Traditional Anterior Approach Research Articles

The Clinical Outcomes of Spinal Accessory to Suprascapular Nerve Transfer Through a Posterior Approach.

Spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer can restore function to the rotator cuff following brachial plexus injuries. The traditional anterior approach using the lateral branch of the SAN causes denervation of the lateral trapezius limiting shoulder elevation. Suprascapular nerve pathology at the suprascapular notch may be missed resulting in poor reinnervation of the rotator cuff. The posterior approach uses the medial SAN and allows decompression and visualization of the SSN at the notch and nerve transfer coaptation closer to the target muscles with a shorter reinnervation distance. This is a review of 28 patients from 2014 to February 2020 who underwent SAN to SSN nerve transfer via a posterior approach. Patients were evaluated for SSN pathology, external rotation power, and range of motion. Data were evaluated for high-energy trauma (HET) and low-energy trauma/nontraumatic etiology subsets. A total of 8 HET (40%) patients had pathology identified at the suprascapular notch during the posterior approach, including SSN scarring, ruptures, neuromata-in-continuity, and ossification of ligaments. British Medical Research Council grade greater than or equal to 4 shoulder external rotation was achieved in 75% patients with median range of motion 137.5°. Spinal accessory nerve to SSN transfer using a posterior approach allows visualization of pathology involving the SSN and coaptation of a medial SAN transfer close to the target muscles. Following HET, 8 cases (40%) had posterior pathology identified. Spinal accessory nerve to SSN transfer through a posterior approach shows improved external rotation power and range of motion.

Results of Transfibular Total Ankle Arthroplasty. A Series of 50 Implants

Total ankle arthroplasty has become popular in the last few years. The lateral transfibular approach is an alternative to the traditional anterior approach. The purpose of this study was to evaluate our 50 first and consecutive clinical and radiological outcomes of transfibular total ankle replacements (Trabecular Metal Total AnkleR Zimmer Biomet, Warsaw, IN) with a follow-up of at least 3 years. This retrospective study included 50 patients. The main indication was post-traumatic osteoarthritis (n=41). The mean age was 59 (range=39-81). All patients were followed for at least 36 months postoperatively. Patients were assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score and Visual analog scale (VAS) preoperatively and postoperatively. Range of motion and radiological measures were assessed as well. Postoperatively, patients demonstrated statistically significant improvement in the AOFAS score from 32 (range=14-46) to 80 (range=60-100) (p < .01) and VAS from 7.8 (range=6.1-9.7) to 1.3 (range=0-6) (p < .01). The average total range of motion increased significantly from 19.8° to 29.2° of plantarflexion and 6.8° to 13.5° of dorsiflexion. Alignment measured by alpha, beta, and gamma angles was satisfactorily achieved. No patient demonstrated any radiographic evidence of tibial or talar lucency at the final follow-up. Five patients (10%) experienced delayed wound healing. One patient (2%) developed a postoperative prosthetic infection. One patient (2%) developed fibular pseudoarthrosis and 2 patients (4%) suffered impingement. Two patients (4%) needed surgery for symptomatic fibular hardware. This study found excellent clinical and radiological results of transfibular total ankle replacement. This is a safe and effective option that allows the correction of sagittal and coronal malalignment.

New anterior controllable antedisplacement and fusion surgery for cervical ossification of the posterior longitudinal ligament: a biomechanical study.

The traditional anterior approach for multilevel severe cervical ossification of the posterior longitudinal ligament (OPLL) is demanding and risky. Recently, a novel surgical procedure-anterior controllable antedisplacement and fusion (ACAF)-was introduced by the authors to deal with these problems and achieve better clinical outcomes. However, to the authors' knowledge, the immediate and long-term biomechanical stability obtained after this procedure has never been evaluated. Therefore, the authors compared the postoperative biomechanical stability of ACAF with those of more traditional approaches: anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF). To determine and assess pre- and postsurgical range of motion (ROM) (2 Nm torque) in flexion-extension, lateral bending, and axial rotation in the cervical spine, the authors collected cervical areas (C1-T1) from 18 cadaveric spines. The cyclic fatigue loading test was set up with a 3-Nm cycled load (2 Hz, 3000 cycles). All samples used in this study were randomly divided into three groups according to surgical procedures: ACDF, ACAF, and ACCF. The spines were tested under the following conditions: 1) intact state flexibility test; 2) postoperative model (ACDF, ACAF, ACCF) flexibility test; 3) cyclic loading (n = 3000); and 4) fatigue model flexibility test. After operations were performed on the cadaveric spines, the segmental and total postoperative ROM values in all directions showed significant reductions for all groups. Then, the ROMs tended to increase during the fatigue test. No significant crossover effect was detected between evaluation time and operation method. Therefore, segmental and total ROM change trends were parallel among the three groups. However, the postoperative and fatigue ROMs in the ACCF group tended to be larger in all directions. No significant differences between these ROMs were detected in the ACDF and ACAF groups. This in vitro biomechanical study demonstrated that the biomechanical stability levels for ACAF and ACDF were similar and were both significantly greater than that of ACCF. The clinical superiority of ACAF combined with our current results showed that this procedure is likely to be an acceptable alternative method for multilevel cervical OPLL treatment.

