Pedicle Resection Research Articles

Percutaneous Endoscopic Posterior Lateral Approach for the Treatment of Central Cervical Disc Herniation

To design percutaneous endoscopic surgery via a posterolateral approach for the treatment of central cervical disc herniation. From October 2019 to October 2020, 12 consecutive patients with central cervical disc herniation underwent percutaneous endoscopic posterior lateral cervical surgery. The imaging examination (dynamic X-ray, computed tomography, and magnetic resonance imaging of the cervical spine) was conducted after the operation. Visual analog scale score and the modified Japanese Orthopaedic Association score was performed before and after the operation. Twelve patients (6 men and 6 women; mean age 52.08±9.3years) were included, and the average operation time was 105.00±10.55minutes. Postoperative computed tomography and magnetic resonance imaging results showed that the treatment segment of all patients was prominent, the cervical intervertebral disc was completely removed, the cervical spinal cord was fully decompressed, and there were no cases of infection, cerebrospinal fluid leakage or neurological complications. The average follow-up time after the operation was 22.83±3.13months. One year after the operation, there was no cervical instability in the X-ray examination of cervical flexion and extension position. Preoperative visual analog scale score and the modified Japanese Orthopaedic Association score were significantly improved at the last follow-up. Percutaneous endoscopic posterior lateral cervical discectomy provides a new surgical method for the endoscopic treatment of central cervical disc herniation. This treatment has a better surgical field and easier operation, which can remove the protruding cervical disc under the endoscope and make sure that the cervical spinal cord is fully decompressed. The clinical effect is satisfactory. A small amount of pedicle resection will not cause cervical instability.

Thoracic pediculectomy for acute spinal cord decompression in high-risk spinal deformity correction: illustrative case.

Neurological complications are higher in patients with severe spinal deformities (Cobb angle >100°). The authors highlight a known technique for thoracic concave apical pedicle resection that is useful for spinal cord decompression in patients with high-risk spinal deformities in the setting of intraoperative neuromonitoring (IONM) changes. A 14-year-old female with progressive idiopathic scoliosis presented for evaluation of her clinical deformity. Scoliosis radiographs showed a double major curve pattern comprising a 107° right main thoracic curve and a compensatory 88° left thoracolumbar curve. She underwent 2 weeks of halo-gravity traction that reduced her major thoracic curve to 72°. During thoracic posterior column osteotomies, the authors were alerted to decreases in IONM signals that were not responsive to increases in mean arterial pressure, traction weight reduction, and convex compression maneuvers. The dural surface was tightly draped over the two thoracic apical pedicles of T7 and T8, so emergent pediculectomies were performed at both levels for spinal cord decompression. IONM signals gradually improved and eventually became even better than baseline. The patient woke up without any neurological deficits. Pediculectomy of the concave apical pedicle(s) should be considered for spinal cord decompression if there are IONM changes during high-risk spinal deformity surgery.

P144. Posterior approach to resection of spinal meningiomas leads to no differences in outcomes regardless of dural attachment location: A series of 121 patients with an average of 33 months of follow-up

