Multilevel Degenerative Disease Research Articles

Minimally invasive lateral single-position surgery for multilevel degenerative lumbar spine disease: feasibility and perioperative results in a single Latin-American spine center.

Within advances in minimally invasive spine surgery, the implementation of lateral single position (LSP) increases efficiency while limiting complications, avoiding intraoperative repositioning and diminishing surgical time. Most literature describes one-level instrumentation of the lumbar spine; this study includes the use of LSP for multilevel degenerative disease. The objective of the article is to analyze initial clinical results and complications in the use of LSP for multiple level instrumentation in adults with lumbar degenerative disease. A retrospective early clinical series was performed for patients who had multiple level instrumentation in LSP between August 2019 and September 2022 at the Hospital Universitario San Ignacio in Bogota, Colombia. Inclusion criteria were patients older than 18years with symptomatic lumbar degenerative disease, undergoing any combination of multilevel anterior lumbar interbody fusion, lateral lumbar interbody fusion (LLIF) and pedicle screw fixation. Forty patients with an average age of 61.3years were included, with diagnosis of multilevel degenerative spondylotic changes. Four-, three- and two-level interventions were performed in 52.5, 35 and 12.5%, respectively. Average time per level was 68.9min, and length of hospital stay had an average of 2.4days, with all patients starting ambulation within the first postoperative day. Procedural time and blood loss were similar to those reported in literature. No severe lesions, postoperative infections or reinterventions took place. Although it was a small number of patients and further clinical trials are needed, LSP for multiple levels is apparently safe with adequate outcomes which may improve efficiency in the operating room.

Recombinant human bone morphogenetic protein-2 in spine surgery: recommendations for use and alternative bone substitutes-a narrative review.

Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been extensively studied in preclinical, animal, and human studies and has been used widely in spine fusion surgery. Evidence demonstrates that fusion rates with rhBMP-2 are similar to or higher than those achieved with autologous bone graft. However, there have been concerns regarding the cost, optimal dosage, and potential complications of rhBMP-2 use in spine surgery. The objective of this paper is to provide a current review of the available evidence regarding rhBMP-2 and other bone graft substitutes used for spinal surgery. We searched Ovid Medline, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, and Database of Abstracts of Review of Effectiveness for 2 studies regarding physiology of bone fusion in spine surgery, formulations and indications of rhBMP-2, cancer risk of rhBMP-2, and alternatives to rhBMP-2 published from 1965 to 2022 in English. The debate regarding indications and cost effectiveness of rhBMP-2 is presented based on increasing data and use criteria. Here, we focus on the effectiveness and economic costs (both direct and indirect) of rhBMP-2 and alternative bone graft substitutes. Based on the cumulative literature, we provide recommendations for rhBMP-2 use in spine surgery. Based on our review of the literature, we recommend the following: (I) clear informed consent processes between surgeons and patients regarding current evidence of the benefits and risks of using rhBMP-2 and available alternative bone graft substitutes. (II) Consideration of rhBMP-2 for spinal fusion surgery (excluding anterior cervical procedures), especially adult spinal deformity (ASD) surgery, lumbar surgery for multilevel degenerative disease, revision surgery for pseudoarthrosis, and surgery in patients with a low-quantity or low-quality autograft. (III) Regulatory oversight of the type, volume, and dose of bone graft substitute (both per level and per procedure) to ensure appropriate indications, prevent excessive usage, and thereby enhance cost containment.

An Algorithmic Posterior Approach to the Treatment of Multilevel Degenerative Cervical Spine Disease: A Multicenter Prospective Study.