Femoral nerve neuromonitoring for lateral lumbar interbody fusion surgery

BACKGROUND CONTEXTThe transpsoas lateral lumbar interbody fusion (LLIF) technique is an effective alternative to traditional anterior and posterior approaches to the lumbar spine; however, nerve injuries are the most reported postoperative complication. Commonly used strategies to avoid nerve injury (eg, limiting retraction duration) have not been effective in detecting or preventing femoral nerve injuries. PURPOSETo evaluate the efficacy of emerging intraoperative femoral nerve monitoring techniques and the importance of employing prompt surgical countermeasures when degraded femoral nerve function is detected. STUDY DESIGN/SETTINGWe present the results from a retrospective analysis of a multi-center study conducted over the course of 3 years. PATIENT SAMPLEOne hundred and seventy-two lateral lumbar interbody fusion procedures were reviewed. OUTCOME MEASURESIntraoperative femoral nerve monitoring data was correlated to immediate postoperative neurologic examinations. METHODSFemoral nerve evoked potentials (FNEP) including saphenous nerve somatosensory evoked potentials (snSSEP) and motor evoked potentials with quadriceps recordings were used to detect evidence of degraded femoral nerve function during the time of surgical retraction. RESULTSIn 89% (n=153) of the surgeries, there were no surgeon alerts as the FNEP response amplitudes remained relatively unchanged throughout the surgery (negative group). The positive group included 11% of the cases (n=19) where the surgeon was alerted to a deterioration of the FNEP amplitudes during surgical retraction. Prompt surgical countermeasures to an FNEP alert included loosening, adjusting, or removing surgical retraction, and/or requesting an increase in blood pressure from the anesthesiologist. All the cases where prompt surgical countermeasures were employed resulted in recovery of the degraded FNEP amplitudes and no postoperative femoral nerve injuries. In two cases, the surgeons were given verbal alerts of degraded FNEPs but did not employ prompt surgical countermeasures. In both cases, the degraded FNEP amplitudes did not recover by the time of surgical closure, and both patients exhibited postoperative signs of sensorimotor femoral nerve injury including anterior thigh numbness and weakened knee extension. CONCLUSIONSMultimodal femoral nerve monitoring can provide surgeons with a timely alert to hyperacute femoral nerve conduction failure, enabling prompt surgical countermeasures to be employed that can mitigate or avoid femoral nerve injury. Our data also suggests that the common strategy of limiting retraction duration may not be effective in preventing iatrogenic femoral nerve injuries.

Comparison of femoral tunnel and early curative effect analysis between arthroscopic three approach and traditional anteromedial portal for reconstruction of anterior cruciate ligament

To study the three-approach and traditional anterior medial technique to establish the femoral tunnel of position, length, and coronal angle and the early efficacy of anterior cruciate ligament reconstruction. Through retrospective research, from December 2018 to June 2019, a total of 36 patients diagnosed with simple anterior cruciate ligament tear and undergoing surgery were collected. All patients had a clear history of knee sprains and were divided into two groups. A group of 16 patients, including 11 males and 5 females, with an average age of (30.13±6.54) years and an injury time of 7 to 60 (30.19±15.78) days, three-approach technique was used to drill the femoral tunnel to reconstruct the anterior cruciate ligament. Another group of 20patients, including 15 males and 5 females, with an average age of (30.80±8.60) years, and an injury time of 7 to 60 (27.35±15.50) days, the traditional anterior medial approach was used to drill the femoral tunnel to reconstruct anterior cruciate ligament. CT 3D reconstruction technique was used to evaluate the femoral tunnel and the knee joint function was evaluated by Lysholm score of the knee joint. All patients achieved primary healing after the surgical incision. No femoral tunnel fracture, vascular and nerve damage, difficulty in graft passage during the operation, and venous thrombosis occurred. All 36 patients were followed up on an outpatient basis, with a follow up period of 9 to 15 (12.00±2.83) months. Three-dimensional CT reconstruction was used to evaluate the femoral tunnel of the patients. The position of the femoral tunnel was described using the quartile method as the three-approach group:the lower (27.83±1.97) % of the femoral condyle and the posterior (25.57±3.20) %;the traditional approach group:the lower (28.38±3.21) % of the femoral condyle and the posterior (26.23±3.20) %. Bone tunnel length, three-approach group:(35.20±5.52) mm in total length, (23.20±2.07) mm in thick bone tunnel;traditional approach group:(34.60±4.26) mm in total length, (22.56±2.50) mm in thick bone tunnel. Coronal plane angle, three-approach group:(47.93±5.98) °;traditional approach group:(41.78±6.62) °. Knee joint Lysholm score, three-approach group:48.67±4.18 before surgery;97.00±2.48 at last follow up;traditional approach group:49.75±5.33 before surgery, 97.30±2.68 at last follow up, there were significant differences before and after surgery, no significant statistical difference between two groups. The positions of the femoral tunnel drilled by the two methods were within the range of the anatomic stop of the anterior cruciate ligament, and there was no statistical difference. Compared with the traditional anterior medial approach, the coronal plane angle of the femoral tunnel drilled by the three-approach approach is relatively large, and there were no statistical differences in the length of the tunnel, the early postoperative effect of the two surgical methods, and the operation time. But the three approach has a wider and clearer vision. In addition, the knee flexion angle required for drilling the femoral tunnel during surgery is significantly smaller than that of traditional approach technology, which reduces the difficulty of surgery.

