Wide Surgical Field Research Articles

Liver Transection-First Approach in Left Trisectionectomy for Perihilar Cholangiocarcinoma.

Left trisectionectomy [(LT) resection of segments 2, 3, 4, 5, 8, and 1] for perihilar cholangiocarcinoma is still a challenging procedure with high postoperative morbidity and mortality. To perform LT safely, the liver transection-first approach was developed. In this approach, liver transection is started without dividing the right anterior hepatic artery (RAHA) and right anterior portal vein (RAPV). After the completion of liver transection, the RAHA and RAPV, which run into the future resected liver, can be easily identified and divided under the wide surgical field at the hepatic hilus. The liver transection-first approach appears to be safer than the conventional LT, leading to less postoperative morbidity and mortality.

Anterior Cervical Discectomy and Fusion combined with thyroid gland surgery, a tailored case and literature review

BackgroundNowadays, Anterior Cervical Discectomy and Fusion (ACDF) is considered a routine procedure. However, unexpected difficulties do occasionally arise, especially when anterior neck pathologies or anatomical variations are encountered. In such cases, proactive thinking will allow surgeons to tailor appropriately their approach and eliminate surgical risks.Case presentationWe present the case of a 50-year-old male patient suffering from left upper limb radiculopathy that underwent a C7-T1 ACDF combined with a hemithyroidectomy. Excision of the right thyroid lobe was offered to the patient because of a goiter found during the preoperative work-up. Furthermore, the hemithyroidectomy provided a wide surgical field so the ACDF performed without excreting excessive traction to the adjacent neck structures.ConclusionsThe patient had an uncomplicated post-operative. To our knowledge this is the first report of a planned hemithyroidectomy being carried out as the first step towards an ACDF procedure.

Extirpation of primary malignancies in the pterygopalatine and infratemporal fossa via modified maxillary swing approach

Five patients with primary malignancies in the pterygopalatine fossa (PPF) and infra temporal fossa (ITF) were enrolled in this retrospective study between January 2012 and January 2018. After malignancies proven by biopsy and evaluation with CT and MRI scan, all patients received modified maxillary swing (MMS) approach for extirpation of malignant tumors in the PPF and ITF under general anesthesia. En bloc resection with wide surgical margins was successfully performed in all cases. Negative margins were observed in 4 cases and positive margins were found in one patient with adenoid cystic carcinoma who received postoperative radiotherapy. The most common complication was facial numbness. During the follow-up period (range 12 to 57 months), one patient suffered from recurrence while others did not. The advantages of MMS include wide surgical field, full exposure and easy manipulation. The MMS approach is expected to become an standard method for monobloc resection of malignancies in the PPF and ITF.

Microsurgical Resection of a Ventral Pontine Cavernoma via Supratrigeminal Zone by Anterior Transpetrosal Approach: 2-Dimensional Operative Video.

Brainstem cavernomas with recurrent bleeding and gradual neurological deterioration should be considered an indication for surgical treatment. However, surgery is challenging for cavernous hemangiomas located in the ventral part of the pons. In such cases, safe surgical access to the brainstem is limited and obtaining a good surgical field, regardless of the approach selected, is often difficult. Here, we show a 73-year-old man with a history of 3 episodes of intracranial bleeding associated with a cavernous hemangioma located in the right ventral pons. The hemangioma was removed via the supratrigeminal zone of the brainstem using an anterior transpetrosal approach (ATPA). ATPA was first described in 1985 for upper petroclival lesions by Kawase T.1 This approach requires epidural subtemporal procedures to expose the petrous apex adequately. The petrous apex must be totally resected and the dura of the temporal lobe and posterior fossa is then cut to ligate the superior petrosal sinus and tentorium. In this procedure, the most important things are to preserve the internal carotid artery (C2 segment) and greater superficial petrosal nerve (GSPN). To identify the GSPN, facial nerve integrity monitor (Medtronic Inc, Dublin, Ireland) is very useful. In the extradural bone removal, Sonopet Ultrasonic Aspirator (Stryker Ltd, Portage, Michigan) is a very excellent surgical tool for avoiding the injury of the internal carotid artery. As demonstrated by Cavalcanti DD2, ATPA is particularly useful for accessing lesions located in the upper ventral pons via the supratrigeminal zone because it provides a wide and shallow surgical field above the trigeminal nerve without requiring retraction of the cerebellum. We received written informed consent from the patient for this publication.

