Anterior cervical epidural abscess treated by endoscopy-assisted minimally invasive microsurgery via posterior approach

Microendoscopic Tailored Spine Decompression as a Less-Invasive, Stability-Preserving Surgical Option to Instrumented Correction in Complex Spine Deformities: A Preliminary Multicenter Experience

OBJECTIVES

The aim of this study was to explore the effectiveness of a less-invasive posterior spine decompression in complex deformities. We studied the potential advantages of the microendoscopic approach, supplemented by the piezoelectric technique, to decompress both sides of the vertebral canal from a one-sided approach to preserve spine stability, ensuring adequate neural decompression.

METHODS

A series of 32 patients who underwent a tailored stability-preserving microendoscopic decompression for lumbar spine degenerative disease was retrospectively analyzed. The patients underwent selective bilateral decompression via a monolateral approach, without the skeletonization of the opposite side. For omo- and the contralateral decompression, we used a microscopic endoscopy-assisted approach, with the assistance of piezosurgery, to work safely near the exposed dura mater. Piezoelectric osteotomy is extremely effective in bone removal while sparing soft tissues.

RESULTS

In all patients, adequate decompression was achieved with a high rate of spine stability preservation. The approach was essential in minimizing the opening, therefore reducing the risk of spine instability. Piezoelectric osteotomy was useful to safely perform the undercutting of the base of the spinous process for better contralateral vision and decompression without damaging the exposed dura. In all patients, a various degree of neurologic improvement was observed, with no immediate spine decompensation.

CONCLUSIONS

In selected cases, the tailored microendoscopic monolateral approach for bilateral spine decompression with the assistance of piezosurgery is adequate and safe and shows excellent results in terms of spine decompression and stability preservation.

Costotransversectomy in the Surgical Treatment of Mediolateral Thoracic Disk Herniations: Long-Term Results and Recent Minimally Invasive Technical Adjuncts

Thoracic herniated disks are relatively rare. They account for approximately 2% of all intervertebral herniated disks in large series. Traditional surgery via laminectomy has frequently yielded disappointing results, although the recent literature reports that anterior calcified thoracic herniation was successfully treated with this approach. This issue has encouraged a search for alternatives, such as anterolateral, lateral, and posterolateral approaches to the thoracic spine. From January 2009 to December 2019, we selected 66 patients harboring a symptomatic median-paramedian herniated disk at the level of the thoracic spine, treated at the authors' institutions. The present experience would give further support to the use of costotrasversectomy, along with its "mini-invasive" modifications, as a suitable and safe approach for thoracic disk disease. Although we must admit that endoscopy is likely to become the gold standard of surgical method in the future and that the anterior approach with mini-toracotomy without rib removal will become popular, the future scenario could certainly reserve an important place for the approach we have used in the surgical management of this challenging spinal pathology, mainly because of the approach's versatility and short learning curve.

Case report: Anterior midline decompression of a cervical epidural abscess: Technical note and case series of seven patients

Background

A spinal epidural abscess (SEA) of the cervical spine is a relatively rare disease and is generally characterized by progressive neurological deterioration due to compression of the spinal cord. Up to 40% of cervical SEAs are located ventrally of the spinal cord. Urgent surgical intervention is warranted to decompress the spinal cord and collect material for cultures to guide antibiotic treatment. However, the optimal timing of the intervention is unclear, and the associated risk of spinal instability in the presence of an extensive infection is a significant clinical dilemma.

Methods

In this paper, we present a novel surgical technique to treat a cervical SEA by anterior decompression through a linear transvertebral midline approach. This technique has the advantage of effectively draining the ventrally located SEA and obtaining material for bacteria culture while maintaining spinal stability without additional instrumentation.

Results

This case study presents seven patients with cervical SEAs who were successfully treated with surgical decompression by this transvertebral linear midline technique and antibiotic treatment.

Conclusion

Anterior decompression through a linear transvertebral midline approach for a ventrally located cervical SEA is a safe and pragmatic surgical procedure to achieve spinal cord decompression and collect bacteria culture without destabilizing the cervical spine.

Spinal endoscopy: evidence, techniques, global trends, and future projections

The utilization of indirect visualization during procedures has been increasingly replacing traditional forms of direct visualization across many different surgical specialties. The adoption of arthroscopy, using small cameras placed inside joints, has transformed musculoskeletal care over the last several decades, allowing surgeons to provide the same anatomic solutions with less tissue dissection, resulting in lower requirements for inpatient care, reduced costs, and expedited recovery.  For a variety of reasons, spine surgery has lagged behind other specialties in the adoption of indirect visualization.  Nonetheless, patient demand for less invasive spine procedures and surgeon drive to provide these solutions and improve care quality has driven global adoption of spinal endoscopy.  There are numerous endoscopic platforms and techniques currently utilized, and these systems are rapidly evolving.  Additionally, the variance in technology and health system incentives across the globe has generated tremendous regional heterogeneity in the utilization of spinal endoscopic procedures.  We present a consolidated review, including the background, evidence, techniques, and trends in spinal endoscopy, so that clinicians can gain a deeper understanding of this rapidly evolving domain of spinal healthcare.

Anterior transcorporeal full-endoscopic drainage of a long-span ventral cervical epidural abscess: A novel surgical technique

BACKGROUND

A long-span ventral cervical epidural abscess is a rare and devastating condition. Typically, extensive procedures are chosen to deal with this condition and usually end up with limited cervical motion. Here, we describe a novel minimally invasive anterior full-endoscopic transcorporeal approach for drainage of large ventral cervical epidural abscess.