Power-Optimizing Repair for Distal Biceps Tendon Rupture: Stronger and Safer

PurposeMany approaches have been described to accomplish tendon reattachment to the radial tuberosity in a distal biceps tendon rupture, with significant success, but each is associated with potential postoperative complications, including posterior interosseous nerve (PIN) injury. To date, there has been no consensus on the best approach to the repair. The purpose of this study was to evaluate the supination strength and the distance of drill exit points from the PIN in a power-optimizing distal biceps repair method and compare the findings with those of a traditional anterior approach endobutton repair method.MethodsCadaveric arms were dissected to allow for distal biceps tendon excision from its anatomic footprint. Each arm was repaired twice, first with the power-optimizing repair using an anterior single-incision approach with an ulnar drilling angle and biceps tendon radial tuberosity wraparound anatomic footprint attachment, then with the traditional anterior endobutton repair. Following each repair, the arm was mounted on a custom-built testing apparatus, and the supination torque was measured from 3 orientations. The PIN was then located posteriorly, and its distance from each repair exit hole was measured.ResultsFive cadaveric arms, each with both the repairs, were included in the study. On average, the power-optimizing repair generated an 82%, 22%, and 13% greater supination torque than the traditional anterior endobutton repair in 45° supination, neutral, and 45° pronation orientations, respectively. On average, the power-optimizing repair produced drill hole exit points farther from the PIN (23 mm) than the traditional anterior endobutton repair (14 mm).ConclusionsThe power-optimizing repair provides a significantly greater supination torque and produces a drill hole exit point significantly farther from the PIN than the traditional anterior endobutton approach.Type of study/level of evidenceTherapeutic III.

Revision Surgery for Postoperative Spondylodiscitis at Cage Level after Posterior Instrumented Fusion in the Lumbar Spine-Anterior Approach Is Not Absolutely Indicated.

Spondylodiscitis at the cage level is rare but remains a challenge for spine surgeons. In this study, the safety and efficacy of revision surgery by a posterior approach to spondylodiscitis developed at the cage level were evaluated, and these data were compared to those of patients treated with revision surgeries using the traditional anterior plus posterior approach for their infections. Twenty-eight patients with postoperative spondylodiscitis underwent revision surgeries to salvage their infections, including 15 patients in the study group (posterior only) and 13 patients in the control group (combined anterior and posterior). Staphylococcus aureus was the most common pathogen in both groups. L4-L5 was the most common infection site in both groups. The operation time (229.5 vs. 449.5 min, p < 0.001) and blood loss (427.7 vs. 1106.9 mL, p < 0.001) were the only two data points that were statistically significantly different between the two groups. In conclusion, a single posterior approach with ipsilateral or contralateral transforaminal lumbar interbody debridement and fusion plus extending instrumentation was safe and effective for spondylodiscitis developed at the cage level. This strategy can decrease the operation time and blood loss.

Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy

BackgroundOver the years, several techniques for performing robot-assisted prostatectomy have been implemented in an effort to achieve optimal oncological and functional outcomes. ObjectiveTo provide an evidence-based description and video-based illustration of currently available dissection techniques for robotic prostatectomy. Design, setting, and participantsA literature search was performed to retrieve articles describing different surgical approaches and techniques for robot-assisted radical prostatectomy (RARP) and to analyze data supporting their use. Video material was provided by experts in the field to illustrate these approaches and techniques. Surgical procedureMultiple surgical approaches are available: extraperitoneal, transvesical, transperitoneal posterior, transperitoneal anterior, Retzius sparing, and transperineal. Surgical techniques for prostatic dissection sensu strictu are the following: omission of the endopelvic fascia dissection, bladder neck preservation, incremental nerve sparing by means of an antegrade or retrograde approach, and preservation of the puboprostatic ligaments and dorsal venous complex. Recently, techniques for total or partial prostatectomy have been described. MeasurementsDifferent surgical approaches and techniques for robotic prostatectomy have been analyzed. Results and limitationsTwo randomized controlled trials evaluating the extraperitoneal versus the transperitoneal approach have demonstrated similar results. Level I evidence on the Retzius-sparing approach demonstrated earlier return to continence than the traditional anterior approach. The question whether Retzius-sparing RARP is associated with a higher rate of positive surgical margins is still open due to the intrinsic bias in terms of surgical expertise in the available comparative studies. This technique also offers an advantage in patients who have received kidney transplantation. Retrospective evidence suggests that the more the anatomical dissection (eg., more periprostatic tissue is preserved), the better the functional outcome in terms of continence. Yet, two randomized controlled trials evaluating the different techniques of dissection have so far been produced. Partial prostatectomies should not be offered outside clinical trials. ConclusionsSeveral techniques and approaches are available for prostate dissection during RARP. While the Retzius-sparing approach seems to provide earlier return to continence than the traditional anterior transperitoneal approach, no technique has been proved to be superior to other(s) in terms of long-term outcomes in randomized studies. Patient summaryWe have summarized available approaches for the surgical treatment of prostate cancer. Specifically, we described the different techniques that can be adopted for the surgical removal of the prostate using robotic technology.

Minimally invasive lateral lumbar intervertebral fusion versus traditional anterior approach for localized lumbar tuberculosis: a matched-pair case control study

BACKGROUND CONTEXTMinimally invasive lateral lumbar intervertebral fusion (LLIF) procedure has been reported as a feasible alternative to the traditional anterior approach for patients with lumbar tuberculosis. However, there is still no study in the existing literature comparing LLIF to traditional surgeries in the treatment of such patients. PURPOSETo evaluate the clinical, radiological, and functional outcomes of LLIF versus the traditional anterior approach for treating localized lumbar tuberculosis. STUDY DESIGNRetrospective case-control study. PATIENT SAMPLEA total of 60 patients with single-level localized lumbar tuberculosis. OUTCOME MEASURESThe outcome parameters included incision length, operation time, blood loss, complications, segmental lordosis, fusion status, Frankel grade, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analog scale (VAS), and Oswestry Disability Index (ODI). METHODSWe matched 20 patients treated by LLIF with 40 patients undergoing traditional anterior surgery (ratio, 1:2) by age, sex, lesion level, and radiographic features. The LLIF group consisted of 12 men and eight women with a mean age of 42.2±11.1 years, while the traditional group consisted of 22 men and 18 women with a mean age of 40.0±14.5 years. Both the demographics and radiographic data were reviewed. Pre- and postoperative segmental lordosis Cobb angle was measured on lateral X-ray films, while fusion status was assessed on computed tomography scans. The VAS and ODI were used to evaluate functional outcomes. RESULTSThe average follow-up was 24 months in the LLIF group and 39 months in the traditional group. Incision length, operation time, and blood loss were significantly less in the LLIF group than in the traditional group. A similar improvement in segmental lordosis after operation was found in both groups. There was no significant difference between the two groups in neurological recovery, blood infection markers (ESR, CRP), functional outcome, or fusion rate, except for the postoperative VAS score, which was significantly lower in the LLIF group than in the traditional group (2.7±1.0 vs. 3.6±1.0, p=.003). Four patients in the traditional group received a transfusion and 4 patients had a superficial wound infection, while no patient in the LLIF group received a transfusion or experienced any infection; however, the difference between the two groups was not statistically significant (p=.291). CONCLUSIONSBoth LLIF and traditional anterior surgery are sufficient for treating patients with localized lumbar tuberculosis, but the LLIF approach results in significantly shorter operation time and less blood loss.

