Multilevel Laminectomy Research Articles

Technical Considerations for the Surgical Management of a C2 Spinal Cord Hemangioblastoma and Subjacent Cervical Spondylotic Myelopathy: A 2-Dimensional Operative Video.

Hemangioblastomas are characterized as benign tumors of the central nervous system and are typically associated with von Hippel-Lindau disease in 20% to 30% of patients.1 Spinal hemangioblastomas are rare entities accounting for 2.1% of spinal cord tumors and are most frequently observed in the cervical spinal region.1-4 Treatment interventions include microsurgical resection and stereotactic radiosurgery.5 Understanding the granular detail of surgical management in these complex cases is necessary for optimal clinical outcomes. In this 2-dimensional operative video, we detail the technical nuances for resection of a World Health Organization Grade I hemangioblastoma in the upper cervical spine of a 51-year-old man. The lesion and severe adjacent canal stenosis resulted in extensive spinal cord compression, causing him to experience progressive myelopathic symptoms and neurological deficits. A C1-C7 laminectomy provided exposure of the hemangioblastoma and adequate decompression of the subjacent spondylotic disease. Intraoperative ultrasound was used to localize the tumor and perform a targeted durotomy. The sunburst-colored lesion was eccentric to the left side of C1-C2 and found in the epi-pial region, with pial thickening present in the surrounding area. The feeding vessels and deep draining vein were coagulated and cut. Low-power suction was used for traction/counter-traction dissection of the tumor planes. Owing to a multilevel laminectomy having been performed, hardware placement was performed from C2-T1. Adequate placement of all screws was confirmed with intraoperative 3-dimensional image acquisition. The patient provided informed consent for the operation and for sharing his clinical information, including digital media, for publication; Institutional Review Board not required per institutional policy.

A Technical Note on Alternating Laminectomies Plus Folding Cystectomy: A Novel Technique for Spinal Arachnoid Cyst.

We report the case of a 33-year-old male patient with no past medical history presenting to our tertiary referral center with progressive (two years) deficit of lower limb motor impairment (2/5 Medical Research Council [MRC] scale) and sensory impairment. T2- and T1-weighted MRI images clarified thenature of the cyst from T3 to T8. In our case, surgical management was warranted to relieve tension over the spinal cord, thus improving symptoms. Two multilevel laminectomies were performed, one centered on the proximal pole and the other on the distal pole; subsequently, the epidural cyst was gradually folded until it was totally extracted without complications.In the present study, we discuss a technique of extended spinal compressive arachnoid cyst. To the best of our knowledge, this technique has not been previously described in the existing body of literature. Here, we present a caseof a successfulprocedure that seems both efficient and safe. Further study will be required to confirm its safety and efficacy.

Risk factors of instrumentation failure after laminectomy and posterior cervical fusions (PCF)

BackgroundFor patients with multilevel degenerative cervical myelopathy, laminectomy and posterior cervical fusions (PCF) with instrumentation are widely accepted techniques for symptom relief. However, hardware failure is not rare and results in neck pain or even permanent neurological lesions. There are no in-depth studies of hardware-related complications following laminectomy and PCF with instrumentation.MethodsThe present study was a retrospective, single centre, observational study. Patients who underwent laminectomy and PCF with instrumentation in a single institution between January 2019 and January 2021 were included. Patients were divided into hardware failure and no hardware failure group according to whether there was a hardware failure. Data, including sex, age, screw density, end vertebra (C7 or T1), cervical sagittal alignment parameters (C2-C7 cervical lordosis, C2-C7 sagittal vertical axis, T1 slope, Cervical lordosis correction), regional Hounsfield units (HU) of the screw trajectory and osteoporosis status, were collected and compared between the two groups.ResultsWe analysed the clinical data of 56 patients in total. The mean overall follow-up duration was 20.6 months (range, 12–30 months). Patients were divided into the hardware failure group (n = 14) and no hardware failure group (n = 42). There were no significant differences in the general information (age, sex, follow-up period) of patients between the two groups. The differences in fusion rate, fixation levels, and screw density between the two groups were not statistically significant (p > 0.05). The failure rate of fixation ending at T1 was lower than that at C7 (9% vs. 36.3%) (p = 0.019). The regional HU values of the pedicle screw (PS) and lateral mass screw (LMS) in the failure group were lower than those in the no failure group (PS: 267 ± 45 vs. 368 ± 43, p = 0.001; LMS: 308 ± 53 vs. 412 ± 41, p = 0.001). The sagittal alignment parameters did not show significant differences between the two groups before surgery or at the final follow-up (p > 0.05). The hardware failure rate in patients without osteoporosis was lower than that in patients with osteoporosis (14.3% vs. 57.1%) (p = 0.001).ConclusionsOsteoporosis, fixation ending at C7, and low regional HU value of the screw trajectory were the independent risk factors of hardware failure after laminectomy and PCF. Future studies should illuminate if preventive measures targeting these factors can help reduce hardware failure and identified more risk factors, and perform long-term follow-up.