<h3>BACKGROUND CONTEXT</h3> The optimal surgical approach to resection of a spinal meningioma remains controversial, especially for tumors with ventral or ventrolateral dural attachments. There is a paucity of literature investigating the impact of dural attachment location on outcomes following a posterior approach for resection of a spinal meningioma. <h3>PURPOSE</h3> We sought to investigate differences in short and long-term outcomes between dural attachment location subgroups in spinal meningioma patients undergoing a posterior-based resection. <h3>STUDY DESIGN/SETTING</h3> This is a single-institution, retrospective cohort study. <h3>PATIENT SAMPLE</h3> All patients who underwent resection of a spinal meningioma from 1997 to 2017 at the University of California, San Francisco Department of Neurological Surgery. <h3>OUTCOME MEASURES</h3> Outcome measures were determined using patient medical records and included: largest diameter of tumor resected, radiographic extent of resection, incidence of pedicle resection, incidence of fusion, operative time, perioperative complications, long-term neurological deficit, postoperative radiation therapy, and incidence of recurrence. <h3>METHODS</h3> A retrospective review of a single institution experience from 1997 to 2017 of all patients who underwent resection of a spinal meningioma was performed. Clinical and surgical characteristics as well as outcomes were collected from patient medical records. Outcomes were compared between patients with varying dural attachments. Multivariate analysis was utilized. <h3>RESULTS</h3> A total of 121 patients were identified. Mean age was 61 years with 95 women. Sites of dural attachments were as follows: 12 (9.3%) dorsal, 28 (21.7%) dorsolateral, 10 (7.8%) lateral, 38 (29.5%) ventral, and 33 (25.6%) ventrolateral. Most meningiomas were WHO Grade I (91.7%) and in the thoracic spine (62.8%) with no differences in medial-lateral, craniocaudal, or superior-inferior tumor radiographic measurements between subgroups. All patients underwent a posterior approach for tumor resection. There were no differences in largest diameter of tumor resected (p=0.224), gross-total (GTR) or subtotal resections (STR,p=0.068), operative time (p=0.082), perioperative complications (p=0.232), long-term neurological deficit (p=0.437), or postoperative radiation therapy (p=0.969) between subgroups. Thoracic spine location was associated with GTR (OR:5.30,CI:1.85-15.10,p=0.002) on multivariate analysis. The overall incidence of recurrence/progression was 5.5% with no difference (p=0.313) between subgroups. Similarly, the average length of follow-up was 33.0 months with no difference between subgroups (p=0.255). <h3>CONCLUSIONS</h3> Posterior-based approaches for resection of spinal meningiomas are safe and effective, regardless of dural attachment location, with similar surgical and neurologic outcomes between dural attachment subgroups. Comparison of long-term recurrence rates between dural attachment subgroups is required. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Resection strategy for colorectal liver metastasis focusing on intrahepatic vessels and resection margins.

We analyzed the impact of surgical margins and vessel preservation on the oncological outcomes of patients with colorectal liver metastases (CRLM). In this retrospective study, resected CRLM (n = 242) from 116 patients were assigned to one of the following groups: Group A, apart from vessels (n = 201); Group B, hepatic vein contact (n = 27); or Group C, Glissonean pedicle contact (n = 25). We analyzed the local recurrence rates (LRR) in each group. The total LRR and that in Groups A, B, and C were 11.6%, 10.4%, 7.4%, and 20%, respectively. In group A, R1 resections were associated with a significantly higher LRR than R0 resections (27.6% vs 7.6%, respectively; P = 0.001); however, the margin widths were not related to the LRR. In group B, the LRR for hepatic vein preservation and resection did not differ. In group C, the Glissonean pedicle preservation group had a higher LRR than the Glissonean pedicle resection group (66.7% vs 5.3%, respectively; P = 0.001). The 5-year overall survival rate of the local recurrence group (25%) was significantly lower than that of the no recurrence group (84%, P < 0.001) and the intrahepatic recurrence group (60%, P = 0.026). R0 resections for CRLM, apart from those involving vessels, can achieve local control. While preserving hepatic vein contact with CRLM is acceptable, the Glissonean pedicle should be resected because of the higher LRR.

Superior Mesenteric Vein-First Approach for Robotic Salvage Surgery with Indocyanine Green Fluorescence Angiography

Inadequate lymphadenectomy is still a major concern in colon cancer surgery. The superior mesenteric vein (SMV)-first approach is a novel, standardized, reproducible method for robotic complete mesocolic excision surgery. Our aim was to present the application of the SMV-first approach principles to facilitate robotic salvage surgery for recurrent disease within the mesocolon. A 78-year-old female presented with a malignant lymph node deposit within residual right mesocolonic tissue, approximately 3months following a laparoscopic right hemicolectomy for colon cancer. Dissection was initiated with a transverse curvilinear incision along the inferior aspect of the remaining ileocolic pedicle to identify the SMV. Dissection continued along the ventral aspect of the SMV in a cephalad direction to identify and expose the middle colic vessels at their origin. The use of idocyanine green (ICG) confirmed the vascular anatomy, demonstrating the right branch of the middle colic artery traversing the malignant deposit in the residual mesocolon. Following ligation at the origin of the right branch of the middle colic and ileocolic vessels, the retro-mesocolic plane dissection was completed to excise the malignant deposit and the residual mesocolon. The patient was discharged home the following day. The pathological specimen confirmed metastatic poorly differentiated adenocarcinoma in one of nine lymph nodes, and the vascular pedicle resection margin was negative for tumor. Following the SMV-first approach principles provides a safe plane for dissection, and, in conjunction with ICG, facilitates the delineation of the vascular anatomy, to enable robotic salvage surgery to be performed.1-3.

