Infection post anterior cervical decompression and fusion (ACDF) is not a frequent complication, the infection rate is around 0.6%. Occlusive vascular lesions secondary to infection, affecting the spinal cord, are diagnostic challenges. Spinal cord infarction due to deep infectious cause, particularly MRSA (Methicillin Resistant Staphycoccus aureus) is rare. We present here a rare case of post C6–C7 ACDF infection with MRSA that leading to cord ischemia with radiological changes and rapidly evolving neurological deterioration. Rapid evaluation with MRI scanning and initiation of antibiotic produced dramatic response with our patient and satisfactory recovery at one year follow up. We assume that is the first reported case of MRSA cord infection with ischemic mylopathic changes.
Objective: To know the impact of the Dynesys system on the functional outcomes in patients with spinal degenerative diseases.
Summary of background data: Dynesys system has been proposed as an alternative to vertebral fusion for several spinal degenerative diseases. The fact that it has been used in people with different diagnosis criteria using different tools to measure clinical outcomes makes very difficult unifying the results available nowadays.
Methods: The data base of Medlars Online International Literature (MEDLINE) via PubMed©, EMBASE©, and the Cochrane Library Plus were reviewed in search of all the studies published until November 2012 in which an operation with Dynesys in patients with spinal degenerative diseases and an evaluation of the results by an analysis of functional outcomes had taken place. No limits were used to article type, date of publication or language.
Results: A total of 134 articles were found, 26 of which fulfilled the inclusion criteria after being assessed by two reviewers. All of them were case series, except for a multicenter randomized clinical trial (RCT) and a prospective casecontrol study. The selected articles made a total of 1507 cases. The most frequent diagnosis were lumbar spinal canal stenosis (LSCS), degenerative disc disease (DDD), degenerative spondylolisthesis (DS) and lumbar degenerative scoliosis (LDS). In cases of lumbar spinal canal stenosis Dynesys was associated to surgical decompression. Several tools to measure the functional disability and general health status were found. Oswestry Disability Index (ODI), the ODI Korean version (K-Odi), Prolo, Sf-36, Sf-12, Roland-Morris disability questionnaire (RMDQ), and the pain Visual Analogue Scale (VAS) were the most used. They showed positive results in all cases series reviewed. In most studies the ODI decreased about 25% (e.g. from a score of 85% to 60%). Better results when dynamic fusion was combined with nerve root decompression were found. Functional outcomes and leg pain scores with Dynesys were statistically non-inferior to posterolateral spinal fusion using autogenous bone. When Dynesys and decompression was compared with posterior interbody lumbar fixation (PLIF) and decompression, differences in ODI and VAS were not statistically significant.
Conclusions: In patients with spinal degenerative diseases due to degenerative disc disorders, spinal canal stenosis and degenerative spondylolisthesis, surgery with Dynesys and decompression improves functional outcomes, decreases disability, and reduces back and leg pain. More studies are needed to conclude that dynamic stabilization is better than posterolateral and posterior interbody lumbar fusion. Studies comparing Dynesys with decompression against decompression alone should be done in order to isolate the effect of the dynamic stabilization.
An anterior sacral meningocele is a rare form of spinal dysraphism that is sometimes associated with syndromes such as Currarino and Marfan syndromes. These lesions rarely causes neurological complications, but meningitis, sepsis, obstetric problems, and bowel and bladder difficulties are common secondary conditions, surgical treatment is the standard for symptomatic or growing masses as these lesions usually do not regress spontaneously. Anterior or posterior approaches are used to repair the dural defect.
We present a case of a 14 yr-old female patient with a giant nonsyndromic anterior sacral meningocele that we successfully treated using an open posterior approach. We discuss the treatment options and present a brief review of the literature.
Study Design: Consecutive Prospective Study.
Summary of Background Data: Lumbar fusion is considered the “gold standard” treatment for chronic low back pain (CLBP) that is believed to be due to degenerative disc disease (DDD) and is not relieved by prolonged conservative treatment. Instrumented intercorporal fusion is believed to restore disc height and prevent postoperative kyphosis better than instrumented posterolateral fusion (PLF). A new technique to perform PLF, using modern pedicle screw systems, challenges this belief.
Objective: This study has two main objectives: to measure disc height and segmental lordosis pre-, post-, and late post-operative in patients operated on with a variant of PLF and to compare the results with reported measurements with other techniques.
Material: The study included 97 consecutive patients (56 female) age 20-73, all with CLBP; 84 patients were diagnosed as DDD only, 13 patients had a spondylolisthesis with concurrent DDD. Forty-nine, patients were treated at one segment, 47 at two segments, and one patient at three segments. All patients were X-rayed preoperatively, immediately post-operative, and at late follow-up (≥ 10 months).
Methods: In all patients, PLF’s were performed using a pretension-distraction technique. Disc height and lordosis were calculated for all treated segments according to evaluated methods. The values on disc height and lordosis were compared for each patient preoperatively, immediately post-operative, and at follow-up.
Results: All treated segments had an increase of disc height at post-operative examinations. Despite some reduction of this increase at late control follow-up, the increase was still significant for L3-L4 segment (men) and L4-L5 and L5-S1 segments (women). Lordosis was reduced postoperatively with less than the measurement error for the method.
Conclusions: When this method of PLF was used, long-term increase in disc height and maintenance of lordosis was as favorable as reported on intercorporal fusions.