Vertebral body resection and lumbar corpectomies

Corpectomies in the lumbar spine are unique operations with important and well-deserving nuances that determine their ultimate safety and efficacy. Lumbar vertebral resections are indicated in deformity and non-deformity settings. For deformities, they are reserved for those that are severe and rigid. Infections, fractures, and tumors that compromise the weight-bearing capacity of the anterior and middle columns of the spine are also indicated for lumbar vertebrectomy. Anterior column structural support is required in non-deformity situations and may be accomplished with the use of polymethyl methacrylate (PMMA) cement, osseous strut grafts (i.e. allografts/autograft), or titanium cages (static vs. expandable). The newest generation of cages have wide, rectangular footprints that span the apophyseal ring and provide a sound biomechanical environment and minimize the risk of cage subsidence compared to those with circular footprints. Neural decompression and placement of structural support can be accomplished by a variety of surgical approaches. While a traditional anterior approach is the gold-standard for lumbar vertebrectomies, minimally invasive lateral approaches and a posterior-only approach are viable management strategies. Supplemental fixation is also required and may be achieved with anterior-only instrumentation, posterior-only instrumentation, and circumferential instrumentation. In the review to follow, an evidence-based approach will be used to outline appropriate indications, surgical technique, and concomitant reconstructive and stabilization options for lumbar corpectomies. The discussion to follow ideally will help optimize outcomes for patients treated with vertebral resection and lumbar corpectomies in the lumbar spine.

Biomechanics of an Expandable Lumbar Interbody Fusion Cage Deployed Through Transforaminal Approach.

A novel expandable lumbar interbody fusion cage has been developed which allows for a broad endplate footprint similar to an anterior lumbar interbody fusion; however, it is deployed from a minimally invasive transforaminal unilateral approach. The perceived benefit is a stable circumferential fusion from a single approach that maintains the anterior tension band of the anterior longitudinal ligament. The purpose of this biomechanics laboratory study was to evaluate the biomechanical stability of an expandable lumbar interbody cage inserted using a transforaminal approach and deployed in situ compared to a traditional lumbar interbody cage inserted using an anterior approach (control device). Twelve cadaveric spine specimens (L1-5) were tested intact and after implantation of both the control and experimental devices in 2 (L2-3 and L3-4) segments of each specimen; the assignments of the control and experimental devices to these segments were alternated. Effect of supplemental pedicle screw-rod stabilization was also assessed. Moments were applied to the specimens in flexionextension (FE), lateral bending (LB), and axial rotation (AR). The effect of physiologic preload on construct stability was evaluated in FE. Segmental motions were measured using an optoelectronic motion measurement system. The deployable expendable transforaminal lumbar interbody fusion (TLIF) cage and control devices significantly reduced FE motion with and without compressive preload when compared to the intact condition (P < .05). Segmental motions in LB and AR were also significantly reduced with both devices (P < .05). Under no preload, the deployable expendable TLIF cage construct resulted in significantly smaller FE motion compared to the control cage construct (P < .01). Under all other testing modes (FE under 400N preload, LB, and AR), the postoperative motions of the 2 constructs did not differ statistically (P > .05). Adding bilateral pedicle screws resulted in further reduction of range of motion for all loading modes compared to intact condition, with no statistical difference between the 2 constructs (P > .05). The ability of the deployable expendable interbody cage in reducing segmental motions was equivalent to the control cage when used as a standalone construct and also when supplemented with bilateral pedicle screw-rod instrumentation. The larger footprint of the fully deployed TLIF cage combined with preservation of the anterior soft-tissue tension band may provide a better biomechanical fusion environment by combining the advantages of the traditional anterior lumbar interbody fusion and TLIF approaches.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Understanding Lumbar Stenosis/Spondylolisthesis: 15. Decreased operative time and estimated blood loss in lateral trans psoas versus anterior approach to lumbar interbody fusion for degenerative spondylolisthesis