Huge extradural multilevel lumbar abscess

Extensive spinal epidural abscesses (ESEAs), occupying three or more spinal regions, are rare forms of vertebral infection. Multilevel laminectomy in these cases is controversial because of the risk of vertebral instability. We report the case of a 47-year-old patient known with ureterohydronephrosis 2nd degree, admitted for severe vertebral pain (VAS 8/10) from 2 months, paraparesis (ASIA 1/5 left, 4/5 right, retention of urine and faeces) from three days. The analysis discovered Diabetes Mellitus type 2, and high levels of inflammatory tests. CT and MRI of the vertebral area with contrast revealed dorsal compression of the spinal cord and cauda equina by an epidural abscess extending from L1-L5, bilateral in the soft adjacent paravertebral tissues especially psoas muscles but sparing the intervertebral discs. Surgical treatment: alternate fenestrations L1-L5, more important on the left side. By this technique, we removed the fluid pus and also granulomatous pus from posterior epidural space L1-L5, bilateral medial foramina, interspinous and supraspinous space, and psoas muscles. The identified germ was Staphylococcus aureus ++++. Postoperatively, we used a continuous drainage washing system with Vancomicyne and diluted Betadine—a course of six-week Vancomycin 2 grams/day iv. The drainage system was blocked after 24 hours and we had to remove it and all the wires of the suture. We had to dress up every day for the surgical field and wash deep inside the field with diluted betadine for 3 weeks till the surgical field was completely cured. After 3 months postoperatively the patient was cured radiologically and clinically. Follow up 18 months. Conclusion: alternate fenestration has the advantages of removing liquid and granulomatous pus in the epidural posterior area and preserving the spine stability.

Combined endoscopic and microsurgical approach for the drainage of a multisegmental thoracolumbar epidural abscess: illustrative case.

Spinal epidural abscess is a rare but serious infectious disease that can rapidly develop into a life-threatening condition. Therefore, the appropriate treatment is indispensable. Although conservative treatment is justifiable in certain cases, surgical treatment needs to be considered as an alternative early on because of complications such as (progressive) neurological deficits or sepsis. However, traditional surgical techniques usually include destructive approaches up to (multilevel) laminectomies. Such excessive approaches do have biomechanical effects potentially affecting the long-term outcomes. Therefore, minimally invasive approaches have been described as alternative strategies, including endoscopic approaches. The authors describe a surgical technique involving a combination of two minimally invasive approaches (endoscopic and microsurgical) to drain a multisegmental (thoracolumbar) abscess using the physical phenomenon of continuous pressure difference to minimize collateral tissue damage. The combination of minimally invasive approaches, including the endoscopic technique, may be an alternative in draining selected epidural abscesses while achieving a similar amount of abscess removal and causing less collateral approach damage in comparison with more traditional techniques.

Ventral Subaxial Cervical Access Using Tailored Access Osteotomies, A Cadaveric Study.

