The role of laminoplasty in preventing spinal deformity in adult patients submitted to resection of an intradural spinal tumor. Case series and literature review

Predictors for spinal deformity following resection of intramedullary tumor via posterior approach: a systematic review and meta-analysis

PURPOSE

The present study aimed to identify the clinical predictive factors for worsened spinal deformity (SD) following surgical resection via posterior approach for primary intramedullary tumors.

METHODS

A systematic search was performed using PubMed, Web of Science, and Scopus databases to extract potential references. Observational studies reporting predictive factors for worsened SD following surgical resection via posterior approach for primary intramedullary tumors were included. The odds ratio (OR) was calculated for dichotomous parameters.

RESULTS

Four retrospective cohort studies were included in the meta-analysis. They were comprised of two groups of patients; those who developed SD (n = 87) and those who did not (n = 227). For patients with IMSCTs, age under 25 years as well as age under 13 years were the demographic variables associated with postoperative SD (odds ratio [OR] 3.92; p = 0.0002 and OR 4.22; p = 0.003). In both the fusion and the non-fusion subgroups, preoperative spinal deformity strongly predicted postoperative SD (OR 11.94; p < 0.001), with the risk highly elevated among the non-fusion patients (OR 24.64; p < 0.0002). Thoracolumbar junction involvement was also found to be a predictor of postoperative SD for patients with IMSCT (OR 2.89; p = 0.02).

CONCLUSION

This study highlights the importance of considering age, preoperative spinal deformity, and thoracolumbar junction involvement as predictors of postoperative spinal deformity following surgical resection for IMSCT. These findings may provide guidance for the management of these patients, including the development of preoperative planning strategies and the selection of the most appropriate surgical approach for high-risk patients.

Impact of Surgical Resection Without Spinal Fusion for Thoracic Dumbbell Tumors on Postoperative Global Spinal Sagittal Alignment and Clinical Outcomes

STUDY DESIGN

A retrospective comparative study.

OBJECTIVES

This study investigated radiographical changes in global spinal sagittal alignment (GSSA) and clinical outcomes after tumor resection without spinal fusion in patients with thoracic dumbbell tumors.

METHODS

Thirty patients with thoracic dumbbell tumors who were followed up for at least 3 years were included in this study. Variations in the outcome variables were analyzed using individual GSSA parameters measured on radiography. Clinical outcomes were assessed using the modified McCormick scale (MMCS), Japan Orthopaedic Association (JOA) score, and visual analog scale (VAS). To assess the impact of the affected levels on these outcomes, we divided the patients into three groups according to the location of the tumor (upper [T1-4], middle [T5-8], or lower [T9-12] thoracic spine).

RESULTS

The GSSA parameters (cervical lordosis, T1 slope, thoracic kyphosis [global, upper, middle, and lower], thoracolumbar kyphosis, lumbar lordosis, sacral slope, pelvic incidence, and pelvic tilt) of all the patients did not change significantly after surgery. Eleven of thirty patients had preoperative gait disturbances but they could walk without support (MMCS grade I or II) at the final follow-up. The JOA score and VAS showed significant postoperative improvements. No statistically significant differences were observed in each postoperative sagittal profile or clinical outcome between the upper, middle, and lower groups.

CONCLUSIONS

Tumor resection without spinal fusion did not affect the various GSSA parameters and resulted in satisfactory clinical outcomes, indicating that spinal fusion may not always be necessary when resecting thoracic dumbbell tumors.

Spinous Process-Splitting Laminectomy Approach for Tumor Excision at Conus Medullaris or Cauda Equina Level Results in Satisfactory Clinical Outcomes Without Affecting Global Spinal Sagittal Alignment

STUDY DESIGN

Retrospective comparative study.

OBJECTIVES

The present study investigated radiographical changes in global spinal sagittal alignment (GSSA) and clinical outcomes following tumor resection using spinous process-splitting laminectomy (SPSL) approach without fixation in patients with conus medullaris (CM) or cauda equina (CE) tumor.

METHODS

Forty-one patients with CM or CE tumor (19 males, 22 females, mean age at surgery of 52.9 ± 13.0 years) were included in this study. The variations of outcome variables were analyzed in various GSSA profiles using radiographic outcomes. The clinical outcomes were assessed using Japan Orthopaedic Association (JOA) score and JOA back pain evaluation questionnaire (JOABPEQ).

RESULTS

In all cases, the various GSSA parameters (sagittal vertical axis, C2-7 lordosis, T1 slope, thoracic kyphosis, T10-L2 kyphosis, lumbar lordosis [LL; upper, middle, and lower], sacral slope, pelvic incidence, and pelvic tilt) did not significantly change in the 2-years postoperative period. Moreover, age at surgery, the number of resected laminae, preoperative T12-L2 kyphosis, or LL did not affect the postoperative changes in T12-L2 kyphosis or LL, and had no statistically significant correlation among them. The scores of each postoperative JOA domain and the Visual Analogue Scale included in the JOABPEQ were significantly improved. There was no statistical significant group difference in each sagittal profile or clinical outcomes between CM and CE groups postoperatively.