Comparing two surgical treatment methods for mucous cysts of the distal interphalangeal joint in elderly patients

Objective To contrast and compare two surgical treatments for mucous cysts of the distal interphalangeal joint. Methods Clinical data from April 2004 to January 2016 were retrospectively analyzed.Patients who underwent tumor excision, osteophyte excision, and local flap coverage were assigned into a flap group(n=16), while patients who received osteophyte excision, cyst pedicle resection, and cystic fluid drainage were assigned into a simple osteophyte resection group(n=17). Procedure time, pain, satisfaction score, and hand function were compared between the two groups. Results Patients in the flap group were followed up for 14 to 28 months(mean=19.5 months); the simple osteophyte resection group for 15 to 26 months(mean=20.5 months). There was no recurrence in either group.The rate of excellent efficacy was 81.25%(13/16)for the skin flap group and 82.35%(14/17)for the simple osteophyte resection group, and the difference was not statistically significant(χ2=0.007, P>0.05). Pain relief was achieved in both groups after operation, and the postoperative satisfaction score was higher than the pre-operation score.There was no statistical difference in pre-operation pain and satisfaction scores(t=0.14 and 0.35, both P>0.05), no statistical difference in postoperative pain scores(t=-0.09, P>0.05), but a statistically significant difference in postoperative satisfaction scores(t=-4.15, P<0.05)between the two groups. Conclusions Two surgical treatments of mucous cysts can achieve satisfactory aesthetic and clinical outcomes.The simple osteophyte resection method is characterized by a short procedure time and a high level of postoperative satisfaction, but it requires training in microsurgery.Local flap coverage is simple and suitable for lower level hospitals where staff surgeons may lack microsurgical skills, but it may result in certain minor injuries. Key words: Mucocele; Osteophyte; Surgical flaps; Pedicle resection

Mini-open Lateral Retropleural Approach for Symptomatic Thoracic Disk Herniations

Surgeries for symptomatic thoracic disk herniations (TDH) remain challenging. A mini-open lateral retropleural approach is described and the clinical outcomes are reported. A total of 23 patients underwent mini-open lateral retropleural diskectomy. Patients were placed in a lateral position. A 5-cm lateral incision was made followed by resection of the rib after careful dissection of its undersurface from the endothoracic fascia. The fascia was incised and separated from parietal pleura to widen the retropleural space. The rib head was removed followed by a pedicle resection below the TDH to expose the dura. A posterior partial corpectomy above and below the disk was performed to create a space ventral to the TDH, which was later dissected away from the dura and removed. Fourteen males and 9 females comprised the clinical cohort. Five presented with axial back pain, 7 with radicular pain and 11 with myelopathy. All but 2 disks were successfully removed. The mean blood loss was 214cc and the mean hospital stay was 5.3 days. There was no mortality or new neurological deficits. The mean follow-up was 15.4 months. Mini-open lateral retropleural approach is safe and effective to remove symptomatic TDH with minimal morbidities and fast patient recovery.

