical long-term outcome. High fusion rates can be achieved, with only minor loss of correction, typically occurring in the 1st year. However, open thoracotomy carries the risks of additional complications and development of post-thoracotomy syndrome.

Minimal-invasive stabilization and circumferential spinal cord decompression in metastatic epidural spinal cord compression (MESCC)

Surgery with instrumentation to the spine has been shown to provide excellent pain relief, stabilization and quality of life in patients with spinal metastasis [1, 4, 12, 13, 15]. Surgery may also offer superior outcomes to other treatments, such as radiation in cases of acute spinal cord compression and neurological deficits [7, 11]. In comparison to degenerative spinal disorders [5], there is little data on the use of minimally invasive surgery (MIS) as an alternative to open approaches for spinal metastatic surgery [9]. The benefits of MIS in spinal surgery compared to open approaches include reduction in muscular trauma, blood loss, cost and hospital stay [3, 6, 10, 14]. Here we present a surgical technique of posterior percutaneous instrumentation with minimal-invasive circumferential spinal cord decompression and subsequent thoracoscopically reconstruction of the anterior vertebral column with an expandable titanium cage.

Einfluss des Operationsverfahrens auf Lebensqualität und Korrekturverlust bei traumatischen Wirbelkörperfrakturen des thorakolumbalen Übergangs

There are a variety of surgical strategies for the treatment of traumatic thoracolumbar vertebral fractures. There is still no proof for the superiority of any strategy concerning clinical or radiological outcomes. The aim of this study was the evaluation of residual complaints and correlation with radiological findings. 87 patients, who underwent different types of surgery for vertebral fractures of the thoracolumbar region were included. Patients were treated by posterior stabilisation with internal fixation alone, by a combined approach using posterior internal fixation and anterior fusion by bone graft from the iliac crest with or without additional anterior plating or with a combined approach using posterior stabilisation and anterior implantation of an expandable titanium cage. Data were collected using results of physical examination, standardised testing of several established quality of life scores (SF-36, VAS, LBOS and Oswestry score) as well as radiological findings (post-traumatic kyphosis, loss of correction). There was no difference in the overall results of quality of life in the different subgroups. Analysis of the subgroups revealed differences in the complaints according to the surgical strategy used (a high rate of non-fusion where bone grafts, especially without additional anterior plating were used, combined with a high rate of bone graft morbidity, intercostal neuralgia in cage implantation). Loss of correction as documented in the radiological course showed a maximum in patients who underwent posterior stabilisation without an additional anterior approach. There was no correlation of loss of correction and quality of life. Overall outcomes of the four surgical strategies were comparable in our study concerning loss of correction and quality of life, respectively. The use of bone grafts, however, results in a high rate of non-fusion with a remarkable number of patients complaining about bone graft morbidity. Therefore we prefer the use of expandable titanium cages for anterior stabilisation if additional anterior stabilisation is necessary due to type of fracture or damage of adjacent discs. In any other cases, a limited approach by posterior instrumentation alone should be considered.

Vertebral and Pulmonary Actinomycosis Mimicking Metastatic Lung Cancer

Actinomycosis of the spine with spinal cord compression is rare. Only 22 cases are reported in the literature. The authors describe a remarkable case of a large lesion leading to bony destruction and spinal cord compression in the cervicothoracic junction with a large intrathoracic extension, which was considered to be a metastatic pulmonary disease but turned out to be actinomycosis. A 55-year-old man presented with acute tetraparesis. Magnetic resonance imaging (MRI) and computed tomography (CT) imaging showed vertebral body collapse of T1 and partially C7 with spinal cord compression as well as a mass in the right upper lobe with multiple intrapulmonary nodules. Moreover, dorsal elements (laminae and spinous process) were also involved and partially destructed. Differential diagnosis favored metastatic pulmonary disease. Decompression surgery was performed by anterior corpectomy of T1, stabilization with an expandable titanium cage and additional anterior plate C7-T2. Histology revealed typical sulfur granules. Microbiology exams were positive for Actinobacillus actinomycetemcomitans. There was no proof of malignancy in thoracic biopsy in the late diagnostic work-up. To prevent instrumentation failure, an external immobilization (halo fixation) was applied until complete fusion was documented in CT during the postoperative course. After an 11-month course of ampicillin/sulbactam, there was complete resolution of the intrapulmonary and spinal pathology. Thoracic actinomycosis with spinal involvement is a rare disease. Therefore, diagnosis may be difficult. Surgical intervention, correct diagnosis, and specific long-term antibiotic treatment resulted in favorable outcome.