The choice of surgical method for the treatment of multilevel degenerative cervical spine disease is based on the assessment of neurological symptoms and anatomical source of compression. However, such decision-making process remains complex and poorly defined. To analyze the effectiveness of an algorithmic posterior approach to the surgical treatment of patients with multilevel degenerative disease of the cervical spine based on the preoperative clinical and imaging parameters. Prospective nonrandomized multicenter cohort study. The study included 338 patients with multilevel degenerative disease of the cervical spine. Two groups of patients were evaluated at 3 neurosurgical centers between 2015 and 2019. The prospective group (Group I, n = 214) consisted of patients who were treated using an algorithm to decide whether they should be treated with an instrumented arthrodesis or a nonfusion procedure. The control group (Group II, n = 124) consisted of patients who underwent posterior decompression with or without stabilization between 2007 and 2014. A total of 192 patients in Group I and 112 in Group II had more than 2 years of follow-up. Visual analog scale (VAS) neck pain, Neck Disability Index (NDI), MacNab and Nurick Scales were collected. Perioperative complications were identified. At 2-year follow-up, Group I had significantly better clinical outcomes based on VAS neck pain score (P = 0.02), NDI score (P = 0.01), satisfaction with surgery on the MacNab Scale (P < 0.001), and outcome of surgery based on the Nurick Scale (P < 0.001). Complication rate was lower in Group I, 5.7% compared with 34.8% in Group II, P = 0.004. The algorithmic posterior approach to the surgical treatment of patients with multilevel degenerative disease of the cervical spine resulted in significant improvement of functional outcomes and a decrease in complications at a minimum 2 years of follow-up.

Intramedullary Spinal Cord Abscess with Concomitant Spinal Degenerative Diseases: A Case Report and Systematic Literature Review.

Intramedullary spinal cord abscess (ISCA) is a rare clinical pathology of the central nervous system that usually accompanies other underlying comorbidities. Traditionally it has been associated with significant mortality and neurological morbidities because it is often difficult to diagnose promptly, owing to its nonspecific clinical and neuroimaging features. The mortality rate and the outcome of these infections have been improved by the introduction into clinical practice of antibiotics, advanced neuroimaging modalities, and immediate surgery. We report the case of a 65-year-old male patient who presented with a progressive spastic gait and lumbar pain, predominantly in the left leg. An MRI image revealed an expansile intramedullary cystic mass in the thoracic spinal cord, which was initially diagnosed as a spinal tumor. He underwent laminectomy and myelotomy, and eventually the pus was drained from the abscess. The follow-up MRI showed improvement, but the patient’s paraplegia persisted. In light of his persistent hypoesthesia and paraplegic gait with developing neuropathic pain, he was readmitted, and an MRI of his lumbar spine revealed multilevel degenerative disease and tethered spinal cord syndrome with compression of the medulla at the L2–L3 level. The patient underwent central flavectomy with bilateral foraminotomy at the L2–L3 level, and the medulla was decompressed. Postoperatively, his neurological symptoms were significantly improved, and he was discharged from hospital on the third day after admission. In support of our case, we systematically reviewed the recent literature and analyzed cases published between 1949 and May 2022, including clinical features, mechanisms of infection, predisposing factors, radiological investigations, microbial etiologies, therapies and their duration, follow-ups, and outcomes. Initial clinical presentation can be misleading, and the diagnosis can be challenging, because this condition is rare and coexists with other spinal diseases. Hence, a high index of suspicion for making an accurate diagnosis and timely intervention is required to preclude mortality and unfavorable outcomes. Our case is a clear example thereof. Long-term follow-up is also essential to monitor for abscess recurrences.

A meta-analysis of prospective studies comparing the results of laminoplasty and laminectomy with instrumental fixation in the surgical treatment of patients with multilevel degenerative cervical spine diseases