CONCLUSIONS

Tumor resection using SPSL approach did not affected the various GSSA parameters examined and resulted in satisfactory clinical outcomes, indicating that SPSL approach is a suitable surgical technique for patients with CM or CE tumor.

Is There a Role for Intraoperative Neuromonitoring in Intradural Extramedullary Spine Tumors? Results and Indications from an Institutional Series

While intraoperative neurophysiological monitoring (IONM) is considered a standard for intramedullary spinal cord tumor surgery, the effective role of IONM in intradural extramedullary (IDEM) tumors is still debated. We present the results of 60 patients affected by IDEM tumors undergoing surgery with the aid of IONM. Each patient was evaluated according to the modified McCormick scale (MMS) at admission, discharge and at follow-up. During surgery, motor evoked potentials (MEPs) and somatosensory evoked potentials (SEPs) were studied using the Medtronic NIM-eclipse^® 32-channel system (Medtronic Xomed, Inc. 6743 Southpoint Drive North Jacksonville FL USA). Patients' age, gender and tumor location did not affect MMS modifications. Tumors involving more than three levels had an increased likelihood of MMS worsening, while meningioma pathology was associated with worse preoperative and 1-year follow-up MMS. No MEP amplitude ratio was able to predict clinical variations, while intraoperative SEP worsening was associated with 100% risk of poor MMS at discharge and with 50% risk of poor MMS at long-term follow-up. In our opinion, SEP monitoring is a valid tool that may contribute to the preservation of the patient's neurological status. MEP monitoring is not mandatory in IDEM surgery while more studies are required to explore the feasibility and the role of D-wave in this kind of surgery.

Long-term Follow-up Results of Reconstructive Laminoplasty With L-shaped Leibinger Mini-plate for Posterior Approach in the Treatment of Intraspinal Tumor Surgery

OBJECTIVE

Laminoplasty using mini-plates is one of the most common surgical techniques in surgery for intraspinal pathologies. However, limited are present in the literature. The aim of this study was to determine its long-term clinical and radiologic outcome, specifically using an L-shaped mini-plate.

METHODS

Patients who underwent surgery for spinal intradural pathology from January 2008 to December 2019 were retrospectively reviewed. Those who received laminoplasty using the Leibinger mini-plate and were followed for more than 2 years were included. Patient demographics and clinical and radiographic data were reviewed and analyzed. A total of 117 patients (male:female = 47:70; mean age 50.9 years, range 16-92 years) were included, and mean follow-up period was 50.3 months (range 24-151 months).

RESULTS

The most common pathology was schwannoma (n = 66, 56.4%) followed by meningioma (n = 30, 25.6%). Gross total resection was achieved in 82.9% (n = 97). Clinical outcomes at last follow-up were mostly good and excellent (n = 95, 81.2%). Computed tomography at the postoperative 1-year follow-up were available in 32 patients (27.4%) and the overall fusion rate was 89.3% (50 of 56 laminae). The fusion rate was significantly lower in the cervical spine compared to other locations (50% vs. thoracic [100%], lumbar [85.7%], P < 0.002). No displacement of laminae or postoperative spinal deformity were observed throughout the follow-up.

CONCLUSIONS

Laminoplasty using L-shape Leibinger mini-plates had an 89.3% fusion rate, and no displacement of the re-attached laminae was observed. We think it is a safe and feasible option in surgeries for intraspinal pathologies.

Clinical and Biomechanical Study of Laminoplasty for Thoracic and Lumbar Intradural Tumors

(1) Background: Primary intraspinal tumors account for 2-15% of all central nervous system (CNS) tumors. Most intraspinal tumors are benign, and about 40% of them occur intradurally, for which early surgery is the preferred treatment. Laminectomy with pedicle screw fixation is the conventional surgical treatment. However, laminectomy with pedicle screw fixation is likely to reduce the spinal range of motion (ROM), with many other complications, although it can maintain the stability of the spine. The aim of this study is to determine whether laminoplasty as a new surgical approach for thoracic and lumbar intradural tumors is superior to laminectomy in preserving spinal ROM, maintaining spinal stability and reducing postoperative complications. (2) Methods: We retrospectively analyzed 50 patients who received intradural tumor resection, including 23 who received traditional laminectomy with pedicle screw fixation and 27 who received new laminoplasty. Spinal ROM was evaluated by lumbar flexion/extension radiograph and biomechanical evaluation. Spinal stability was evaluated by imaging observations of the spinal Cobb angle and laminar bone fusion. Postoperative complications were evaluated according to cerebrospinal fluid (CSF) leakage and the length of hospital stay. (3) Results: Compared with the laminectomy group, patients in the laminoplasty group exhibited a better spinal ROM (31.6 ± 12.0° vs. 21.7 ± 11.8°, p = 0.013), a smaller Cobb angle (9.6 ± 4.3 vs. 12.5 ± 5.3, p = 0.034), a lower incidence of CSF leakage (4/14.8% vs. 11/47.8%, p = 0.015), and a shorter length of hospital stay (13.1 ± 1.8 vs. 15.1 ± 2.3 days, p = 0.001). Most patients in the laminoplasty group had satisfactory bone fusion. The biomechanical experiment also demonstrated that spinal ROM in laminoplasty was larger than that in the laminectomy group. (4) Conclusions: Compared with the traditional surgery, the new laminoplasty surgery can better maintain the stability of the spine, preserve spinal ROM, and reduce postoperative complications. It is a surgical method that can be clinically popularized.