Analysis of Surgical Approaches to Skull Base Tumors Involving the Pterygopalatine and Infratemporal Fossa.

Selecting an appropriate surgical approach for resection of huge skull base tumors involving pterygopalatine and infratemporal fossa is challenging because of their rarity and high possibility of vital anatomical structure injuries. To suggest the guidance of selecting the appropriate approach by analyzing outcomes and satisfactions of known surgical approaches with our previous experience, the authors retrospectively analyzed skull base tumor cases experienced for 24 years, and condensed to 4 well-known surgical approaches: maxillary swing, infratemporal fossa type C, transzygomatic, and a combined transzygomatic-midfacial degloving approach: to review indications, advantages, and limitations of these approaches. Maxillary swing approach was useful in large-sized tumors as it provided wide surgical field; however, inevitable facial scar was the main drawbacks, especially in adolescents. Infratemporal fossa approach type C was helpful in the involvement of vital vascular structures; however, long incision scar with temporal area depression and permanent conductive hearing loss were the factors of patients' dissatisfaction. Transzygomatic approach could be the good alternative to the infratemporal fossa approach type C; however, en bloc tumor resection was impossible due to its limited operative space. To overcome limitations of these approaches, transzygomatic approach was combined with midfacial degloving approach, and it enabled lateral and anterior access without prominent facial scar and/or deformity while providing wide surgical space. Based on our 24 years of surgical experience in managing huge skull base tumors, the authors recommend the combined transzygomatic-midfacial degloving approach, which enables complete resection with short postoperative healing periods and no disfiguring facial incisions.

Endoscopic versus Microscopic Pituitary Adenoma Surgery: An Institutional Experience.

Aim:The aim of this study was to compare the efficacy of endoscopic versus microscopic excision of pituitary adenoma, and to evaluate the merits and demerits of each approach.Materials and Methods:Prospective data were collected and patients were surgically treated for pituitary adenoma at SMS Hospital, Jaipur, Rajasthan, India. Patients consent was obtained. Age, sex, presenting symptoms, length of hospital stay, pre- and post-operative hormone status, extent of resections of tumors, and intra- and post-operative complication were noted.Results:A total of thirty patients with pituitary adenoma were operated transsphenoidally. Seventeen patients were operated by endonasal endoscopic transsphenoidal surgery and 13 patients were operated by microscopic transsphenoidal surgery. In an endoscopic group, complete tumor excision was achieved in 11 (64.71%) patients, and in microscopic group, it was achieved in 6 (46.15%) patients. In endoscopic group, mean operative time was 111.29 ± 21.95 min (ranged 80–135 min), and in microscopic group, it was 134.38 ± 8.33 min (ranged 120–145 min). In endoscopic group, mean blood loss was 124.41 ± 39.64 ml (60–190 ml), and in microscopic group, it was 174.62 ± 37.99 (100–220 ml). Postoperative sinusitis was present in 1 (5.88%) patient in endoscopic group and in 2 (15.38%) patients in microscopic group.Conclusion:Endoscopic approach provides a wide surgical field and broad lateral vision making easier distinction of tumor tissues. Thus, there is less blood loss, greater extent of tumor removal and it had less operative time, less postoperative complication, and early discharge from the hospital.

Use of the facial dismasking flap approach for surgical treatment of a multifocal craniofacial abscess.

The decision of which surgical approach to use for the treatment of a multifocal craniofacial abscess is still a controversial matter. A failure to control disease progress in the craniofacial region can potentially put the patient’s life at risk. Therefore, understanding the various ways to approach the craniofacial region helps surgeons to obtain satisfactory results in such cases. In this report, we describe a patient who visited the emergency department with a large swelling in his right cheek. A blood test and computed tomography revealed odontogenic maxillary sinusitis. The patient developed sepsis due to a progressive multifocal abscess. An abscess was seen in the temporal muscle, infratemporal fossa, and interorbital region. To control this multifocal abscess, we used the facial dismasking flap (FDF) approach. After debridement using the FDF approach, we succeeded in obtaining sufficient drainage of the abscess, and the patient recovered from sepsis. The advantages of the FDF approach are that it provides a wide surgical field, extending from the parietal region to the mid-facial region, and that it leaves no aesthetically displeasing scars on the face. The FDF approach may be one of the best options to approach multifocal abscesses in the craniofacial region.