Ventral lesions of the subaxial cervical spine are challenging because approaches must circumvent endodermal and neurovascular structures. To use cadaveric study to describe 4 posterolateral approaches to the ventral subaxial cervical spine with various facilitating techniques and osteotomies. Three cadaveric specimens of the cervical spine were sequentially subjected to multilevel laminectomy (Type 1), transfacet (Type 2), transpedicular (Type 3), and extreme lateral transforaminal (Type 4) approaches. Approach working angles and proportion of visualized zones were compared, the former calculated using trigonometric methods. There was a significant stepwise increase in working angle in the ventral space, associated with increasing osteotomy type, from an average of 3.7° in single-level type 1 to 19.47° in the type 4 osteotomy. Regarding anatomic zones, proportional partial and total visualization achieved with Type 2 to 4 approaches were significantly greater than with Type 1. Complex osteotomies allowed superior access to be obtained to contributing and adjacent vessels of the ventral spinal axis. Ventral subaxial cervical lesions are difficult to access. We report increased working angles using quantified cadaveric data in increasingly complex posterior and posterolateral approaches graded as type 1 through 4. We advocate continued translational research in such approaches to lesions often considered to lie in surgically inaccessible locations.

Efficacy of intrathecal morphine administration in pediatric patients undergoing selective dorsal rhizotomy.

The purpose of this study was to evaluate the effectiveness of intrathecal morphine following selective dorsal rhizotomy in pediatric patients previously diagnosed with cerebral palsy. This was a retrospective, cohort analysis over the course of four years. The analysis consisted of a treatment group which received intrathecal morphine (5 mcg/kg) injection and a control group that did not receive the injection prior to dural closure. All patients underwent multilevel laminectomies for selective dorsal rhizotomy at Akron Children's Hospital. The effectiveness of the treatment was measured by total dose of hydromorphone administered on patient-controlled analgesia (PCA), number of days on oral narcotics, and cumulative dose of oral narcotic. Of the analyzed 15 pediatric patients, seven patients received intrathecal morphine injection while the other eight did not receive the treatment prior to dural closure. There was a difference of 1135 mcg in total PCA dose between the study group (3243 mcg) and the control group (4378 mcg). The total PCA dose based on weight was lower in the study group (163 mcg/kg) than in the control group (171 mcg/kg). Based on these findings, the administration of intrathecal morphine clinically reduces the opiate need in the first 96 hours post-operatively.

Differences in spinal cord biomechanics after laminectomy, laminoplasty, and laminectomy with fusion for degenerative cervical myelopathy.

Spinal cord stress/strain during neck motion contributes to spinal cord dysfunction in degenerative cervical myelopathy (DCM), yet the effect of surgery on spinal cord biomechanics is unknown. It is expected that motion-preserving and fusion surgeries for DCM will have distinct effects on spinal cord biomechanics. The aim of this study was to compare changes in spinal cord biomechanics after laminectomy with fusion, laminectomy, and laminoplasty using a patient-specific finite element model (FEM) for DCM. A patient-specific FEM of the cervical spine and spinal cord was created using MRI from a subject with mild DCM. Multilevel laminectomy with fusion, laminectomy, and laminoplasty were simulated for DCM using the patient-specific FEM. Spinal cord von Mises stress and maximum principal strain during neck flexion-extension, lateral bending, and axial rotation were recorded. Segmental range of motion, intradiscal pressure, and capsular ligament strain were also measured. FEM outputs were calculated as a change with respect to the preoperative values and compared between the three models. Across the surgical levels, spinal cord stress increased after laminectomy for neck flexion (+50%), neck extension (+37.8%), and axial rotation (+23%). Similarly, spinal cord strain increased in neck extension (+118.4%) and axial rotation (+75.1%) after laminectomy. Laminoplasty was associated with greater spinal cord stress in neck flexion (+57.4%) and increased strain in lateral bending (+56.7%) and axial rotation (+20.9%). Compared with laminectomy and laminoplasty, spinal cord biomechanics for laminectomy with fusion revealed significantly reduced median extension stress (13.7 kPa vs 9.7 kPa, p = 0.03), lateral bending strain (0.01 vs 0.007, p = 0.007), axial rotation stress (3.7 kPa vs 2.1 kPa, p = 0.04), and axial rotation strain (0.017 vs 0.009, p = 0.04). Spinal cord strain decreased in neck flexion in all three models, yet spinal cord stress increased with neck flexion for laminectomy and laminoplasty. Changes in spinal cord biomechanics for laminoplasty parallel those for laminectomy with fusion except during neck flexion, lateral bending, and axial rotation. Compared with motion-preserving approaches such as laminectomy and laminoplasty, laminectomy with fusion was associated with the lowest spinal cord stress and strain in flexion-extension, lateral bending, and axial rotation of the neck.