BACKGROUND CONTEXT The lateral trans psoas approach was introduced as a less-invasive alternative with potentially accelerated postoperative recovery relative to the traditional anterior approach to lumbar interbody fusion. Lumbar fusion through the lateral trans psoas approach is associated with low estimated blood loss, improvement in postoperative patient reported outcomes, and low complication rates, but is also associated with exposure-related sensory and motor changes in the ipsilateral lower extremity. Both anterior and lateral trans psoas approaches for single level fusions at any lumbar segment yield similar complication rates, radiographic and early clinical outcomes. There is, however, a paucity of literature specifically comparing anterior lumbar interbody fusion with lateral trans psoas for degenerative spondylolisthesis. PURPOSE The goal of the study was to compare outcomes of lateral trans psoas versus anterior approaches to lumbar interbody fusion for single level degenerative spondylolisthesis. The hypothesis is that lateral trans psoas lumbar interbody fusion for degenerative spondylolisthesis results in less estimated blood loss and operative time as well as similar postoperative patient-reported outcomes, without increasing complications rates, compared to anterior lumbar interbody fusion. STUDY DESIGN/SETTING The study was a retrospective cohort of consecutive patients undergoing single-level interbody fusion for L4-5 degenerative spondylolisthesis via anterior retroperitoneal or lateral trans psoas approach between 2008 and 2012 at a single academic center. PATIENT SAMPLE Patients undergoing lumbar interbody fusion at the L4-5 level for degenerative spondylolisthesis at a single academic center. OUTCOME MEASURES Differences in patient demographics, peri-operative data (estimated blood loss, operative time, adjunct procedures or additional implants), 30-day complications (infection, DVT/PE, weakness/paresthesia, etc.), and patient reported outcomes (leg and back Numerical Rating Scale, and Oswestry Disability Index) were assessed. METHODS Differences between groups were assessed with chi-squared or Fisher's exact tests, with a two-sided level of significance of α=0.05. Mean and 95% confidence intervals (CI) were reported for normally distributed variables, versus median and interquartile range (IQR) for non-normally distributed variables, RESULTS Both estimated blood loss during surgery (median 100 ml, IQR 50-100 ml) and operative time (241 minutes, CI 209-273 minutes) were significantly less for lateral trans psoas approach than for anterior approach (median 250 ml, IQR 150-400 p CONCLUSIONS The lateral trans psoas approach is associated with diminished blood loss and operative time compared to the anterior approach, without an increase in complication rates or difference in patient reported outcomes. Continued efforts to directly compare approaches for specific indications will minimize complications and improve outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Radiological Study of the Ethmoid Preservation during the Endoscopic Superior Ethmoidal Approach Compared with the Traditional Endoscopic Anterior Cranial Base Approach to Intracranial Pathologies

Radiological Study of the Ethmoid Preservation during the Endoscopic Superior Ethmoidal Approach Compared with the Traditional Endoscopic Anterior Cranial Base Approach to Intracranial Pathologies

A Modified Anterior Approach to L 1 Vertebra: An Early Clinical Experience

Purpose: To study the results of a new surgical approach to the L1 vertebra which is a modified anterior approach and is extrapleural and retroperitoneal in nature. Materials and Methods: Five patients with fracture L1 vertebra underwent surgical decompression and stabilization via this modified anterior approach. In this approach, the L1 vertebra is approached anteriorly without invading the pleural cavity or the peritoneal cavity by gentle, blunt dissection (extrapleural and retroperitoneal approach) Results: No significant complications, especially pulmonary complications, were noted in any of the 5 cases. Conclusions: This modified anterior approach to L1 vertebra allows effective, circumferential decompression of the thoracolumbar spinal canal without the associated morbidity of the traditional anterior approach. However, comparative studies between the 2 approaches will be needed in the future to more accurately ascertain benefits of this approach.

Distal Biceps Tendon Anatomic Repair

Distal biceps injuries, which usually occur in active middle-aged men, can result in chronic pain and loss of supination and flexion strength3,4. Surgical repair of a ruptured distal biceps tendon can reliably decrease pain and improve strength compared with nonoperative management3,4. However, even following successful healing and rehabilitation of a surgically repaired biceps tendon, full supination strength is rarely restored5-7. The expected outcome following distal biceps repair using a traditional anterior approach is a measurable loss of rotational strength, especially from neutral to supinated positions5,7. This deficit can lead to difficulty with occupational and recreational activities5,8. The center of an uninjured biceps tendon inserts into the radial tuberosity 6.7 mm anterior to its apex9,10. This posterior location forces the biceps tendon to wrap around the radial protuberance during pronation, thus utilizing the protuberance as a mechanical cam during forceful forearm supination10,11. The distal biceps tendon comprises a medial short head and lateral long head; the 2 heads are continuations of the proximal muscles2,20,21. The short head inserts distal to the long head on their radial attachment site2,20,21. Performing a distal biceps repair via an anterior approach typically places the center of the reattachment site 12.9 mm anterior to its apex or approximately 6 mm anterior to an uninjured control tendon9. This shifts the repair site from its anatomic location (posterior to the radial protuberance) to a new nonanatomic location (on top of the protuberance). This anterior reattachment location decreases the cam effect of the radial protuberance, resulting in an average supination loss of 10% in neutral rotation and 33% in 60° of supination7,10. A posterior approach to the radial tuberosity using 2 separate intramedullary buttons for the short and long heads reliably positions the distal biceps insertion at its anatomic footprint, which is posterior to the radial protuberance9,10,11. This technique has been named the distal biceps tendon anatomic repair. Not only does it restore the normal supination cam effect of the radial protuberance, but it also provides superior initial fixation strength, with load to failure strength similar to the native tendon1. The distal biceps anatomic repair can be divided into the following 9 key steps: Step 1: Preoperative planning; Step 2: Positioning; Step 3: Identifying and retrieving the tendon; Step 4: Preparing the 2 heads of the tendon; Step 5: Posterior exposure of tendon footprint; Step 6: Drilling the short and long-head drill holes; Step 7: Passage of the tendon; Step 8: Unicortical button fixation; Step 9: Alternative fixation: cortical trough; and Step 10: Postoperative management.