Anterior Cervical Intercorporal Fusion in Patients With Osteoporotic or Tumorous Fractures Using a Cement Augmented Cervical Plate System

Prospective observational clinical study. The aim of this study is to evaluate the technical feasibility and the safety of additional cement augmentation of anterior cervical implants in patients with poor bone quality because of osteoporosis or tumor infiltration. With an increasing number of elderly patients in spinal surgery the problem of implant dislocation after cervical instrumentation will become a more and more important problem. Whereas in the thoracolumbar area cement augmented screws have become widely accepted to ensure a rigid fixation in patients with reduced bone quality there are no data concerning an additional intravertebral cement augmentation after cervical plating. Nine patients (4 males, 5 females, mean age 62.8 y) with newly diagnosed fractures of 1 or 2 cervical vertebrae because of tumor infiltration (6 cases) or osteoporosis (3 cases) were included in our study. A standard 1-level or 2-level cervical corpectomy with vertebral body replacement by an in situ expandable titanium cage and additional anterior plating was carried out. After this, additional cement augmentation was performed as a vertebroplasty of the anterior two thirds of the cranial and caudal adjacent vertebra by a new anterior hole. The cement should enclose the screws and stabilize the endplates of the adjacent vertebrae. Follow-up comprised clinical examinations, SF-36 questionnaire and visual analog scale 3, 6, and 12 months after surgery. Cervical spine radiographs were obtained 3 and 6 months after surgery and computed tomography scans 6 and 12 months after surgery. The median follow-up was 10 months with a range of 4-18 months. There was no intraoperative cement leakage into the spinal canal. The visual analog scale decreased from 8.2 to 4.2 at 6 months, physical and mental component summaries of SF-36 increased significantly from 27.7 to 36.1 and 31.5 to 48.6 at 6 months, respectively. Loosening of screws or plates was not detected throughout the whole observation period. There was 1 subsidence of a titanium cage into an adjacent vertebra without any clinical consequences. There was no adjacent fracture during the follow-up period and other surgical interventions or revisions were not necessary in any patient. In patients with severe osteoporosis or in patients with advanced tumor disease, excellent surgical, clinical, and radiologic results are possible following our method. In our opinion, a second-step posterior approach can be avoided by this technique.

Six-year outcome of thoracoscopic ventral spondylodesis after unstable incomplete cranial burst fractures of the thoracolumbar junction: ventral versus dorso-ventral strategy

The purpose of this study is to determine the long term-results after thoracoscopic spondylodesis particularly with respect to a ventral versus dorso-ventral treatment strategy. In this prospective cohort study, a follow-up examination was performed in 19 patients (seven men, 12 women, average age: 37.7 years, follow-up rate: 79 %), six years after ventral thoracoscopic spondylodesis of unstable, incomplete burst fractures. Nine patients received a ventral monosegmental spondylodesis with iliac crest bone graft. The other ten cases were treated dorso-ventrally, five undergoing a ventral monosegmental treatment with iliac crest bone graft; the other five a ventral bisegmental treatment with expandable titanium cage. The complication rate was 15.7 %, the rate of revision of 10.5 %. No complication was related to the ventral thoracoscopic approach, whereas all of them were related to the iliac crest bone graft. The operative bisegmental kyphotic reduction was higher in the dorso-ventrally treated group. Afterwards, the loss of reduction was similar in both study groups. The mean VAS spine score summed up to more than 80 in both groups. The mean PCS scores were comparable to a normal healthy collective of the same age. The ventral thoracoscopic approach to the spine seems to be a safe therapeutic strategy. A dorso-ventral treatment concept goes along with a higher operative reduction potential.