Intravenous Tranexamic Acid Reduces Blood Loss in Multilevel Spine Surgeries.

Complex spine surgeries are associated with notable blood loss requiring numerous strategies to preserve blood volume. Tranexamic acid (TXA) is efficacious in reducing blood loss when used topically during surgery, intravenously with or without postoperative maintenance treatment. We aimed to evaluate the effect of preoperative weight-independent intravenous administration of 1 g intravenous TXA on perioperative blood loss in lumbar microdiskectomy, single-level lumbar spinal fusion, and multilevel lumbar decompression (two or more levels). This is a retrospective cohort study comparing patients who underwent microdiskectomy, single-level lumbar fusion, and multilevel laminectomies with and without preoperative IV TXA administration between 2016 and 2020. Two hundred ten patients underwent spine surgery without preoperative IV TXA administration between 2016 and 2018 compared with 109 patients who received preoperative 1 g of IV TXA between 2018 and 2020. Preoperative IV TXA treatment did not change blood loss after microdiskectomy, 77.2 ± 53.9 mL and 77.2 ± 95.2 mL, respectively ( P = 0.792). Preoperative IV TXA treatment reduced blood loss after multilevel lumbar laminectomy and lumbar posterior spinal fusion with a transforaminal intervertebral fusion (PSF and TLIF) ( P = 0.004 and P = 0.0001, respectively). The same effect was found for intraoperative blood loss and postoperative drainage, with preoperative TXA administration reducing intraoperative blood loss and postoperative drainage for the multilevel lumbar laminectomy and lumbar PSF and TLIF cohorts. No IV TXA treatment adverse events were registered in all cohorts. A routine administration of preoperative weight-independent 1 g intravenous TXA protocol is efficacious and safe in reducing perioperative blood loss for lumbar multilevel laminectomies and PSF and TLIFs.

Spinal Epidural Lipomatosis Causing Lumbar Canal Stenosis: A Pictorial Essay on Radiological Grading and the Role of Bariatric Surgery Versus Laminectomy

Spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of adipose tissue in the spinal canal that can have a compressive effect on intraspinal neuroanatomical structures, leading to clinical symptoms. Several different conservative and surgical treatment strategies have been proposed but the treatment and outcomes remain controversial. There is a lack of severity-based evidence documenting the success of decompressive laminectomy in SEL and there are only anecdotal reports of clinico-radiological success with weight loss from bariatric surgery. This article demonstrates the resolution of SEL in two patients with bariatric surgery with the help of pre and postoperative MR imaging. The authors also highlight the classic “types” of spinal epidural lipomatosis with a surgically relevant grading system and elucidate the existence of concurrent extraspinal lipomatosis (i.e. mediastinal and intra-abdominal lipomatosis), drawing parallels with the natural history of SEL. The controversial question remains whether a symptomatic SEL patient needs a multilevel laminectomy for spinal decompression or bariatric surgery that can indirectly help the spinal condition. We propose that bariatric intervention could be better frontline management in patients with multifocal/multisystem lipomatosis (i.e., combined spinal and extraspinal) and spinal decompression would be ideal for those SEL patients with coexisting bony and/or ligamentous spinal canal or foraminal stenosis. This manuscript serves as a comprehensive and contemporary update on the radiological profile and two plausible treatment paths and will look toward further verification by a randomized clinical trial.

Role of electromyography and ultrasonography in the diagnosis of double crush lumbar radiculopathy and common fibular injury: illustrative cases.