Transcutaneous aponeurotic repair with small detachment of the levator aponeurosis for aponeurotic blepharoptosis in Japanese patients

To examine the surgical outcomes of a modified transcutaneous aponeurotic repair for aponeurotic blepharoptosis in a Japanese population. This retrospective study included 75 eyelids of 45 patients with aponeurotic blepharoptosis who had undergone a modified transcutaneous aponeurotic repair. This procedure included a long skin incision for securing a wide surgical field, creation of a double eyelid crease, and a small extent of detachment of the levator aponeurosis from the tarsal surface. Functional success was defined as a postoperative margin reflex distance-1 of 2-5 mm without serious complications at 3 months postoperatively. Cosmetic success was judged by achieving a ≤ 1-mm laterality of eyelid height, a ≤ 2-mm laterality of pretarsal show, and symmetry of the eyelid contour at 3 months postoperatively. The functional success rate was 70.7% among all patients, with 84.4%, 86.7%, and 88.9% of patients showing cosmetic success regarding symmetry of eyelid height, pretarsal show, and eyelid contour, respectively. After applying functional and all 3 cosmetic criteria simultaneously, 28 patients (62.2%) were satisfied in this study. No serious complications occurred during the follow-up period. This modified procedure provided good functional and cosmetic outcomes for aponeurotic blepharoptosis, indicating an acceptable blepharoptosis repair for East Asian patients.

前経錐体到達法で摘出した橋腹側海綿状血管腫の1例

Brainstem cavernous hemangiomas with recurrent bleeding and gradual neurological deterioration should be considered an indication for surgical treatment. However, surgery is challenging for cavernous hemangiomas located in the ventral part of the pons. In such cases, safe surgical access to the brainstem is limited and obtaining a good surgical field, regardless of the approach selected, is often difficult. We successfully treated a 73-year-old man with a history of three episodes of intracranial bleeding associated with a cavernous hemangioma located in the ventral pons. The hemangioma was removed via the supratrigeminal zone of the brainstem using an anterior transpetrosal approach. We conclude that the anterior transpetrosal approach is particularly useful for accessing lesions located in the upper ventral pons via the supratrigeminal zone because it provides a wide and shallow surgical field above the trigeminal nerve without requiring retraction of the cerebellum.

Indication for and Limitation of the Facial Dismasking Flap Approach for Skull Base Surgery to Achieve the Best Esthetical and Functional Results.

The facial dismasking flap (FDF) approach to operations on the deep skull base region consists of a coronal incision and a circumpalpebral incision. This approach provides a wide surgical field for extirpation of deep extended craniofacial tumors without leaving any undesirable scars on the face. Therefore, the FDF approach can provide satisfactory esthetical and functional results. Meanwhile, in some cases, especially in patients with a history of skull base surgery or orbital extension, patients are not fully satisfied even when the FDF approach is used. In this study, we evaluated the indication for and limitation of the FDF approach. We reviewed 26 patients who underwent the FDF approach for skull base surgery. The patients were 16 men and 10 women, and average age was 37 years. Of these patients, 21 were treated using a hemi-FDF approach, and the remaining 5 were subjected to a bilateral FDF approach. Patients were divided into 2 groups in this study: group A (11 patients), patients with no history of skull base surgery and orbital extension; and group B (15 patients), patients with a history of skull base surgery and/or orbital extension. There was no FDF loss or facial palsy in either group A or group B. In group A, there was no lagophthalmos or scar contracture of the eyelid. In group B, there were 5 cases (33%) of ectropion and lagophthalmos and 7 of eyelid scar contracture (46%). As for esthetical evaluation, group B showed a significantly higher rate of facial asymmetry than group A. Moreover, in group A, the total ratings for above average reached 90.9%, whereas in group B, nearly half of the patients (48.9%) gave ratings of fair and poor. The FDF approach could be a good option for skull base surgery. In particular, patients without a history of skull base surgery and orbital extension could obtain satisfactory esthetical and functional outcomes. However, the procedure had limited effectiveness for patients with a history of skull base surgery or orbital extension because esthetical and functional outcomes inevitably became worse.