A posterior versus anterior debridement in combination with bone graft and internal fixation for lumbar and thoracic tuberculosis

BackgroundSurgery treatment is usually required for spinal tuberculosis. The aim of this study was to compare the clinical efficacy and outcomes of anterior and posterior surgical approach in combination with debridement, bone grafting, and internal fixation.MethodsAll patients with thoracic and lumbar tuberculosis who underwent either the anterior or posterior surgery in combination with debridement, bone grafting, and internal fixation from August 2009 to August 2016 were reviewed retrospectively.ResultsA total of 186 patients were recruited in the analyses, 37 of whom received the anterior approach and 149 treated with the posterior approach. In the entire study population, there was no statistically significant difference between the groups in terms of kyphosis Cobb’s angle, VAS pain score, neurological status, operation duration, perioperative blood loss, and hospitalization days (p > 0.05). Good clinical outcomes were achieved in both treatment groups. In lumbar vertebra-affected patients, the average preoperative kyphosis Cobb’s angle was 8.7 ± 16.6° and − 5.6 ± 16.0° for the anterior and posterior groups, respectively, which were corrected to − 3.3 ± 13.2° and − 10.1 ± 13.8° after surgery. For thoracic vertebra-affected patients, the corrected kyphosis Cobb’s angle was 8.1 ± 9.7° and 10.3 ± 6.5°, respectively. After surgery, 32.4% of patients in the anterior group and 48.3% of patients in the posterior group claimed no pain (p = 0.24), while 83.8 and 85.9% recovered to Frankel grade E, respectively (p = 0.85).ConclusionsThe posterior debridement joint bone graft and internal fixation is an alternative procedure to treat lumbar and thoracic tuberculosis compared to the traditional anterior approach with similar clinical efficacy in terms of pain control, Cobb’s angle, and neurological function. The posterior approach is sufficient for lesion debridement.

Ovine Lumbar Intervertebral Disc Degeneration Model Utilizing a Lateral Retroperitoneal Drill Bit Injury.

Intervertebral disc degeneration is a significant contributor to the development of back pain and the leading cause of disability worldwide. Numerous animal models of intervertebral disc degeneration have been developed. The ideal animal model should closely mimic the human intervertebral disc with regard to morphology, biomechanical properties and the absence of notochordal cells. The sheep lumbar intervertebral disc model fulfils these criteria. We present an ovine model of intervertebral disc degeneration utilizing a drill bit injury through a lateral retroperitoneal approach. The lateral approach significantly reduces the incision and potential morbidity associated with the traditional anterior approach to the ovine spine. Utilization of a drill-bit method of injury affords the ability to produce a consistent and reproducible injury, of precise dimensions, that initiates a consistent degree of intervertebral disc degeneration. The focal nature of the annular and nucleus pulposus defect more closely mimics the clinical condition of focal intervertebral disc herniation. Sheep recover rapidly following this procedure and are typically mobile and eating within the hour. Intervertebral disc degeneration ensues and sheep undergo necropsy and subsequent analysis at periods from eight weeks. We believe that the drill bit injury model of intervertebral disc degeneration offers advantages over more conventional annular injury models.

Single-stage Transpedicular Vertebrectomy and Expandable Cage Placement for Treatment of Unstable Mid and Lower Lumbar Burst Fractures.

Retrospective clinical and radiographic study. To examine the efficacy and safety of vertebrectomy and expandable cage placement by a single-stage posterior approach for unstable mid and lower lumbar burst fractures (below the L3). Patients with unstable mid and lower lumbar burst fractures require surgical treatment to relieve pain, address paralysis, and stabilize the spine to prevent further segmental deformity. However, controversy remains regarding the optimal surgical treatment. Eleven patients underwent single-stage posterior-only vertebral column resection and vertebral body reconstruction using an expandable cage. Neurological status was classified using the American Spinal Injury Association (ASIA) Impairment Scale, whereas functional outcome was analyzed using a visual analog scale for back pain. Segmental Cobb angles were measured above and below the fractured vertebral body preoperatively, immediate postoperatively, and at the last follow-up. The preoperative neurological status was ASIA grade E in 2 patients, grade D in 5 patients, grade C in 2 patients, and grade B in 2 patients. Postoperatively, neurological stability was demonstrated in 3 patients (27%), and 8 (73%) showed improvement in the ASIA grade. The mean preoperative visual analog scale score was 8.3, which decreased to 4.5 postoperatively, and to 1.8 at the final follow-up. The mean preoperative segmental lordotic angle was 9.2 degrees, which increased to 16.9 degrees postoperatively, and decreased to 15.1 degrees at the last follow-up. The mean operating time was 208.8 minutes, and the mean blood loss was 1006.3 mL. Regarding surgical complications, 1 patient experienced a dural tear and 1 patient demonstrated cage subsidence. The results of this small series suggest the feasibility, efficacy, and safety of this surgical option for unstable mid and lower lumbar burst fractures. This technique from a single posterior approach offers several advantages over traditional anterior or combined approaches using strut graft or nonexpandable implants.