BACKGROUNDDouble crush syndrome consists of two compression sites along a peripheral nerve and is rare in the lower extremities. Electrodiagnostic and ultrasound (US) studies may be helpful in evaluating foot drop involving overlapping pathologies.OBSERVATIONSCase 1 involved a man who presented with left dorsiflexor weakness and left foot numbness. Electromyography (EMG) revealed a left common fibular nerve entrapment neuropathy and left L5 radiculopathy. US and magnetic resonance imaging (MRI) revealed a large cystic lesion of the left common fibular nerve treated by cyst removal. The left foot drop persisted postoperatively. Lumbar computed tomography myelography revealed severe left foraminal stenosis at L5–S1. Multilevel lumbar laminectomies and facetectomies with an L5–S1 fusion were performed. Within 1 month postoperatively, the left foot drop had improved. Case 2 involved a man who developed a right foot drop caused by right lumbar foraminal stenosis at L4–5 and L5–S1. EMG and US of the right common fibular neuropathy showed large fascicles involving the right common fibular nerve. MRI revealed a hyperintense signal of the right common fibular nerve. Spontaneous improvement occurred within 6 months without surgery.LESSONSSpine surgeons should recognize double crush in the lower extremities. EMG and US are valuable in detecting peripheral nerve abnormalities, especially in cases with overlapping lumbar pathology.

Clinical study on modified Topping-off technology in the treatment of multiple lumbar degenerative diseases

To explore the clinical effect of the modified Topping-off technique in the treatment of multiple lumbar degenerative diseases. From October 2019 to May 2020, 42 patients who underwent modified Topping-off operation (modified Topping-off group) and 42 patients who underwent multilevel total laminectomy and interbody fusion with screw rod system internal fixation (whole laminectomy group) were observed and analyzed. There were 15 males and 27 females in the modified Topping-off group, aged from 28 to 80 years old, with an average of (59.57±11.85)years old. There were 14 males and 28 females in the whole laminectomy group, aged from 45 to 82 years old, with an average of (64.26±9.19) years old. Visual analogue scale (VAS) and Oswestry Disability Index (ODI) were evaluated before operation, 1 week, 6 weeks and 12 weeks after operation. The intraoperative blood loss, incision length, operation time, postoperative drainage, weight-bearing time, hospitalization time, intervertebral space height, intervertebral foramen height and lumbar mobility were statistically analyzed. All patients were followed up for 12 weeks. The intraoperative blood loss and postoperative drainage in the modified Topping-off group were significantly less than those in the whole lamina group (P<0.05). The incision length, operation time, weight-bearing time and hospital stay in the modified Topping-off group were shorter than those in the whole lamina group(P<0.05). There were significant differences in intervertebral space height, intervertebral foramen height and lumbar mobility between the two groups at 12 weeks after operation(P<0.05). The modified Topping-off group had significantly lower VAS 1, 6, 12 weeks after operation and ODI 12 weeks after operation compared with rhose before operation. The VAS at 1, 6, 12 weeks in the whole lamina group were significantly lower those that before operation(P<0.05). The ODI at 12 weeks in the whole lamina group were significantly lower than those before operation(P<0.01). There were significant differences in VAS scores between the two groups at 1 week, 6 weeks and 12 weeks after operation(P<0.01). There was significant difference in ODI between the two groups 12 weeks after operation(P<0.01). The application of modified Topping-off technique in the treatment of multi segmental lumbar degenerative diseases can reduce the total length of fusion segments, avoid or slow down the degeneration of adjacent segments, and has a positive effect on maintaining the normal movement of the spine.

Microendoscopic Dorsal Laminectomy for Multi-Level Cervical Intervertebral Disc Protrusions in Dogs.