Background: Dorsal decompressive-stabilizing techniques laminotomy with laminoplasty (LP) and laminectomy with instrumental fixation (LF) are effective methods for surgical treatment of patients with multi-level degenerative diseases of the cervical spine. At the same time, there is currently no priority in determining the optimal method for posterior decompression and stabilization.&#x0D; Aim: conduct a comparative analysis of intraoperative parameters, clinical outcomes, radiological results and complications of LP and LF in the treatment of patients with multilevel degenerative diseases of the cervical spine.&#x0D; Methods: A meta-analysis of prospective cohort clinical trials was carried out, the primary sources were searched using the databases PubMed, CNKI, eLibrary and the Cochrane Library, published until March 2019, which compared the results of applying the LP and LF methods in the treatment of patients with multilevel degenerative diseases of the cervical spine. For dichotomous variables, the relative risk and the 95% confidence interval were calculated; in turn, for the continuous variables, the standardized difference of the mean values and their 95% confidence intervals were used, using random effect models and a fixed effect.&#x0D; Resuts: The meta-analysis included 6 prospective clinical trials, one of which was a randomized controlled trial. In total, the results of surgical treatment of 493 patients with multilevel degenerative diseases of the cervical spine were evaluated. In the group of drugs, statistically significantly smaller parameters of the duration of surgical intervention were verified (p 0.00001). At the same time, comparable parameters of cervical lordosis after surgery, the level of pain in the cervical spine, functional status according to NDI and JOA after surgery, the frequency of perioperative complications (p = 0.17, p = 0.05, p = 0.94, p = 0.96, p = 0.24, respectively).&#x0D; Conclusions: A meta-analysis showed that the functional outcomes of LP and LF, as well as instrumental results in the treatment of multilevel degenerative diseases of the cervical spine, are not clinically significant. In this case, the LP technique can be performed in a shorter period of time compared with LF.

Development of differentiated surgical technique for treating patients with multilevel degenerative diseases of cervical spine

Background.Currently, there is no uniform tactics for the differentiated use of dorsal decompressive-stabilizing techniques for multilevel degenerative diseases of the cervical spine, and the results of these technologies application are largely controversial.Aim.Analysis of the unsatisfactory outcomes of dorsal decompressive-stabilizing interventions in the treatment of patients with multilevel degenerative diseases of the cervical spine and development of a clinicalinstrumental algorithm for differentiated surgical tactics.Material and methods.A retrospective study included 112 patients with degenerative diseases of the cervical spine at two levels or more due to hernias of intervertebral discs, yellow ligament hypertrophy and arthrosis of facet joints, which in 2007-2014 underwent dorsal decompressive-stabilizing interventions in the volume of laminotomy with laminoplasty (LP) and laminectomy with fixation for lateral masses (LF). A correlation analysis of clinical parameters with anamnestic data, instrumental parameters, a feature of accepted surgical tactics and postoperative adverse effects.Results.In the analysis, it was established that «satisfactory» postoperative outcomes of LP are associated with a neutral or lordotic configuration of the cervical spine, the preservation of segmental movements without clinical and instrumental signs of instability; In addition, the use of LF is possible with mobile kyphotization of the cervical spine and the presence of translational instability of the cervical segments. The «unsatisfactory» postoperative results of the LP and LF are in direct correlation with the duration of the disease, the presence of myelopathic focus and rigid kyphosis of the cervical region.Conclusion. Differential use of dorsal decompressive-stabilizing techniques based on a comprehensive assessment of disease duration, configuration of the cervical spine, spinal cord condition and volume of segmental movements allows to reduce neurological symptoms, improve the level of pain and improve the functional status of patients, as well as significantly reduce the number of adverse outcomes associated with the progression of kyphotic deformity, deterioration of neurological symptoms and revision on-line decompressive-stabilizing interventions.