Modified cyst excision for treatment of distal interphalangeal joint mucous cysts

Objective To investigate the clinical effects of osteophytes removal, pedicle resection and deep cystic fluid drainage in the treatment of distal interphalangeal joint mucous cysts. Methods From April 2009 to September 2014, 15 patients with 19 distal interphalangeal joint mucous cysts were treated with osteophytes removal, pedicle resection and deep cystic fluid drainage. Cysts located in the unilateral distal interphalangeal joint were 10, bilateral were 7, both sides communicated with each other were 2. The range of cysts was 0.5 cm×0.4 cm to 2.1 cm×1.8 cm. Results Postoperatively, 1 case occurred incision infection which healed after dressing change. Other incisions achieved primary healing. All the patients were follow-up for 16 to 24 months with an average of 12.5 months. Preoperative clinical symptoms were improved. During the follow-up period, one cyst recurred which was cured after reoperation. Conclusion Application of osteophytes removal, pedicle resection and deep cystic fluid drainage for treatment of distal interphalangeal joint mucous cysts can achieve satisfactory clinical effects due to its low postoperative recurrence rate and good joint functional recovery, which is worthy of popularizing. Key words: Cysts; Drainage; Osteophytes removal; Pedicle resection

Aesthetic and Functional Evaluation of Total Nasal Reconstructions.

The loss of a portion or the totality of the nose has great relevance on the perception of the beauty of a face and can result in a catastrophic quality of life impairment. Several surgical techniques are currently available for the reconstruction of the nasal pyramid. However, there are very few nasal reconstruction quality evaluation protocols that allow the surgeon to choose objectively the best technique for each kind of defects. Six total nasal reconstruction performed in University of Sassari Maxillofacial Unit were evaluated with a protocol that investigate objectively and subjectively the surgical aesthetic and functional outcome. Sensitivity recovery on the reconstructive flaps was also assessed. Patients reported a satisfactory nasal reconstruction both functionally and aesthetically. Sensitivity recovery on the forehead flap was always present even after pedicle resection or in case of traumatic section of the infraorbital nerve. The use of a three layer reconstruction has proved a viable technique both aesthetically and functionally. In particular the use of the forehead flap to reconstruct the outer layer of the nose allows to carry a tissue with very similar characteristics to the original with a recovery of the sensitivity almost complete.

Comparative Analysis of Left- Versus Right-sided Resection in Klatskin Tumor Surgery: can Lesion Side be Considered a Prognostic Factor?

BackgroundAchievement of negative margins is the goal of curative intent surgery for hilar cholangiocarcinoma. This study analyzed factors affecting survival in hilar cholangiocarcinoma patients and compared short- and long-term outcomes of left- and right-sided resections. MethodsOne hundred and five patients out of 124 diagnosed with Klatskin tumors underwent major liver resection. Sixty-one patients underwent right-sided resections (right group), whereas 44 underwent left-sided resections (left group). Perioperative morbidity, perioperative mortality, and overall and disease-free survival were compared between the groups. ResultsMorbidity and mortality were higher in the right group (59 and 8.2 %, respectively) than in the left group (38.6 and 2.3 %, respectively) (p < 0.005). The most frequent cause of death was liver failure. The R0 rate was 75.4 % in the right and 61.4 % in the left group. The 5-year survival rate was 42.8 % in the right and 35.3 % in the left group (p < 0.05). Patients in the left group more frequently developed local recurrence (87 vs. 69 % in the right group). ConclusionLesion side impacts outcome: right resections still cause significant morbidity related to extensive parenchymal sacrifice but are associated with better long-term survival because right hepatic pedicle resection enables better radicality compared with left resections.

Anatomic liver resection of right paramedian sector: ventral and dorsal resection.

The purpose of anatomic resection of the liver is to systemically eliminate malignant tumors that spread via the portal vein. Moreover, it results in reducing bleeding and bile leakage from the cut surface of the liver because Glisson's pedicle resection leads to parenchyma transection. Anatomical resection includes hemi-hepatectomy, sectionectomy, and segmentectomy. Recently, it has been noticed that this concept is not always appropriate for the liver resection including the right paramedian sector. It can be divided vertically into the ventral and the dorsal area according to the ramification of the third order of the portal veins. In the present study, we focused on the right paramedian sector and described techniques of surgical procedures of hepatectomy including resection of the ventral or dorsal areas.