The objective of this study was to evaluate the feasibility and clinical outcomes of microendoscopic dorsal laminectomy for multi-level cervical intervertebral disc protrusions in dogs. Eight client-owned dogs diagnosed with multi-level cervical intervertebral disc protrusions using computed tomography (CT) and magnetic resonance imaging (MRI) were included in this retrospective case series. Microendoscopic dorsal laminectomies (MEL) were performed with an integrated endoscopic system to the cranial and caudal vertebrae of the affected intervertebral joints. Pre- and post-operative neurological status, operation time, intra-operative complications, and postoperative complications were reviewed. Post-operative CT images were obtained to measure the dimensions of laminectomy and compared to those of planned laminectomy. Full endoscopic procedures were feasible in 7 dogs (87.5%) and the laminectomy dimensions were in agreement with pre-operative planning. In all dogs, major intra- and postoperative complications did not occur. Conversion to open surgery was required in one case. Short-term postoperative clinical deterioration was found in two dogs. Long-term clinical outcomes were good and comparable to those reported in previous studies of open dorsal laminectomies. MEL is a promising minimally invasive approach to multi-level cervical dorsal laminectomy for intervertebral disc protrusions. This technique may improve postoperative discomfort compared to the open approach. Further studies are needed to directly compare outcomes between these two approaches.

The Role of Minimally Invasive Percutaneous Pedicle Screw Fixation for the Management of Spinal Metastatic Disease

Optimal surgical management of spinal metastatic disease remains controversial. Skip and diffuse spinal lesions, patient frailty, and the need for timely adjuvant chemoradiation complicate surgical decision-making. Minimally invasive percutaneous pedicle screw fixation (MIPSF) is an attractive concept that can confer stability and allow early postoperative mobilization. To date, outcomes of the MIPSF technique remain under-investigated. A single-center retrospective review of patients undergoing percutaneous instrumentation for multilevel spinal metastatic disease between January 2012 and October 2020 was performed. Twenty-four patients were identified, and their primary tumor diagnoses, modified Tokuhashi scores, Spine Instability Neoplastic Scores, neurologic functions, pain scores, and procedure types were noted. Of these patients, 17 underwent fixation of 6 or more levels (L-MIPSF), whereas 7 underwent fixation of <6 levels (S-MIPSF). All patients had screw-and-rod constructs placed percutaneously using bi-planar fluoroscopy guidance. Patients undergoing corpectomy, multilevel laminectomies, or open posterior instrumentation were excluded. Improvement in pain and neurological function was noted in nearly all patients who underwent MIPSF. Average skin incision-to-closing time was 130 minutes, and standard deviation of 55 minutes. Likewise, the average estimated operative blood loss was 402 mL, and standard deviation of 388 mL. Only one patient required hardware revision due to proximal loss of fixation. Two patients required mini-open decompression procedures due to tumor recurrence at different levels than the index pathology. Multilevel minimally invasive spinal fixation is feasible in patients with diffuse spinal metastasis. The percutaneous nature of the technique minimizes dissection, blood loss, and operative times. Early outcomes of MIPSF are promising and demonstrate utility in avoiding multiple subsequent procedures in a cohort of deconditioned patients.

Laminectomy and fusion in multilevel degenerative cervical myelopathy – Correlation between objective and subjective postoperative restriction of cervical spine mobility

For patients with multilevel degenerative cervical myelopathy (DCM), laminectomy and fusion is an established technique. A concomitant effect of multilevel fusion is a restriction of cervical spine mobility. This retrospective study on DCM-patients with at least 4 laminectomy and fusion levels, compares data between objective and subjective restriction of the postoperative cervical spine mobility. The patient-reported restriction of cervical spine mobility was acquired by a five-step score. Measurements of cervical range of motion were performed using the CROM device and were correlated with the subjective scores. Fusion was performed over 6 levels in most of the 36 patients. For the subjective cervical spine mobility, 52.8% reported none to medium, 38.9% severe and 8.3% complete restriction. Mean objective cervical range of motion was 45.0° for flexion-extension, 26.3° for total lateral flexion and 51.4° for total rotation and therefore evidently reduced compared to non-operated patient cohorts in literature. There was a significant medium, negative correlation between the objective measurements and the patient-reported general restriction of cervical spine mobility, and with the physical component summary of SF-8. The significant objective reduction of cervical range of motion after laminectomy and multilevel fusion correlates with the patient-reported assessment for general restriction.