Real-World Data on the Usage of Hemopatch® as a Hemostat and Dural Sealant in Cranial and Spinal Neurosurgery

Background and objectives Cerebrospinal fluid (CSF) leakage is a significant complication in cranial and spinal interventions. Hemostatic patches such as Hemopatch^® are therefore used to support the watertight closure of the dura mater. Recently, we published the results of a large registry documenting the effectiveness and safety of Hemopatch^® in various surgical specialties, including neurosurgery. Here we aimed to analyze the outcomes from the neurological/spinal cohort of this registry in more detail. Methods Based on the data from the original registry, we performed a post hoc analysis for the neurological/spinal cohort. The Hemopatch^® registry was designed as a prospective, multicenter, single-arm observational study. All surgeons were familiar with the application of Hemopatch^® and it was used at the discretion of the responsible surgeon. The neurological/spinal cohort was open for patients of any age if they had received Hemopatch^® during an open or minimally invasive cranial or spinal procedure. Patients with known hypersensitivity to bovine proteins or brilliant blue, intraoperative pulsatile severe bleeding, or an active infection at the potential target application site (TAS) were excluded from the registry. For the posthoc evaluation, we stratified the patients of the neurological/spinal cohort into two sub-cohorts: cranial and spinal. We collected information about the TAS, intraoperative achievement of watertight closure of the dura, and occurrence of postoperative CSF leaks. Results The registry comprised 148 patients in the neurological/spinal cohort when enrolment was stopped. The dura was the application site for Hemopatch^® in 147 patients (in one patient in the sacral region after tumor excision), of which 123 underwent a cranial procedure. Twenty-four patients underwent a spinal procedure. Intraoperatively, watertight closure was achieved in 130 patients (cranial sub-cohort: 119; spinal sub-cohort: 11). Postoperative CSF leakage occurred in 11 patients (cranial sub-cohort: nine; spinal sub-cohort: two). We observed no serious adverse events related to Hemopatch^®. Conclusion Our post hoc analysis of real-world data from a European registry confirms the safe and effective use of Hemopatch^® in neurosurgery, including cranial and spinal procedures, as also observed in some case series.

A Novel Technique of Mixed Reality Systems in the Treatment of Spinal Cord Tumors

Several reports have compared spinal cord tumor removal techniques but none have clearly described the appropriate site and level of indication for laminectomy or laminoplasty. The approach method for tumor removal depends on the type and localization of the tumor and the surgeon's skill. Therefore, a system that can suggest various surgical techniques is useful for spinal cord tumor surgery. The mixed reality system introduced in this paper is an excellent system that can suggest various surgical procedures. Using this system for spinal cord tumor removal, we made the surgery less invasive; therefore, we introduced this system and demonstrated its usefulness. Stereoscopic data of the patients with spinal cord tumors were obtained from preoperative myelogram-CT data. Stereoscopic laminectomy models including tumors were created using Blender, a free three-dimensional (3D) image editing software. We observed these data as 3D object images using a head-mounted display (HMD). This HMD is commercially available and relatively inexpensive. The surgical procedure is determined by considering those 3D images, radiological diagnosis, and the skill of surgeons. Intraoperative confirmation of the laminectomy site could be performed using the HMD. The 3D visualization of pathological conditions resulted in correct preoperative surgical planning and less invasive surgery in all five cases. Stereoscopic images using HMDs allow us a more intuitive understanding of the positional relationship between the tumor and spinal structure. These 3D object images can bring us more accurate preoperative planning and proper determination of surgical methods.

A refined method of en bloc open-door laminoplasty for resection of intradural spinal tumors in the thoracic and lumbar spine

BACKGROUND

The open-door laminoplasty has been used to treat cervical spondylotic myelopathy. This technique has been applied to the surgical treatment of thoracic and lumbar spinal canal tumors instead of simple laminectomy or hemilaminectomy. However, previously reported laminoplasty methods did not keep posterior supporting elements intact such as the laminae and the spinous processes with supraspinous and interspinous ligaments, and almost all of them needed instruments for the fixation of reconstructed laminae. The purpose of this paper is to introduce our open-door laminoplasty method, which keep all posterior supporting elements intact and reconstruct the laminae without instrument.

METHODS

Eight patients (mean age 61 years) underwent en bloc open-door laminoplasty in the thoracic and lumbar spine for resection of intradural spinal tumors. Two grooves are made bilaterally on the laminae just medial side of the facet joints. One-half of each spinous process of the adjacent vertebrae above and below the laminoplasty is cracked diagonally to create a green stick fracture and bent to the hinged side for sufficient elevation of the laminar flap. After tumor resection, the laminar flap is restored to its original site, resulting in the complete preservation of the posterior supporting elements.