Superficial Temporal Artery-Sparing Mini-Pterional Approach for Cerebral Aneurysm Surgery.

ObjectiveThe purposes of this study were to introduce a superficial temporal artery (STA)-sparing mini-pterional approach for the treatment of cerebral aneurysms and review the surgical results of this approach.MethodsBetween June 2010 and December 2015, we performed the STA-sparing mini-pterional approach for 117 patients with 141 unruptured intracranial aneurysms. We analyzed demographic, radiologic, and clinical variables including age, sex, craniotomy size, aneurysm location, height of STA bifurcation, and postoperative complications.ResultsThe mean age of patients was 58.4 years. The height of STA bifurcation from the superior border of the zygomatic arch was 20.5 mm±10.0 (standard deviation [SD]). The craniotomy size was 1051.6 mm2±206.5 (SD). Aneurysm neck clipping was possible in all cases. Intradural anterior clinoidectomy was performed in four cases. Contralateral approaches to aneurysms were adopted for four cases. Surgery-related complications occurred in two cases. Permanent morbidity occurred in one case.ConclusionOur STA-sparing mini-pterional approach for surgical treatment of cerebral aneurysms is easy to learn and has the advantages of small incision, STA sparing, and a relatively wide surgical field. It may be a good alternative to the conventional pterional approach for treating cerebral aneurysms.

Therapeutic strategies for locally advanced laryngeal cancer. Part 1: Radical treatment

According to the Union for International Cancer Control (UICC)/ American Joint Committee on Cancer (AJCC), staging system for the locally advanced laryngeal cancer generally denotes stage III or IV, stage III being represented by T3 or N1 tumors and the non-metastatic stage IV including N2-N3 or T4 tumors. The main therapeutic goals are local control and survival, but also the functional organ preservation (speech, swallowing and airway patency), if possible. To achieve these objectives, the management should be established by a multidisciplinary tumor board, based on the analysis of patient-specific factors (age, performance status, comorbidities, and psychosocial support), cancer topography and staging, but also the physician expertise and the availability of rehabilitation services. Regarding the larynx preservation, there are two major therapeutic strategies: total laryngectomy (associated with adjuvant radio- and chemotherapy) and larynx preservation strategy, which includes neoadjuvant chemotherapy followed by exclusive radiotherapy or concurrent radio-chemotherapy or radio-biotherapy. Total laryngectomy can be performed by open surgery or, in order to avoid a wide surgical field and reduce the local morbidity, by transoral techniques. After laryngectomy, the recurrence can be local, at the resection site, nodal, at cervical lymph nodes, or distal, the lung being the most common site of recurrence as a distant metastasis. To improve locoregional control and survival, adjuvant treatments are proposed, including radiotherapy, chemo- and biotherapy.

Ocular Motility After Repair of Combined Medial and Inferior Orbital Wall Fractures With Extended Conjunctival Incision With Inferior Oblique Reattachment.

To describe ocular motility and effectiveness of an extended conjunctival incision with reattachment of the inferior oblique muscle to repair combined orbital medial and inferior wall fractures. The authors retrospectively studied 20 eyes from 20 patients who underwent combined orbital medial and inferior wall fractures surgery with reattachment of the inferior oblique muscle from January 2007 to December 2011. Single large L-shaped implant was inserted into the fracture site. All patients were evaluated preoperatively and postoperatively at 1, 3, and 6 months, by computed tomography, Hertel exophthalmometry, the Hess test of ocular motility, and the Goldmann diplopia test. Sixteen patients (80%) had no significant enophthalmos or diplopia after surgery. Inferior oblique motility was not changed in 12 patients (60%) after reattachment of the inferior oblique muscle. After 1 month, inferior oblique underaction was presented in 8 patients (40%) and in 4 patients (20%) after 6 months. Finally, only 2 patients (10%) had the inferior oblique underaction remained, it was not improved. The extended conjunctival incision with reattachment of the inferior oblique muscle for combined orbital wall fracture repair offers a wide surgical field and space for a single large implant insertion and corrects the enopthalmos. The reattachment of the inferior oblique muscle does not contribute to the development of inferior oblique underactions or diplopia that was resolved spontaneously within 6 months after surgery.