Intramedullary spinal cord abscess—rare complication of a congenital dermal sinus: Report of a case in a toddler

Abstract Lumbosacral region is the commonest location for a dermal sinus (DS). The DS provides a natural pathway for infections of the deeper tissues such as the meninges or spinal cord, depending on its termination. One of the rarest and serious complications of a DS is an intramedullary spinal cord abscess. One such case has been reported here. A 2-year boy presented with high-grade fever, acute onset flaccid paraplegia and urinary retention. A L5 level DS was noted. Imaging showed a D12-L5 heterogeneously enhancing intradural lesion suggestive of an abscess. Multi-level laminectomy and drainage of abscess with removal of an inclusion epidermoid was performed. Complete recovery of all neurological functions was achieved that remained stable at 60 months follow up.

Patients Undergoing 3-Level-or-Greater Decompression-Only Surgery for Lumbar Spinal Stenosis Have Similar Outcomes to Those Undergoing Single-Level Surgery at 2 Years.

Stability following multilevel decompressive laminectomy without fusion has been debated using in vitro biomechanical and radiographic models. However, there is a lack of information regarding clinical outcomes for these patients. The aim of the present study was to determine the association between clinical outcomes and number of levels decompressed via laminectomy for treatment of lumbar spinal stenosis. We performed a retrospective cohort analysis of patients who underwent a primary lumbar laminectomy between 2009 and 2015 by senior orthopedic spine surgeons for lumbar spinal stenosis. Patients were divided into 2 groups based on the number of decompression levels: single level or 3 or more levels. Patient-reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey scores, and Veterans Rand 12-Item Health Mental and Physical Survey scores. Overall, 138 consecutive patients were assessed, of which 106 underwent a single-level and 32 underwent a 3-or-more-level laminectomy. Average follow-up was 24.2 months. There were no significant differences in the preoperative VAS back, VAS leg, or ODI scores between the single-level laminectomy and 3-or-more-level laminectomy groups. Both groups of patients experienced significant improvements in these clinical outcomes postoperatively with no clinically significant difference in the degree of improvement. Reoperation rates were low and similar between the 2 groups. Patients undergoing decompression of 3 or more levels present with similar postoperative outcomes to those who undergo a single-level decompression for lumbar spinal stenosis. Under specific clinical and radiographic criteria, a multilevel decompression of 3 or more levels may be a safe and effective procedure with acceptable outcomes at 2 years after surgery. 3.

Long-Term Results after Multilevel Fusion of the Cervical Spine and the Cervicothoracic Junction: To Bridge or Not To Bridge?

For patients with multilevel degenerative cervical myelopathy, laminectomy and fusion are widely accepted techniques for ameliorating the disorder. However, the idea of whether one should bridge the cervicothoracic junction to prevent instrument failure or adjacent segment disease has been a subject of controversial discussion. In the present study, we compared the incidence of these complications and the revision rates in multilevel fusions extending to C7 or T1-T3. In the present single-center, retrospective cohort study, patients with multilevel degenerative cervical myelopathy treated with laminectomy and fusion to C7 or T1-T3 from 2004 to 2016 were included for evaluation. The primary outcome measure was radiologically proven complications at the most caudal level or the adjacent spinal fusion level. Laminectomy and multilevel fusion were performed in 84 patients. After applying the exclusion criteria, 20 patients with fusion to C7 (treated from 2004 to 2012; follow-up, 124.6 ± 10.6 months) and 38 patients with fusion to T1-T3 (treated from 2008 to 2016; follow-up, 58.2 ± 15.7 months) were evaluated. The incidence of complications at the most caudal or adjacent level of fusion was twice as high (P= 0.087; NS) in the C7 group (11 of 20; 55.0%) compared with the T1-T3 group (11 of 38; 28.9%). In the C7 group, 9 of the 20 patients (45.0%) had required revision surgery compared with 2 of 38 patients (5.3%) in the T1-T3 group (P= 0.001). We found that fewer revisions were necessary if the fusion had extended to the thoracic spine. Thus, we recommend bridging the cervicothoracic junction when fusion starts at C0-C3.