Infection with bacteroides thetaiotaomicron during posterior decompression and dynamic stabilization of the lumbar spine: a case report and review of the literature

Patient and surgical risk factors have often been implicated for postoperative posterior spinal wound infection. A 56-year-old male with widely disseminated multiple myeloma presented with severe back pain and lower extremity weakness as a result of fracture and collapse of the L4 vertebral body. Posterior decompression involving bilateral pedicle resection and partial L4 corpectomy was performed. Stabilization was performed by Dynesys instrumentation of L3–5, screw supplementation with polymethylmethacrylate, and posterolateral fusion was performed. Postoperatively, the patient suffered from multiple infections, including Bacteroides thetaiotaomicron, which were eventually resolved with antibiotic as well as incision and debridement treatment regimens. In cases with numerous perioperative risk factors for infections, the best therapeutic approach may be a preventative one. An understanding of the relevant risk factors may enable the physician to facilitate a perioperative condition best suited for optimal treatment. A case report of infection with Bacteroides thetaiotaomicron during lumbar decompression and dynamic stabilization as well as a review of the literature regarding infection risk factors are presented.

Sphenopalatine artery ligation with nerve resection in patients with vasomotor rhinitis and polyposis: a prospective, randomized, double-blind investigation

Conclusions: Sphenopalatine artery ligation relieves symptoms of rhinorrhea, sneezing, and nasal itching in patients with vasomotor rhinitis associated with nasal polyps. Objectives: Nasal polyps often arise in a setting of vasomotor rhinitis. Dysfunctions in nerve fiber activity of the sympathetic and parasympathetic systems are responsible for the accompanying symptoms of rhinorrhea, sneezing, and nasal itching. Sphenopalatine pedicle resection with autonomic denervation could potentially reduce related symptoms. Methods: In a prospective, double-blind setting, 60 patients with vasomotor rhinitis and bilateral nasal polyps randomly assigned to functional endoscopic surgery either with (group A) or without (group B) sphenopalatine artery ligation completed a 3-year follow-up. Preoperative and postoperative (at 1 and 3 years) evaluations included symptom score, fiberendoscopy, and active anterior rhinomanometry. Results: In both treatment groups nasal breathing had improved at 1-year and 3-year follow-up (p < 0.001), whereas an improvement in rhinorrhea (p < 0.001) and sneezing and itching (p < 0.01) was attained only in group A. The inter-group comparison showed that a statistically significant improvement in rhinorrhea and nasal itching (p = 0.002) and in sneezing (p < 0.001) was present in group A at both follow-up visits. Rhinomanometry improved in both treatment groups (p < 0.01). Inter-group comparison showed a significant difference only at the 3-year follow-up visit (p < 0.05).

Modified transpedicular approach for the surgical treatment of severe thoracolumbar or lumbar burst fractures

Background context Conventional transpedicular decompression of the neural canal requires a considerable amount of lamina, facet joint and pedicle resection. The authors assumed that it would be possible to remove the retropulsed bone fragment by carving the pedicle with a high-speed drill without destroying the vertebral elements contributing to spinal stabilization. In this way, surgical treatment of unstable burst fractures can be performed less invasively. Purpose The purpose of this study is to demonstrate both the possibility of neural canal decompression through a transpedicular approach without removing the posterior vertebral elements, which contribute to spinal stabilization, and the adequacy of posterior stabilization of severe vertebral deformities after burst fractures. Study design Twenty-eight consecutive patients with complete or incomplete neurological deficits as a result of the thoracolumbar burst fractures were included in this study. All patients had severe spinal canal compromise (mean, 59.53%±14.92) and loss of vertebral body height (mean, 45.14%±7.19). Each patient was investigated for neural canal compromise, degree of kyphosis at fracture level and fusion after operation by computed tomography and direct roentgenograms taken preoperatively, early postoperatively and late postoperatively. The neurological condition of the patients was recorded in the early and late postoperative period according to Benzel-Larson grading systems. The outcome of the study was evaluated with regard to the adequate neural canal decompression, fusion and reoperation percents and neurological improvement. Methods Modified transpedicular approach includes drilling the pedicle for removal of retropulsed bone fragment under surgical microscope without damaging the anatomic continuity of posterior column. Stabilization with pedicle screw fixation and posterior fusion with otogenous bone chips were done after this decompression procedure at all 28 patients included in this study. Results Twenty-three of 28 patients showed neurological improvement. The percent of ambulatory patients was 71.4% 6 months after the operation. The major complications included pseudarthrosis in five patients (17.8%), epidural hematoma in one (3.5%) and inadequate decompression in one (3.5%). These patients were reoperated on by means of an anterior approach. Of the five pseudarthrosis cases, two were the result of infection. Conclusion Although anterior vertebrectomy and fusion is generally recommended for burst fractures causing canal compromise, in these patients adequate neural canal decompression can also be achieved by a modified transpedicular approach less invasively.