Physiological and Biochemical Responses to Continuous Saline Irrigation Inside the Abdominal Cavity in Anesthetized Pigs.

Water-filled laparoendoscopic surgery (WaFLES) has been proposed as a novel surgical system achieving a wide surgical field in the intra- and extraperitoneal space with continuous irrigation of isotonic fluid into the field. Despite its technical feasibility and advantages, the safety of the technique, particularly with respect to physiological functions, has not been evaluated. Various types of minor abdominal surgeries were performed under general anesthesia in nine adult pigs either by conventional laparoscopy (n = 3) or WaFLES (n = 6). In addition to esophageal temperature and body weight, cardiorespiratory variables such as blood pressure, heart rate, and arterial blood gas parameters were compared before and after the surgeries. Blood samples were obtained for assessing changes in biochemical parameters before and after the surgeries. Three to seven hours of various surgeries were completed without critical cardiorespiratory events in all animals. Oxygenation and ventilation were maintained regardless of the techniques used for the surgeries. A minor increase of body weight (2.5% of initial body weight), metabolic acidosis, hyperkalemia, and impaired hepatic function were observed after WaFLES surgeries. The preliminary study indicated no serious immediate adverse effects of the WaFLES technique.

Two-Step Incision for Periarterial Sympathectomy of the Hand.

BackgroundSurgical scars on the palmar surface of the hand may lead to functional and also aesthetic and psychological consequences. The objective of this study was to introduce a new incision technique for periarterial sympathectomy of the hand and to compare the results of the new two-step incision technique with those of a Koman incision by using an objective questionnaire.MethodsA total of 40 patients (17 men and 23 women) with intractable Raynaud's disease or syndrome underwent surgery in our hospital, conducted by a single surgeon, between January 2008 and January 2013. Patients who had undergone extended sympathectomy or vessel graft were excluded. Clinical evaluation of postoperative scars was performed in both groups one year after surgery using the patient and observer scar assessment scale (POSAS) and the Wake Forest University rating scale.ResultsThe total patient score was 8.59 (range, 6-15) in the two-step incision group and 9.62 (range, 7-18) in the Koman incision group. A significant difference was found between the groups in the total PS score (P-value=0.034) but not in the total observer score. Our analysis found no significant difference in preoperative and postoperative Wake Forest University rating scale scores between the two-step and Koman incision groups. The time required for recovery prior to returning to work after surgery was shorter in the two-step incision group, with a mean of 29.48 days in the two-step incision group and 34.15 days in the Koman incision group (P=0.03).ConclusionsCompared to the Koman incision, the new two-step incision technique provides better aesthetic results, similar symptom improvement, and a reduction in the recovery time required before returning to work. Furthermore, this incision allows the surgeon to access a wide surgical field and a sufficient exposure of anatomical structures.

Decision making in dissection range of temporal bone: refinements to enlarged translabyrinthine approach.