Efficacy of posterior cervical laminectomy for multilevel cervical ossification of posterior longitudinal ligament

Study Design: This study design includes retrospective study of prospectively collected data. Introduction: The purpose is to determine the efficacy of posterior cervical laminectomy for multilevel cervical ossified posterior longitudinal ligament (OPLL). Laminectomy has been a preferred surgical treatment for multilevel cervical OPLL since a long time. Because of the risk associated with progressive kyphosis, the trend is shifted from laminectomy alone to laminoplasty and laminectomy with fusion. The data regarding the efficacy of laminectomy alone in terms of clinical and radiological parameters in multilevel cervical OPLL are scanty. Materials and Methods: We reviewed 82 patients with multilevel cervical OPLL who underwent posterior cervical laminectomy from January 2008 to December 2014. Patients with age ≥45 years, C2–C7 Cobb’s angle ≥ 10º, compression at ≥3 levels, and a minimum of 5 years of follow-up were included in the study. Demographics, pre and postoperative clinical parameters (visual analog scale (VAS), Nurick’s grading, and modified Japanese orthopedic association (mJOA) score), radiological parameters (C2–C7 Cobb’s angle, C2–C7 sagittal vertical axis (SVA)), perioperative parameters, complications, and recovery rate were evaluated. Results: The mean age of the patients was 56.4 (46–72) with M: F of 52:30. The mean blood loss and mean operative time were 93.9 mL and 96.6 min, respectively. There was significant improvement (P < 0.05) in VAS (3.6 ± 1.4 to 1.8 ± 0.8), Nurick’s grading (3.2 ± 0.9 to 1.9 ± 0.6), and mJOA score (8.4 ± 1.4 to 13.8 ± 1.9). C2–C7 Cobb’s angle increased from ‒14.4 ± 1.7º preoperatively to ‒8.2 ± 1.5º postoperatively and C2–C7 SVA from 18.4 ± 12.5 to 29.8 ± 15.8. Intraoperatively four patients had a dural tear. Three patients showed neurological deterioration postoperatively and three had unilateral C5 palsy which improved within a period of 6 months. 18.3% had an excellent outcome, 40.3% had good, 34.1% had fair, and 7.3% of the patients had a poor outcome. Conclusion: Multilevel cervical laminectomy is an effective surgical procedure in properly selected patients with multilevel OPLL. The outcomes are satisfactory in terms of radiological and clinical parameters. The risk of postlaminectomy kyphosis is not too high, and we found no correlation of kyphosis with clinical affection.

Guidelines for cortical screw versus pedicle screw selection from a fatigued decompressive lumbar laminectomy model show similar stability and less bone mineral density dependency

BackgroundTraditional pedicle screws are the gold standard for lumbar spine fixation; however, cortical screws along the midline cortical bone trajectory may be advantageous when lumbar decompression is required. While biomechanic investigation of both techniques exists, cortical screw performance in a multi-level lumbar laminectomy and fusion model is unknown. Furthermore, longer-term viability of cortical screws following cyclic fatigue has not been investigated. MethodsFourteen human specimens (L1–S1) were divided into cortical and pedicle screw treatment groups. Motion was captured for the following conditions: intact, bilateral posterior fixation (L3–L5), fixation with laminectomy at L3–L5, fixation with laminectomy and transforaminal lumbar interbody fusion at L3–L5 both prior to, and following, simulated in vivo fatigue. Following fatigue, screw pullout force was collected and “effective shear stress” [pullout force/screw surface area] (N/mm2) was calculated; comparisons and correlations were performed. FindingsIn flexion-extension and lateral bending, all operative constructs significantly reduced motion compared to intact (P < 0.05), regardless of pedicle or cortical screws; only posterior fixation with and without laminectomy significantly reduced motion in axial rotation (P < 0.05). Pedicle screws significantly increased average pullout strength (944.2 N vs. 690.2 N, P < 0.05), but not the “effective shear stress” (1.01 N/mm2 vs. 1.1 N/mm2, P > 0.05). InterpretationIn a posterior laminectomy and fusion model, cortical screws provided equivalent stability to pedicle screw fixation, yet had significantly lower screw pullout force. No differences in “effective shear stress” warrant further investigation of the effect of screw length/diameter in the aforementioned screw trajectories.