RESULTS

Operative exposure was good and permitted complete resection. No complications such as postoperative spinal canal stenosis or kyphosis were observed. Computed tomography(CT) indicated that bony fusion occurred in all cases.

CONCLUSION

The supraspinous and interspinous ligaments above and below laminoplasty were kept intact during surgery in our method. Therefore, the continuity of posterior supporting elements (laminae and spinous processes connected by supraspinous and interspinous ligaments) were completely preserved.

Refining the treatment of spinal cord lesions: experience from 500 cases

OBJECTIVE

Tumorous lesions of the spinal cord, as well as some vascular lesions like cavernous hemangiomas, demand careful consideration as to the indication and approach for surgery. As these lesions are rare in any departmental series, refinement of treatment strategies evolves over long periods. In this context, the authors evaluated a series of 500 intramedullary lesions for approach, technique, outcome, complications, and follow-up.

METHODS

Five hundred intramedullary lesions in 460 patients were treated with a continuously evolving departmental strategy between 1985 and 2020. No lesions of the cauda equina or filum terminale were included. The focus of the evaluation was on the adaptation of exposure, resective methodology, sequelae, imaging, and rate of recurrence. Thirty-seven patients were children at the time of diagnosis.

RESULTS

Among the 348 neoplastic lesions, the largest subtype was ependymoma (n = 192, 55.2%), followed by astrocytoma (n = 89, 25.6%). As a trend, metastases (n = 21) have become more frequent and more apparent only in the past 15 years. Reoperations for recurrent or progressive cases or referrals after incomplete resection were performed in 56 cases, mostly for progressive diffuse or pilocytic astrocytomas. Among the vascular lesions, 68 (54.8%) were hemangioblastomas, followed by 56 (45.2%) cavernous hemangiomas. All intramedullary tumors were approached through a midline myelotomy, refining an en bloc resection technique for endophytic tumors to increase the rate of radical resection. Cavernous hemangiomas reaching the surface and hemangioblastomas were approached directly. Complete removal was possible in 77.2% of endophytic tumors but in only 41.7% of diffuse tumors. All WHO grade II diffuse astrocytomas, WHO grade III tumors, and glioblastoma progressed despite treatment according to standard regimens. Vascular lesions were regularly removed completely, with only 1 recurrence of a large hemorrhagic thoracic cavernous hemangioma. The major sequelae were sensory deficits and neuropathic pain. Stabilizing instrumentation was placed in 5 cases of spinal deformity, mostly when more than 4 levels were affected, and in the pediatric population.

CONCLUSIONS

In a large series of intramedullary surgeries, refinement of treatment strategies related to exposure, implementation of intraoperative adjuncts such as ultrasound, intraoperative neuromonitoring, resective strategies, and reconstruction were evaluated. The authors found that for almost any defined, endophytic medullary lesion, a safe and complete removal can be offered.

Resection of Spinal Meningioma Using Ultrasonic BoneScalpel Microshaver: Cases, Technique, and Review of the Literature

BACKGROUND

Meningiomas of the spinal canal comprise up to 40% of all spinal tumors. The standard management of these tumors is gross total resection. The outcome and extent of resection depends on location, size, patient's neurologic status, and experience of the surgeon. Heavily calcified spinal meningiomas often pose a challenge for achieving gross total resection without cord injury.

OBJECTIVE

To report our experience with the BoneScalpel Micro-shaver to resect heavily calcified areas of spinal meningiomas adherent to the spinal cord without significant cord manipulation, achieving gross total resection and outstanding clinical results.

METHODS

Seventy-nine and 82-yr-old females presented with progressive leg weakness, paresthesias, and gait instability. Magnetic resonance imaging of the thoracic spine showed a homogenous enhancing intradural extramedullary mass with mass effect on the spinal cord. Midline bilateral laminectomy was performed, and the dura was open in midline. The lateral portion of the tumor away from the spinal cord was resected with Cavitron Ultrasonic Surgical Aspirator while the BoneScalpel Micro-shaver (power level 5 and 30% irrigation) was brought into the field for the calcified portion of the tumor adherent to the spinal cord.

RESULTS

Gross total resection was achieved for both cases. At the 2-wk postoperative visit, both patients reported complete recovery of their leg weakness with significant improvement in paresthesias and ataxia.

CONCLUSION

The ultrasonic osteotome equipped with a microhook tip appears to be a safe surgical instrument allowing for effective resection of spinal meningiomas or other heavily calcified spinal masses not easily removed by usual surgical instrumentation.

Cervical meningioma resection including the inner dura through an open-door laminoplasty using hydroxyapatite spacers: A case report

Background:

The ideal surgery for spinal cord tumors is complete resection to prevent recurrence. However, it should be accomplished safely/effectively without risking increased morbidity. Here, we report a cervical meningioma that was totally resected, including the inner dura, through a laminoplasty performed with hydroxyapatite (HA) spacers.