Optimization of Surgical Care and Anesthesia in the Treatment of Multilevel Degenerative Diseases of the Lumbar Spine in Patients with Overweight and Obesity

Background: The provision of surgical care in the treatment of degenerative diseases of the lumbar spine in patients with obesity and obesity is associated with significant risks of anesthesia and the development of perioperative complications. Aims: to analyze the results of the introduction of a combination of surgical procedures and anesthesia in the treatment of multilevel degenerative diseases of the lumbar spine in patients with excessive body weight and obesity.Materials and methods: The results of surgical treatment of 86 patients were studied, 2 groups were identified. In the study group (SG, n=37), minimally invasive surgical techniques and original surgical approach, paravertebral musculature infiltration with bupivacaine with epinephrine, and multimodal anesthesia with dexmedetomidine were used. The comparison group (CG, n=49) consisted of patients who used the technique of traditional open transpedicular fixation in combination with the posterior interbody fusion without the above combination of surgical procedures and anesthesia. Observation and clinical evaluation was performed in the early (during hospitalization) and in the distant (on average 36 months) postoperative periods.Results: In SG there were no changes in hemodynamics and better results were obtained on the speed of recovery of psychomotor functions. The use of local anesthetics significantly reduced the local pain syndrome (p0.05) and the need for analgesics (p=0.002). Comparative analysis in the main group revealed significantly better results in indices of the duration of the operation [SG 145 (105; 155) min, CG 185 (100; 205) min; p=0.02], the volume of blood loss [SG 110 (90; 140) ml, CG 510 (390; 640) ml; p0.001], the activation time [SG 1 (1; 2) days, CG 3 (3; 4) days; p=0.01], the length of hospitalization [SG 10 (9; 11) days, CG 13 (12; 15) days; p=0,03], remote clinical parameters of the pain syndrome level from the visual analogue scale in the lower extremities [SG 3 (1; 4) mm, CG 9 (6; 14) mm; p=0.006] and the lumbar spine [SG 6 (4; 9) mm, CG 16 (11; 21) mm; p=0.001], functional state according to ODI [SG 8 (6; 10) points, CG 16 (12; 24) points; p=0.008], subjective satisfaction with the operation performed on the Macnab scale (p=0.01). The number of postoperative complications in SG was 8%, in CG ― 18% (p=0.006).Conclusions: Analysis of the results of the introduction of a combination of surgical and anesthetic support methods in the treatment of multilevel degenerative diseases of the lumbar spine in patients with overweight and obesity, including minimally invasive surgical techniques, infiltration of paravertebral muscles with bupivacaine and epinephrine, multimodal anesthesia with dexmedetomidine showed its high perioperative safety, low number of complications, as well as better and clinical outcomes in the early and late postoperative periods.

Prophylactic muscle flap reconstruction after complex spine surgery for degenerative disease: case series and institutional protocol.

Wound complications can occur in up to 20% of patients following multilevel posterior spinal fusion. Currently, the use of local flaps has been reported in high-risk patients with a history of spinal neoplasm, radiation therapy, exposed hardware, multiple spine surgeries, or wound infections. However, there are no reports of prophylactic muscle flap wound closure in patients undergoing multi-level spinal fusion for degenerative pathology. Given the extensive soft tissue dissection for exposure compounded by patient comorbidities, there is potential to minimize the risk of wound complications with prophylactic trapezius and/or paraspinal flap coverage. We sought to describe the utility and outcomes of prophylactic muscle flaps for wound coverage after instrumented posterior spinal fusion for multi-level degenerative spine disease and spinal deformity. An institutional review board (IRB)-approved retrospective review of 26 consecutive patients who underwent a multi-level posterior spinal fusion for degenerative pathology with concurrent muscle flap coverage at a single institution (August 2016 to February 2017) was done. Patient demographics, clinical profile, procedures, and outcomes at a minimum 6-month post-operatively have been described. Patients had a mean age of 59.7±13.0 years with a mean body mass index (BMI) of 31.0±8.6 kg/m2. Paraspinous muscle flap (61.5%), trapezius (3.8%), and combination flaps (34.6%) were used for coverage of an average wound defect of 325 cm2 extending over average 10.2 vertebral levels. All wounds healed completely with no complications at an average of 9.1 months follow-up. Only 1 patient (3.8%) developed a seroma for which interventional radiology (IR)-drainage was sufficient. Prophylactic trapezius and/or paraspinous muscle flap coverage using a team approach can reduce the risk of wound complications after extensive spinal fusion for multi-level degenerative disease or adult spinal deformity (ASD). Preliminary results from our institution suggest that routine use of such a protocol has the potential to improve quality of care and reduce healthcare expenditure associated with this relatively morbid procedure.