Combined vitrectomy and glaucoma drainage device implantation surgical approach for complex pediatric glaucomas

To evaluate efficacy of combined vitrectomy with posteriorly placed glaucoma drainage device (GDD) in lowering intraocular pressure (IOP) in children. The medical records of children who underwent vitrectomy with posteriorly placed GDD were reviewed retrospectively. Patients with a minimum of 6months' follow-up were included. The first eye operated on for each patient was analyzed. Success was defined as IOP of 5-20mm Hg and no additional IOP-lowering surgery or visually devastating complications. A total of 20 patients were included, with the following etiologies: primary infantile-onset glaucoma, 5 (25%); traumatic glaucoma, 3 (15%); Peters anomaly, 3 (15%); microphthalmia, 5 (25%); glaucoma following cataract surgery, 2 (10%); microspherophakia, 1 (5%); and retinopathy of prematurity, 1 (5%). Eyes with corneal opacification (8 [40%]) underwent endoscopic vitrectomy (5 [25%]), concurrent penetrating keratoplasty (3 [15%]) and/or keratoprosthesis surgery (1 [5%]). Mean follow-up was 1.9±1.1years (range, 6.5-49.2months). Vision remained stable or improved in 17 eyes (85%). Mean IOP decreased from 27.2±10.1mm Hg to 14.5±6.8mm Hg (P<0.0001) at last follow-up or at failure. Kaplan-Meier curves showed 12- and 24-month rate of IOP control of 69% and 62%, respectively. The number of glaucoma medications decreased from a mean of 2.3±1.4 to 1.3±1.2 (P<0.015) at last follow-up or at failure. Overall successrate was 65%. Complications included hypotony (3 [15%]), vitreous hemorrhage (1 [5%]), and retinal detachment (1 [5%]). Two eyes (10%) required surgery for hypotony; 4 eyes (20%) underwent additional glaucoma surgery. Combined surgical approach with vitrectomy and posteriorly placed GDD decreased IOP in complex pediatric glaucomas. Further, endoscope-assisted vitrectomy is useful in cases with corneal opacification. Complication rates of this combined procedure appear to be comparable to traditional anterior chamber approach.

Integrated Fixation Cage Loosening Under Fatigue Loading.

Screw loosening is a well-known adverse event in traditional spinal fusion instrumentation. This phenomenon may hinder segmental stability of the spine leading to bony non-union. In recent years numerous lumbar integrated fixation cages (IFC) have been introduced that offer a low profile alternative to a standard cage with an anterior plate (AP+C). The fixation approach for IFCs is different than a traditional anterior approach; therefore, it is unclear whether IFCs may loosen from the surrounding bone over time. The purpose of this study was to quantify screw loosening of IFC devices compared to AP+C implants under fatigue loading using micro-CT and image processing techniques. L2-3 and L4-5 functional spinal units (FSUs) were obtained from nine human lumbar spines. These FSUs were then reconstructed with either AP+C or IFC implants designed to attach to vertebral bodies using four screws (two top and two bottom for AP+C; two medial and two lateral for IFC). The reconstructed specimens were fatigued in flexion-extension load of ±3 Nm at 1Hz for first 5,000 cycles and it was increased to ±5 Nm until 20,000 cycles. After removing screws to prevent image artifact, micro-CT scans were performed on all FSUs post-fatigue. These images were post-processed to calculate three-dimensional volumes around screw holes created due to damage at the screw-implant interface. IFC screws had significantly greater (p=0.008) screw hole volumes compared to AP+C screws after fatigue testing. This increased screw hole volume for IFC devices was mainly due to loosening in medial screws. Medial screws had significantly greater (p<0.003) screw hole volumes compared to lateral IFC screws and all AP+C screws. There was no difference (p>0.888) between the screw hole volumes of lateral IFC, top AP+C, and bottom AP+C screws. This study elucidated screw-loosening mechanisms in integrated fixation cages under simulated physiological loading. In particular, spatial differences in fixation was observed for IFC screws across the vertebra where medial screws loosened at a greater frequency compared to lateral screws post-fatigue. This novel technique may also be used to quantitatively investigate screw fixation post-fatigue testing in a variety of spinal devices.