Case Description:

A 61-year-old Asian male presented with a symptomatic intradural extramedullary C4-C6 cervical meningioma. At surgery, this required resection of the inner dural layer through an open-door laminoplasty. Preservation of the outer dural layer facilitated a watertight closure and the avoidance of a postoperative cerebrospinal fluid (CSF) fistula. Notably, the laminoplasty utilized HA spacers which were magnetic resonance (MR) compatible allowing for future follow-up studies to evaluate for tumor recurrence. At 5-year follow-up, the tumor had not recurred, the patient was asymptomatic, and alignment was maintained.

Conclusion:

Gross total resection of an intradural extramedullary C4-C6 cervical meningioma was performed with removal of just the inner dural layer. Preservation of the outer dural layer allowed for a watertight closure and the avoidance of a postoperative CSF leak. Further, laminoplasty using HA spacers allowed for successful tumor resection, adequate fusion/stabilization, while not interfering with future MR studies (e.g., HA MR compatible).

Application of Laminoplasty Combined with ARCH Plate in the Treatment of Lumbar Intraspinal Tumors

Objective

To investigate the bone fusion and clinical effect of laminoplasty combined with ARCH plate fixation in the treatment of lumbar intraspinal tumors.

Methods

This was a clinical study. From June 2017 to January 2019, 24 patients (seven males and 17 females, average age 40 ± 16 years) with lumbar intraspinal tumors underwent laminoplasty combined with ARCH plate fixation in our hospital. The bone fusion was evaluated by X‐ray and computed tomography (CT) scans that were taken 15.2 ± 2.17 months postoperatively. Each segment showed a bone bridge on one side, which was classified as “segmental partial fusion.” Each segment showed bilateral bone bridges, which were classified as “segmental complete fusion”. When all segments of the patient showed bilateral bone bridging so that the replanted lamina and the host lamina became a unit on the CT scan, it was defined as “complete fusion”. In addition, the operation time and blood loss were recorded. Fisher's exact test was used to analyze the potential influencing factors of bone healing, including age (≤40 years vs >40 years), gender, number of operated levels (single vs two). Paired t‐test was used to analyze pre‐ and postoperative Oswestry Disability Index (ODI) scale and low back and leg pain visual analog scale (VAS).

Results

A total of 33 segments of laminoplasty were successfully performed in 24 patients. The average operation time was 128 ± 18 minutes. The average blood loss was 110 ± 19 mL. All patients were followed up at least 12 months after operation (average, 15.2 ± 2.17 months). At the final follow‐up, according to the definition of this study, the proportion of “segmental partial fusion” and “segmental complete fusion” were 30.3% (10/33) and 69.7% (23/33), respectively. And the proportion of patients with “complete fusion” was 70.8% (17/24). Age, gender, and number of operated levels were not associated with the fusion (P = 1.0, 0.37, and 0.06, respectively). ODI and VAS were much better at 1 month after operation and the final follow‐up than those before the operation (P < 0.01). At 6 months after operation, the results of magnetic resonance imaging (MRI) showed that the supraspinous ligament was repaired, and there were no complications, such as spinal epidural scar recompression.

Conclusions

Laminoplasty combined with ARCH plate was a better surgical method, and 70.8% of the patients showed complete bone fusion and there was no case of bilateral nonunion.

[Treatment of benign tumors in thoracic spinal canal by modified replanting posterior ligament complex applying piezoelectric osteotomy]

Objective

To investigate the feasibility and effectiveness of modified replanting posterior ligament complex (PLC) applying piezoelectric osteotomy in the treatment of primary benign tumors in thoracic spinal canal.

Methods

The clinical data of 38 patients with primary benign tumors in thoracic spinal canal between March 2014 and March 2016 were retrospectively analyzed. There were 16 males and 22 females, aged from 21 to 72 years (mean, 47.1 years). The disease duration ranged from 6 to 57 months (mean, 32.6 months). Pathological examination showed 24 cases of schwannoma, 6 cases of meningioma, 4 cases of ependymoma, 2 cases of lipoma, and 2 cases of dermoid cyst. The lesions located in 18 cases of single segment, 15 cases of double segments, and 5 cases of three segments. The length of the tumors ranged from 0.7 to 6.5 cm. There were boundaries between the tumors and the spinal cord, cauda equina, and nerve roots. The preoperative Japanese Orthopaedic Association (JOA) score was 12.2±2.3 and the thoracic Cobb angle was (11.7±2.7)°. Modified PLC replantation and microsurgical resection were performed with piezoelectric osteotomy. Continuity of uniside supraspinal and interspinous ligaments were preserved during the operation. The PLC was exposed laterally. After removing the tumors under the microscope, the pedicled PLC was replanted in situ and fixed with bilateral micro-reconstruction titanium plate. X-ray film, CT, and MRI examinations were performed to observe spinal stability, spinal canal plasty, and tumor resection after operation. The effectiveness was evaluated by JOA score.