Клиническая эффективность ламинопластики при лечении пациентов с многоуровневыми дегенеративными заболеваниями шейного отдела позвоночника

Клиническая эффективность ламинопластики при лечении пациентов с многоуровневыми дегенеративными заболеваниями шейного отдела позвоночника

Hybrid Surgery Combined with Dynamic Stabilization System and Fusion for the Multilevel Degenerative Disease of the Lumbosacral Spine.

As motion-preserving technique has been developed, the concept of hybrid surgery involves simultaneous application of two different kinds of devices, dynamic stabilization system and fusion technique. In the present study, the application of hybrid surgery for lumbosacral degenerative disease involving two-segments and its long-term outcome were investigated. Fifteen patients with hybrid surgery (Hybrid group) and 10 patients with two-segment fusion (Fusion group) were retrospectively compared. Preoperative grade for disc degeneration was not different between the two groups, and the most common operated segment had the most degenerated disc grade in both groups; L4-5 and L5-S1 in the Hybrid group, and L3-4 and L4-5 in Fusion group. Over 48 months of follow-up, lumbar lordosis and range of motion (ROM) at the T12-S1 global segment were preserved in the Hybrid group, and the segmental ROM at the dynamic stabilized segment maintained at final follow-up. The Fusion group had a significantly decreased global ROM and a decreased segmental ROM with larger angles compared to the Hybrid group. Defining a 2-mm decrease in posterior disc height (PDH) as radiologic adjacent segment pathology (ASP), these changes were observed in 6 and 7 patients in the Hybrid and Fusion group, respectively. However, the last PDH at the above adjacent segment had statistically higher value in Hybrid group. Pain score for back and legs was much reduced in both groups. Functional outcome measured by Oswestry disability index (ODI), however, had better improvement in Hybrid group. Hybrid surgery, combined dynamic stabilization system and fusion, can be effective surgical treatment for multilevel degenerative lumbosacral spinal disease, maintaining lumbar motion and delaying disc degeneration.

Sirsasana (Headstand) Pose Causing Compressive Myelopathy With Myelomalacia

A 52-YEAR-OLD WOMAN presented to our institution with bilateral hand numbness. She compulsively practiced yoga for more than 30 years and performed daily headstand poses. Examination showed weak grip, right Hoffmann sign, inability to tandem, and impaired vibration and proprioception. Imaging showed severe multilevel degenerative disease, spinal stenosis, and secondary compressive myelopathy with myelomalacia worse at C5 (Figure).