Lumbar Spinal Stenosis (LSS) is one of the most common spinal pathologies in the United States. LSS is a degenerative spine disorder that affects primarily people over the age of 50 and is one of the most common sine diagnoses requiring surgical intervention in this age group. This article aims to summarize the presentation, examination, work up, and management of the patient with LSS as well as touch upon some the latest clinical trials to aid in the practice of evidence based medicine.
Abstract Study design: Non-randomized chart review of elective lumbar decompression Objective: Compare patient outcome and health system economic impact associated with direct lumbar decompression. Summary of background data: Degenerative lumbar conditions refractory to non-operative measures are traditionally treated via open decompression. Less invasive techniques assisted by tubular retractors or endoscopic visualization continue to grow in popularity. Methods: 338 consecutive patients with spinal stenosis or disc herniation were treated with: Open, Tube-assisted, or Endoscope-assisted procedures based on the surgeons’ typical indications, practice pattern and procedure of choice. Cases stratified by stenosis requiring decompression without discectomy (Stenosis) or disc herniation requiring discectomy (Disc). Data collected preoperatively, one, four and ten months postoperatively. Within strata, perioperative demographics, intraoperative and postoperative complications, and functional outcomes were compared across procedure types. Outcome measures include VAS (back / leg), Oswestry and Medicare subset for Net revenue. Results: 234 Disc and 104 Stenosis cases. Stenosis patients were significantly older than Disc patients (67.0 vs. 52.3 years, p=0.0001). Disc cases: 42.7% Open, 36.8% Endoscope-assisted, 20.5% Tube-assisted. Stenosis cases: 36.5% Open, 63.5% Tube-assisted. Operative time, estimated blood loss, and length of stay were significantly greater for Open procedures both Disc and Stenosis. Disc cases fluoroscopy time was significantly greater for Endo (p<0.0001). Stenosis cases fluoroscopy time was significantly greater for Tube-assisted. Intraoperative complications occurred in 12 (3.5%) patients, 16 experienced postoperative events. A non-significant trend towards greater post-operative complication was seen in Open – stenosis group. Functional outcome improvements for ODI, VASB, and VASL were experienced regardless of case group or procedure type (p<0.0001). Medicare (n=107) revenue generated net positive regardless of case type or location. Conclusions: Functional improvement following treatment of degenerative lumbar conditions via direct decompression should be anticipated regardless of case group or procedure type. Despite their reduction in fluoroscopy, Open cases are associated with a significant increase in length of stay, operating time, estimated blood loss and potentially postoperative infections.
Introduction: In cervical disc disease, the exact location of the posterior osteophyte with relationship to the bodies of the adjacent cervical vertebra at each disc space level, as observed during surgery under operating microscope and correlating it with the histopathological development of the posterior osteophyte has not been documented in literature. A detailed review of literature on the development of posterior osteophytes and its impact on cervical spinal cord is also being reviewed.
Materials and Methods: 1st Phase: In a prospective study conducted over first 5 years (2007-2012), intraoperative observations of 294 disc spaces in 201 patients who were operated for cervical disc disease using the standard anterior cervical microdiscectomy were analyzed. We observed under operating microscope 32 C3-C4 disc spaces, 62 C4-C5, 123 C5- C6, 74 C6-C7, 2 C7- D1 and 1 C2- C3 disc space during the study period.
2nd Phase: The above prospective study was extended into the 2nd phase over next 3 1/2 years (2009-2012), and clinico-radiological (MRI findings) - intraoperative observations of 118 disc spaces in 70 patients who were operated for cervical disc disease were analyzed. These observations were correlated with the histopathological characteristics of the excised disc material.
Results: 1st Phase study: At C3-C4 disc space, posterior osteophyte originates from the upper vertebral body of C3 in 78.13% [25/32] disc spaces. In mobile segments of C4-C5 in 70.96% [44/62] and C5-C6 in 84.55% [104/123] disc spaces, the osteophyte arises from posterior margins of both the vertebral bodies. At C6 –C7, it arises from lower vertebral body of C7 in 71.62% [53/74]) disc spaces.
2nd Phase: It was observed histopathologically and intraoperatively, that posterior osteophytes formation goes through three stages. Posterior osteophyte formation is of Fibrocartilage in 10.17% (12/118), Mixed variety 7.62% (9/118) and Bony type in 82.20% [97/118]. In patients who had Bony type, 89.4% had myelopathy, 75 % had radiculopathy while 89.4% patients had hyperintense signal within the spinal cord.
Discussion: Our results show that there is a definite pattern in the formation of the posterior osteophyte within the cervical disc spaces. At junctional areas like C3-C4 and C6 –C7 the posterior osteophyte originates from the relatively fixed vertebra like C3 and C7. In mobile segments like C4-C5 and C5- C6 the posterior osteophyte originates from both the bodies of adjacent vertebra. We also observed that the posterior osteophyte formation in cervical disc disease goes through the following three stages. 1st stage: Fibrocartilage, 2nd stage: Mixed type consisting of both the fibrocartilage and partially bony and 3rd stage: Bony type. These stages we feel evolve over a span of few years. Patients presenting with myeloradiculopathy and hyperintense signal within the spinal cord are likely to harbor bony posterior osteophytes compressing the thecal sac and requires surgical intervention. This is the first document of its kind in literature.
Detailed reviews of literature on experimental models showing the development of posterior osteophyte supporting our observations, the pathological and radiological impact of the posterior osteophytes on cervical spinal cord, natural history of cervical spondylotic myelopathy and fate of the posterior osteophytes after anterior fusion surgery are being dealt upon in this paper.