Results

The operation time was 56-142 minutes (mean, 77.1 minutes). The intraoperative blood loss was 110-370 mL (mean, 217.2 mL). The tumors were removed completely and the incisions healed well. Three cases complicated with cerebrospinal fluid leakage, and there was no complications such as spinal cord injury and infection. All the 38 patients were followed up 24-28 months (mean, 27.2 months). There was no internal fixation loosening, malposition, or other related complications. At last follow-up, X-ray films showed no sign of kyphosis and instability. CT showed no displacement of vertebral lamina and reduction of secondary spinal canal volume, and vertebral lamina healed well. MRI showed no recurrence of tumors. At last follow-up, the thoracic Cobb angle was (12.3±4.1)°, showing no significant difference when compared with preoperative value ( t=0.753, P=0.456). JOA score increased to 23.7±3.8, showing significant difference when compared with preoperative value ( t=15.960, P=0.000). Among them, 14 cases were excellent, 18 were good, 6 were fair, and the excellent and good rate was 84.2%.

Conclusion

Modified replanting PLC applying piezoelectric osteotomy and micro-reconstruction with titanium plate for the primary benign tumors in thoracic spinal canal can reconstruct the anatomy of the spinal canal, enable patients to recover daily activities quickly. It is an effective and safe treatment.

Comparison of Anterior Cervical Decompression and Fusion versus Laminoplasty in the Treatment of Multilevel Cervical Spondylotic Myelopathy: A Meta-Analysis of Clinical and Radiological Outcomes

OBJECTIVE

Spondylotic cervical myelopathy is a severe condition commonly affecting aging people. Although many investigations have been conducted, a consensus on the best surgical management is still missing. The aim of our study was to systematically review the pertinent literature and carry out a meta-analysis to compare the clinical and radiological outcome of the anterior cervical decompression and fusion (ACDF) and the posterior laminoplasty.

METHODS

This study was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines statement. Different medical database (PubMed, Embase, Scopus) were screened for eligible scientific reports. The key words "cervical," "spondylosis," "myelopathy," "laminoplasty," "ACDF" (MeSH) have been used in any possible combination. As outcome variables, the Japanese Orthopedic Association score, operation time, blood loss, cervical lordosis, range of motion and, complications were evaluated.

RESULTS

A total of 626 articles were screened and 5 finally included in the meta-analysis. Comparing the anterior cervical decompression and fusion (ACDF) and laminoplasty groups, no differences were found in Japanese Orthopedic Association score, operation time, and complication rate. The ACDF was associated with lower intraoperative blood loss and better cervical lordosis preservation, whereas the laminoplasty was associated with a wider cervical range of motion.

CONCLUSIONS

The results of this meta-analysis seem to suggest that ACDF should be preferred to the laminoplasty for the treatment of multilevel cervical myelopathy, although proper designed randomized controlled clinical trials are needed to further investigate this relevant ongoing issue.

Results of TachoSil® associated with fibrin glue as dural sealant in a series of patients with spinal intradural tumors surgery. Technical note with a review of the literature

A major problem of surgery for intradural spinal tumors (IST) is the occurrence in the post-operative period of a cerebrospinal fluid (CSF) leak. To the best of our knowledge, here we report on the largest series of IST patients in whom the TachoSil® associated to fibrin glue was used as dural sealant in this kind of surgery. Moreover, we extensively reviewed the literature reporting the results of TachoSil® in spine surgery. The data of 35 consecutive surgically treated IST patients were reviewed. In all cases TachoSil® associated with fibrin glue was used as dural sealant. Mean age was 58.14 ± 15.56 years and mean follow-up (FU) was 23.20 ± 9.76 months. The Modified McCormick Scale (MMS) was used to assess the functional status of patients pre-operatively and at latest FU. All article dealing with the use of TachoSil® in spine surgery were included in the literature review. A CSF collection (treated conservatively with needle aspiration and bed rest with no consequence) was observed only in 1 out of 35 cases. No wound infection nor adverse reaction to the TachoSil® occurred during the FU. At latest FU we observed an improvement of MMS grade in 23 patients (65.71%) and a stable functional status in 12 cases (34.28%). According to our experience and the literature review using the TachoSil® after dural closure is safe and effective in IST surgery. Better standardized studies are needed to establish the usefulness of TachoSil® for incidental dural tear in degenerative spine surgery.

Intradural extramedullary tumor in the stenotic cervical spine resected through open-door laminoplasty with hydroxyapatite spacers: report of two cases

Background

Safe excision of spinal cord tumors depends on sufficient visualization of the tumor and surrounding structures. In patients with spinal cord tumor adjacent to a stenotic spinal canal, extensive bony decompression proximal and distal to the tumor should be considered for safer excision of the tumor. Extensive wide laminectomy is one choice for such cases, but postoperative problems such as kyphotic deformity remain a concern.