Metastatic lung adenocarcinoma mimicking a colonic polyp

Metastatic lung adenocarcinoma mimicking a colonic polyp

Minimal Access Versus Open Transforaminal Lumbar Interbody Fusion

A quantitative meta-analysis was conducted on published studies reporting fusion rates after open or minimally invasive/mini-open transforaminal lumbar interbody fusion (TLIF) procedures for single or multilevel degenerative disease including stenosis with spondylolisthesis and degenerative disc disease. The primary aim of this study was to establish benchmark fusion rates for open TLIF and minimally invasive TLIF (mTLIF) based on published studies. A secondary goal was to review complication rates for both approaches. Lumbar fusion for the treatment of degenerative disease has evolved from a purely posterior noninstrumented approach to a combination of anterior and/or posterior surgery with instrumentation. The increasingly popular transforaminal approach has advanced to incorporate minimally invasive spinal techniques. There currently exist no controlled comparisons between open TLIF and mTLIF. A Medline search was performed to identify studies reporting fusion rate on open TLIF or mTLIF with instrumentation. A database including patient demographic information, fusion rate, and complication rate was created. Fusion and complication rates were pooled according to whether TLIF was performed with open or minimally invasive technique. Publication bias was assessed with Egger's test, and adjustments were performed using Duval and Tweedie's Trim and Fill algorithm. Twenty-three articles were identified that fit inclusion criteria. In each of the 23 studies, TLIF was performed with pedicle fixation and fusion was evaluated using radiograph or computed tomography scan at minimum 6-month follow-up. Overall, the studies included 1028 patients, 46.8% of which were female. The mean age of all patients was 49.7 (range, 38-64.9), and mean follow-up interval for assessment of fusion was 26.6 months (range, 6-46 months). The usage of recombinant bone morphologic protein was higher in the mTLIF group (50% vs. 12%). Mean fusion rate from 16 studies (716 patients) of open TLIF was 90.9%, whereas mean fusion rate from 8 studies (312 patients) of mTLIF was 94.8%. Complication rate was 12.6% and 7.5% for open and mTLIF, respectively. Fusion rates for both open and mTLIF are relatively high and in similar ranges. Complication rates are also similar, with a trend toward mTLIF having a lower rate. This analysis provides clear benchmarks for fusion rates in open and mTLIF procedures for spine surgeons.

RARE INTRAMEDULLARY TANDEM LESION ON MRI DUE TO SPINAL ARTERIOVENOUS FISTULA

Spinal dural arteriovenous fistula (SDAVF) rarely presents as multiple signal-hyperintense intramedullary lesions on T2-weighted imaging, a finding more commonly seen in multiple neoplastic diseases like lymphoma or in demyelinating, inflammatory, infectious, or multilevel degenerative diseases. We report herein a case of SDAVF with tandem intramedullary hyperintense lesions on T2-weighted imaging. ### Case report. A 58-year-old man with an 8-month history of worsening numbness in both legs progressing to gait disturbance within the next 2 months underwent MRI at another hospital. T2-weighted imaging revealed signal hyperintensities in spinal cord parenchyma at the Th6-8 level and conus medullaris. As no compressing spinal cord lesions were found, multiple sclerosis (MS) was suspected and he was referred to us to rule out intramedullary tumor. Neurologic findings were paraparesis (manual muscle test: right, 4/5; left, 3/5), left patellar hyperreflexia, bilateral hypesthesia and hypalgesia below Th6, position sense disturbance in both legs, dysesthesia at S1-2, and bowel and bladder dysfunction. On T2-weighted imaging (figure, A), separate hyperintense lesions were found at Th6-8 and the conus medullaris. Lesions were isointense compared to normal spinal cord on T1-weighted imaging and displayed faint gadolinium enhancement (figure, B). T2-weighted imaging showed tiny, gadolinium-enhanced signal voids on the posterior spinal cord surface at Th8-10 (figure, A and B). Spinal angiography was performed on suspicion of SDAVF. As left Th7 intercostal arteriography (arterial phase) showed …

Results of posterior cervical foraminotomy for treatment of cervical spondylitic radiculopathy

We evaluated the results of posterior cervical foraminotomy for spondylitic radiculopathy using a questionnaire sent to all 77 patients who had undergone surgery between 1990 and 1995 at our institution. Sixty-two patients (40 male) returned their questionnaires, one of whom had undergone two procedures (dealt with as separate events). Sixty patients complained of pre-operative arm pain; of these 42 (70%) had complete or >75% resolution of their pain, 14 (23%) had <75% improvement in their pain and four (7%) had the same or worsened pain at the time of the questionnaire. Sixteen patients (27%) reported initial improvement in symptoms with subsequent deterioration. The mean patient satisfaction score using a linear analogue scale from 0 to 10 was 7.5. Main postoperative complaints were neck pain (22%), persisting motor deficit (6%) and persisting sensory deficit (9%). One patient suffered nerve root damage at surgery. For unilateral and, in some cases, multi-level degenerative disease causing cervical radiculopathy, posterior cervical foraminotomy is a useful technique with the advantage of avoiding fusion, immobilization and the long-term risk of instability.