In situ pedicle resection in left trisegmentectomy of the liver combined with reconstruction of the right hepatic vein to an inferior vena caval segment transpositioned from the infrahepatic portion

A combination of an in situ pedicle resection of the liver and a hepatic vein reconstruction using a cranially transpositioned segment of the IVC after implantation of an ePTFE graft at the missing IVC was useful in treating a patient who suffered from a huge liver tumor involving all of the hepatic venous confluence and the IVC. Although early tumor recurrence remains an unresolved problem for such patients, a surgical approach is feasible. This technique can be justified as a therapeutic modality, not only because it improves quality of life, but also because it provides patients with an opportunity for additional treatment.

Hyndman-Schneider Procedure for Paraplegia Caused by a Sharp, Angular Scoliosis

Scoliosis causing neurologic deficit is rare. Nonoperative treatment has been shown to be unsuccessful in reversing the condition or preventing further neurologic progression. Surgical intervention using the Hyndman-Schneider approach (costotransversectomy and apical pedicle resection) decompresses the spinal cord by transposing it into the concavity of the deformity. Although it is a demanding procedure with significant risks, lateral spinal cord transposition is the preferable procedure to provide full neurologic recovery in successful cases.

The Use of Harrington Rods in Thoracolumbar Fractures

It would appear that in carefully preselected circumstances, dual Harrington distraction rods may be successfully utilized in a large percentage of thoracolumbar fractures. Mechanistic classification of these fractures offers insight into the extent of soft-tissue disruption. As the circumferential soft-tissue damage increases, the degree of spinal stability obtained with distraction fixation decreases. This is especially true when considering the anterior longitudinal ligament. In compression flexion and vertical compression, the anterior structures are predominantly intact, and thus distraction fixation offers excellent stability. Utmost care must be offered to hook placement and stability, particularly in the proximal area. In the torsional flexion and lateral flexion groups, complex mechanisms of soft-tissue disruption require special consideration when distraction rods are to be employed. Likewise, analysis of soft-tissue and bony disruption in the distractive extension, distractive flexion, and translation injury groups suggests that serious consideration be given to spinal stability prior to the routine use of distraction rods in these patients. Surgically, the posterior approach does not preclude removal of bony fragments from the canal, either by rod distraction and reduction alone or via canal exploration. Below L1, laminectomy with direct access to the fragments is possible. Above L1, pedicle resection and costotransversectomy have been eminently successful procedures in fractures less than 3 weeks old. None of these surgical procedures preclude a subsequent anterior approach if necessary. In no instance was a patient neurally damaged in our series by this surgical protocol. We are loath to allow only internal support during the fusion maturation period and strongly urge external support during this phase. Removal of the rods prior to solid fusion is to be discouraged, as this may predispose to persistent pain and return of deformity. CT scan appears to represent an essential tool preoperatively and postoperatively, particularly in complete neural lesions. We have gleaned some presumptive evidence relative to posterior superior body fragment position, pedicle integrity and position, and possible posterior longitudinal ligament integrity. With the information available through radiographs and CT, we are in the process of attempting to determine prospectively where posterior distraction rods alone may suffice. Thus, we would hope to circumvent the concomitant need for laminotomy, pedicle resection and fragment removal, or reduction or anterior corpectomy. It is hoped that this information will be available soon.