Case presentation

A 76-year-old man and a 60-year-old woman presented with symptomatic intradural extramedullary spinal cord tumors in the cervical spine. Both patients showed a combination of spondylotic changes in the cervical spine and stenotic condition at the level of the tumor. Both tumors were successfully resected through open-door laminoplasty with hydroxyapatite (HA) spacers, with the tumor located on the side of the laminoplasty. Histological diagnosis was schwannoma for both tumors. HA spacers completely bonded to the host bone and did not interfere with postoperative magnetic resonance imaging (MRI) of the inside of the spinal canal. Cervical spine alignment was maintained at the final follow-up of 6 years in both cases.

Conclusion

Laminoplasty with HA spacers enabled successful tumor extirpation, reliable MRI follow-up after surgery, and maintenance of normal cervical spine alignment. Laminoplasty with HA spacers represents a good option for the treatment of cervical spinal cord tumor in patients combined with spinal stenosis.

Utility of the Lateral Base Dural Tacking Method in Cord Tumor Surgery Performed Using Unilateral Hemilaminectomy: A Comparison of Dural Window Widths

OBJECTIVE

Unilateral hemilaminectomy, which is used to remove spinal cord tumors, is simpler than laminoplastic laminotomy and affords certain biomechanical advantages. However, both incomplete tumor removal and inadvertent infliction of spinal cord damage attributable to the narrow surgical corridor remain of concern. When a spinal cord tumor is to be removed, it is important to ensure that the dural window along the surgical corridor is of adequate width. This study aimed to determine that the utility of lateral base dural tacking (LBT) method when cord tumor surgery is performed using a unilateral hemilaminectomy-a comparison of dural window widths with a traditional dural tack-up and a suspending-out (DSO) method with the aid of digital image-analysis software.

METHODS

Twenty-one consecutive patients who had intradural-extramedullary spinal cord tumors removed using a unilateral hemilaminectomy were included in the study and analyzed retrospectively. We acquired DSO and LBT dural window images using surgical microscopes under identical conditions in consecutive order and then removed the tumors using the LBT method. We used digital image-analysis software to analyze the images quantitatively. The pixel numbers of LBT and DSO window were compared using a paired t test.

RESULTS

Twenty-one tumorous lesions were successfully removed without any major problems using a unilateral hemilaminectomy through LBT windows. The mean pixel numbers of the LBT and DSO windows were 126,787 ± 41,938 and 85,940 ± 21,638. The LBT windows were 46% larger than the DSO windows (P < 0.001).

CONCLUSIONS

We objectively proved that the utility of the LBT method for widening the surgical corridor created during hemilaminectomy.

Lumbar Spinal Angiolipoma with Expanding Left Neural Foramen Mimicking Lumbar Schwannoma; Case Report and Review of The Literature

Aim

To describe a patient with lumbar angiolipoma mimicking schwannoma in the posterolateral side of the spinal canal with expansion of the left lumbar foramen and to discuss the clinical, radiologic, and surgical features of these lesions with literature.

Methods

Without language restriction in this paper, the electronic databases; The Cochrane Collaboration the Cochrane, The Cochrane Library (Issue 2 of 12, Feb. 2011), ProQuest, US National Library of Medicine, National Institutes of Health (NLM) and PubMed dating from 1966 September to January Week 2 2017, were searched for comparative experimental studies using the terms: "OR", "AND". On-line literature searches were conducted using the key words "lumbar angiolipoma", "schwannoma ", "spinal angiolipoma", "spinal cord", and "spinal canal". We compared this research with our patient.

Results

Bilateral L2 total laminectomy, excision of the tumors and bilateral L2-L3 transpedicular stabilization were performed, and complaints improved prominently. Pathological examination was reported as angiolipoma.

Conclusion

The research shows that a probable diagnosis in such tumor cases could be made by sufficient pre-op scanning before surgical operations and although angiolipoma has been rarely seen in lumbar posterolateral space, it can be seen in lumbar region and mimic schwannoma as producing symptoms and signs of spinal cord and nerve root compression.

Keyhole approaches to intradural pathologies

OBJECTIVE

Spinal tumors account for 2%–4% of all tumors of the central nervous system and can be intramedullary, intradural extramedullary, or extradural. In the past, wide approaches were used to obtain safe access to these tumors, as complete resection is the goal in treating most tumor entities. To reduce surgical complications due to large skin incisions and destabilizing laminectomies, minimally invasive approaches were established. In this study, the authors share their experience with mini-open approaches to intradural tumor pathologies.

METHODS

The authors retrospectively reviewed cases involving patients with intramedullary and intradural extramedullary lesions treated between 2009 and 2016. They present their surgical mini-open approach to the spinal cord as well as unique characteristics, key steps, and postsurgical complications for specific tumor subgroups (meningioma, neuroma, and intramedullary tumors).

RESULTS

A total of 245 intradural tumors were surgically treated during the study period. Of these lesions, 151 were intradural extramedullary meningiomas (n = 79) or neuromas (n = 72). Nine (12.5%) of the neuromas were dumbbell neuromas. Ninety-four tumors were intramedullary. The mean age of the patients was 51.4 years, and 53.9% were female. The mean duration of follow-up was 46.0 months.