The aim of the study was to describe the refinements to the classic enlarged translabyrinthine approach (ETLA) by modifying the bony dissection range of temporal bone and to analyze the main outcomes achieved in a series of vestibular schwannoma (VS) cases submitted to microsurgery by ETLA. This was a retrospective study of 382 patients who underwent VS surgical removal via ETLA between January 2001 and December 2012. Among those cases, 332 were via classic ETLA, while 28 cases were via ETLA with blind sac technique and middle ear eradication and 22 via transotic approach. Total tumor removal was achieved in 368 cases, whereas near total removal in 11 patients and subtotal in 3 patients. In cases of large VS (>3 cm) via classic ETLA, good short-term and long-term facial nerve function (HB I-II) was gained in 27.8 % (32/115) and 42.6 % (49/115) cases, respectively, meanwhile in VS operated via blind sac technique, good short-term (p = 0.048) and long-term (p = 0.044) facial nerve function was reached in 44.0 % (22/50) and 60.0 % (30/50) cases, respectively. Postoperative facial nerve function was proved to be better in modified ETLA group. CSF leakage occurred in 16 (4.2 %) patients via classic ETLA. In 115 cases of large VS (>3 cm), postoperative CSF leakage occurred in 10 (8.7 %) patients. Whereas in 50 cases via blind sac technique, none developed CSF leakage (p = 0.03). The incidence of CSF leakage was lower in modified ETLA group. Our refinements to classic ETLA by changing the temporal bone resection range provide a wide surgical field, well prevention of CSF leakage and preservation of facial nerve function in large VS.

"Bat Wing Surgical Approach for the Temporomandibular Joint".

The temporomandibular joint (TMJ) is anatomically complex; with its close proximity to neurovascular structures, including the facial nerve that gives a high degree of difficulty during surgical exposure. When the first description on TMJ surgery by Orlow in 1913 was published it gave an account describing the basic retroauricular, preauricular, endoaural and submandibular approaches, on treatment of articular pathologies as used today. The proposed study of the 'Bat Wing' approach, first described in 1993 by Garcia y Sanchez J.M. as a surgical alternative, offers great advantages is that it avoids the section of the ear canal and provides a wide surgical field. The management of the proposed technique has wide application with multiple joints addressed, achieving major objectives such as avoiding facial nerve damage, as well as avoiding the section of the external auditory canal with an optimum visibility of the operative field. The Department of Maxillofacial Surgery National Medical Center XXI Century records over a period of approximately 18 months have completed twenty TMJ surgeries using the 'Bat Wing', approach. The bat wing approach is a surgical alternative that offers broad exposure of the surgical field in TMJ, it is effective and meets the goal of exposing the area to intervene safely, good visibility and access to the site to intervene. It perfectly fulfills the above described.

Long-term follow-up results of canal wall down tympanoplasty with mastoid obliteration using the bone pate plate for canal wall reconstruction in cholesteatoma surgery.

The pathogenesis of recurrent cholesteatoma can be roughly divided into residual lesions and re-retraction of the epithelium. To prevent both residual and re-retraction cholesteatoma, we performed canal wall down tympanoplasty with mastoid obliteration using the bone pate plate for canal wall reconstruction as a fundamental surgical treatment for patients with acquired cholesteatoma. We attempted to achieve the complete extirpation of cholesteatoma in the wide surgical field made by the canal wall down procedure and simultaneously prevent recurrent retraction cholesteatoma and regain the physiologic canal wall, in which patients can have a "maintenance-free ear." The surgical method used in the present study was described, and the long-term postoperative results of this method were evaluated. Retrospective study. Participants were 118 patients with acquired cholesteatoma who underwent canal wall down tympanoplasty with mastoid obliteration and could be followed-up for more than 5 years. Postoperative changes in the reconstructed canal wall, the rate of otorrhea, and exposure of the material were examined using endoscopic images, medical charts, and CT scans. A total of 113 ears (95.8 %) achieved the nearly physiologic appearance of the external auditory canal, and these conditions were maintained throughout the follow-up periods. However, recurrent cholesteatoma was not observed during the follow-up periods. Postoperative otorrhea was observed in 2.5% of ears. Exposure of the bone pate was only noted in 1 patient (0.8 %). Postoperative CT scans confirmed that ossification developed in the bone pate used in the reconstructed canal wall and mastoid surface. Canal wall down tympanoplasty with mastoid obliteration using the bone pate plate for canal wall reconstruction prevents both recurrent and residual cholesteatoma and contributes to a good quality of life for the patient.