All meningiomas and neuromas could be resected using a mini-open keyhole approach, but only 5.3% of the intramedullary lesions could be accessed using this technique. Of the 94 patients with intramedullary tumors, 76.6% required a laminotomy, 7.4% required a hemilaminectomy, and 10.6% required a 2-level laminectomy. Only 2 of the patients with intramedullary tumors needed stabilization for progressive cervical kyphosis during follow-up. None of the other patients developed spinal instability after undergoing surgery via the mini-open (keyhole/interlaminar) approach. There were significantly more surgery-associated complications in the large exposure group than in the patients treated with the mini-open approach (19.1% vs 9.6%, p < 0.01).

CONCLUSIONS

Intradural extramedullary and in selected cases intramedullary pathologies may safely be resected using a mini-open interlaminar approach. Avoiding laminectomy, laminotomy, and even hemilaminectomy preserves spinal stability and significantly reduces comorbidities, while still allowing for complete resection of these tumors.

Three-dimensional Fluoroscopy-based Navigation for the Pedicle Screw Placement in Patients with Primary Invasive Spinal Tumors

Background:

Although pedicle screw placement (PSP) is a well-established technique for spine surgery, the treatment of patients with primary invasive spinal tumor (PIST) has high surgical risks secondary to destroyed pedicles. Intraoperative three-dimensional fluoroscopy-based navigation (ITFN) system permits safe and accurate instrumentation of the spine with the advantage of obtaining intraoperative real-time three-dimensional images and automatic registration. The aim of this study is to evaluate the feasibility and accuracy of PSP using ITFN system for patients afflicted with PIST in the thoracic spine.

Methods:

Fifty-one patients diagnosed with PISTs were retrospectively analyzed, and 157 pedicles screws were implanted in 23 patients using the free-hand technique (free-hand group) and 197 pedicle screws were implanted in 28 patients using the ITFN system (ITFN group). Modified classification of Gertzbein and Robbins was used to evaluate the accuracy of PSP, and McCormick classification was applied for assessment of neurological function. Demographic data and factors affecting accuracy of screw insertion were compared using independent t-test while comparison of accuracy of screw insertion between the two groups was analyzed with Chi-square test.

Results:

Of 51 patients, 39 demonstrated improved neurological status and the other 12 patients reported that symptoms remained the same. In the free-hand group, 145 screws (92.4%) were Grade I, 9 screws (5.7%) were Grade II, and 3 screws (1.9%) were Grade III. In the ITFN group, 192 screws (97.4%) were Grade I, 5 screws (2.6%) were Grade II, and no Grade III screw was detected. Statistical analysis showed that the accuracies of pedicle screws in the two groups are significantly different (χ² = 4.981, P = 0.026).

Conclusions:

The treatments of PISTs include total tumor resection and reconstruction of spine stability. The ITFN system provides a high accuracy of pedicle screw placement.

Management of cervical spine deformity after intradural tumor resection

Management of intradural spinal tumors requires posterior decompressive techniques. Cervical spine deformity secondary to sagittal and/or coronal imbalance after a laminectomy may result in significant cervical pain and functional deterioration, as well as neurological deficits in the most severe cases. In this paper, the authors discuss the management of cervical spine deformity after intradural tumor resection, with emphasis on the surgical strategies required to reestablish acceptable cervical spine alignment and to correct postoperative deformity. In general, after an oncological evaluation, assessing the alignment, extent, and flexibility of the deformity is mandatory before surgical planning. Rigid deformities require an osteotomy and, most often, combined approaches to restore cervical alignment. Flexible deformities can often be treated with a single approach, although a circumferential approach has its advantages.

Complication avoidance in the resection of spinal meningiomas

BACKGROUND

Surgical resection is considered the treatment of choice for spinal meningiomas and can be safe and effective; however, neurologic and surgical complications occur. This article reviews the factors that may predict susceptibility to this postoperative decline and addresses therapeutic choices, adjunctive therapies, and technologic applications that may help avoid complications.

METHODS

A literature search was conducted for articles related to spinal meningiomas addressing surgical treatment, adjuvant treatment, and technologic applications related to management and minimizing of complications.

RESULTS

There were 16 surgical series identified, comprising 1090 patients with median mortality of 1% (range, 0%-4%), nonneurologic surgical morbidity of 4% (range, 0%-24%), and permanent neurologic deterioration of 6% (range, 0%-21%). Common complications were cerebrospinal fluid leaks and fistulas, venous thromboembolic disease, myocardial infarction, and neurologic deterioration with either transient or permanent neurologic deficits. Predictive risk factors of neurologic decline included pathoanatomic features of lesion calcification, anterior dural attachment, infiltrative tumor, and tumoral adherence to the spinal cord and patient-specific factors of preoperative neurologic and advanced age.

CONCLUSIONS

Alongside surgery, selection of more direct approaches and use of adjuvant radiotherapy in patients with higher grade lesions and recurrent disease may lead to improved outcomes. New technologies, including microsurgical technique, intraoperative electrophysiologic monitoring, intraoperative ultrasound, and ultrasonic aspiration, may improve the safety and limit the complications of resection.