Application of modified enlarged translabyrinthine approach in the removal of vestibular schwannoma

To describe and analyze the surgical outcomes of modified enlarged translabyrinthine approach(ETLA), which is combined with middle ear eradication and blind sac technique. A retrospective study was conducted on 28 patients who underwent surgery for vestibular schwannoma (VS) via modified ETLA from Jan. 2001 to Dec. 2012. The sizes of tumors were 25-52 mm[(38.2 ± 9.1) mm (X(-) ± s)]. Main outcomes measures included the rate of total removal, the rate of cerebral spinal fluid (CSF) leakage after surgery, complications, and intraoperative anatomical preservation of facial nerve and facial nerve function. Among the 28 patients who underwent modified ETLA, the rate of total removal was 100%. There was no death after surgery via modified ETLA. The rate of CSF leakage after surgery was 3.5% (1/28). The rate of intraoperative anatomical preservation of facial nerve was 89.3% (25/28).Short-term and long-term good facial nerve function rates were 25.0% (7/28) and 42.9% (12/28), respectively. Modified ETLA is suitable for VS>3 cm with extension to the anterior region of cerebellopontine angle, VS involve with labyrinth part of facial nerve, high jugular bulb, proposing sigmoid sinus and highly pneumatized temporal bone. This approach can provide a wide surgical field and well prevention of CSF leakage.

A chronic flexion-distraction injury with a “fistulous wither” on the split spinous process of the L1 vertebra—a case report of a modified transpedicle wedge osteotomy

Flexion-distraction injuries (FDIs) are caused by high-energy force and momentum on the spine. In general, the posterior column and the posterior wall of the affected vertebra have failed in distraction, and the anterior column has failed in compression based on Denis’ three column theory [1]. Hoshikawa et al. has proposed a motion axis of FDIs, which is defined as a transitional line from the anterior compression to the posterior splitting failure [2]. In terms of biomechanics, the integrity of the posterior tension band of the affected vertebrae has failed in FDIs. As a result of this loss of integrity of the posterior element, kyphotic deformity easily develops and remains unless proper treatment has been optioned in FDIs. Fresh FDIs with minimal displacement are usually treated with an extension brace or body cast, and they have a good prognosis. Meanwhile, treatment of chronic FDIs is complicated. Backache and/or gibbus, which is caused by rigid kyphosis even after bone fusion at the affected segment, is a major residual symptom in chronic FDIs. Nonoperative treatment can rarely cure rigid kyphotic deformity. Malcom et al. stated that persistent back pain in the lumbar spine and the buttocks is usually related to a compensatory hyperlordosis below the kyphotic segment [3]. Although the degree to which kyphosis should be corrected operatively is still controversial, surgical intervention is indicated for some cases with backache and/or ill cosmesis caused by rigid kyphotic deformity in chronic FDIs. LeGay et al. have proposed that a deformity of greater than 17° in kyphosis of FDIs shows a clinically poor result and an instability in vivo [4]. For surgical treatment of a rigid kyphotic deformity of chronic FDIs, access to the damaged vertebra, releasing the scar tissue, correction of the kyphosis and a stable support in the anterior and middle columns are crucial. In the anterior approach, a wide surgical field of the affected segment is obtained, but it is associated with significant pulmonary and incisional morbidity. Conversely, the posterior approach provides more limited access with less morbidity, and it also enables surgeons to directly observe the neural tissue after resection of the damaged posterior elements in FDIs. A supraspinous bursitis is described as “fistulous withers” in horses [5]. It is a mechanical inflammation caused by a poorly fitting tack on horse withers. It begins as a painless encapsulated accumulation of serum associated with the supraspinous bursa. To my best knowledge in English and Japanese literature, there is no report of a symptomatic bursitis on the lumbar spinous process in humans. The supraspinous and the interspinous ligaments are less resilient to stress than the interval disc and the capsular ligament. Thus, there is a possibility that a condition similar to “fistulous withers” in horses develops in humans, when a local post-traumatic kyphosis of chronic FDIs remains in the human thoracolumbar spine. The purpose of the current article is a case report of chronic FDIs in the L1 vertebra. The patient had developed a rigid kyphosis associated with a bursitis on the distracted spinous process. He underwent radical excision of the affected soft tissue, partial resection of the fractured spinous process, a modified transpedicle wedge osteotomy in a fractured line, and augmented with pedicle screws and titanium interbody cages. An excellent prognosis has been obtained in the current case.