CASE DESCRIPTION

A 33-year-old man presented with seizures and acute weakness in all extremities persistent for 2 hours. His motor power of the upper and lower extremities was rapidly declined from grade III to grade 0 within 12 hours. Magnetic resonance imaging (MRI) showed a long-span ventral epidural abscess extending from C2 to T1, cervical spinal cord, and a retropharyngeal abscess. A typical anterior cervical approach to the prevertebral space was performed to evacuate pus from the retropharyngeal abscess, after which anterior transcorporeal full-endoscopic drainage of the large ventral cervical epidural abscess was successfully performed.

OUTCOME

The patient's motor power recovered to grade IV within 2 weeks post-operation. He had no neck pain or instability following the operation. Postoperative MRI and computed tomography revealed diminished epidural abscess.

CONCLUSIONS

For managing cases with a ventral-type cervical epidural abscess, anterior transcorporeal full-endoscopic drainage is an alternative minimally invasive method that yields sufficient debridement and drainage.

Full Endoscopic Removal of Cervical Spinal Epidural Abscess: Case Report and Technical Note

Spinal epidural abscess is a rare disease that is less likely to occur in the cervical region. When it occurs here, cervical spondylodiscitis can develop. Surgical treatment is recommended because of possible life-threatening septic and neurological complications. We present a case of an 81-year-old man who suffered from right side paralysis and was subsequently diagnosed with a C4 to C7 epidural abscess. We utilized full endoscopic surgery for patient management. The traditional surgical methods for treating cervical epidural abscesses may cause spinal instability. There has only been one previous case report on the endoscopic-assisted method. Minimal invasive surgery by a full endoscopic method can be done with a small incision and is associated with minimal blood loss and muscle damage. This is the first report on cervical epidural abscess drainage utilization a full endoscopic method. We recommend this alternative minimally invasive method to manage cervical epidural abscess.

Oblique corpectomy for treatment of cervical spine epidural abscesses: Report on four cases

BACKGROUND

Spinal epidural abscesses (SEAs) in cervical locations are particularly life-threatening. Currently, SEAs are widely treated with bony decompression, followed by internal stabilization in purulent osteomyelitis. However, recently, a growing number of studies have reported minimally invasive approaches without internal fixation.

PURPOSE

We describe four patients with cervical SEAs that were evacuated by oblique corpectomy (OC) without fusion.

METHODS

This study included two women and two men (aged 44-90) that received operations for removing ventral cervical SEAs. All patients presented with progressively increasing myelopathy, and 3 had severe comorbid conditions. In all cases, a multilevel OC without fusion was performed. The amount of bone resection was tailored to fit the needs of granulation removal, with an effort to retain as much of the vertebral bodies as possible. Then, pus was evacuated and debridement of granulation was performed, followed by rinsing and drainage.

RESULTS

The neurological status of 3 patients improved significantly after surgery. At the last follow-up examination, one showed full recovery, and in two a minor residual deficit persisted. During mean follow-up of 5.5 years, no internal stabilization was necessary. The oldest patient was tetraplegic, and had several concomitant diseases. That patient died from sudden cardiac arrest on the third postoperative day. Oblique corpectomy did not affect the anterior or posterior column. Additionally, it provided a broad view of the ventral aspect of the spinal canal.

CONCLUSIONS

Oblique corpectomy allows appropriate spinal cord decompression and granulation removal in the case of cervical spine epidural abscess, without sacrificing spinal stability.

Endoscopic Transnasal Odontoidectomy With Anterior C1 Arch Preservation and Anterior Vertebral Column Reconstruction in Patients With Irreducible Bulbomedullary Compression by Complex Craniovertebral Junction Abnormalities: Operative Nuance

BACKGROUND

During the past decades, the transoral transpharyngeal approach has been advocated as the standard route for the removal of odontoid causing an irreducible symptomatic neural compression. However, it may be potentially associated with a significant built-in morbidity because of the splitting of the soft palate for an adequate working angle, tracheostomy, and incision of the oral mucosa, causing exposure to a higher risk of infection by oral flora.

OBJECTIVE

To describe our experience with the minimally invasive pure endoscopic transnasal odontoidectomy in patients with bulbomedullary compression affected by complex anterior craniovertebral junction abnormalities.

METHODS

Five patients underwent a pure endoscopic neuronavigation-assisted transnasal odontoidectomy with anterior C1 arch preservation. Moreover, the anterior cervical spine column was reconstructed by filling the gap between the C1 arch and the residual C2 body with autologous/artificial bone. Neither tracheostomy nor enteral tube feeding were needed in any case.

RESULTS

A postoperative neurological improvement was observed in all patients. Postoperative imaging confirmed a satisfactory spinal cord decompression with cervical anterior column arthrodesis, and without evidence of instability at follow-up, so far.

CONCLUSION

The endoscopic transnasal approach seems to represent an efficient and safe alternative to the transoral route for the resection of odontoid process causing irreducible bulbomedullary compression. It provides a straightforward and minimally invasive natural surgical corridor to the anterior craniocervical junction, allowing a better working angle with preservation of spine biomechanics, while minimizing potential comorbidities.

Endoscopic endonasal approach to the craniocervical junction: the importance of anterior C1 arch preservation or its reconstruction

We report our experience with the endoscopic endonasal approaches (EEA) for different craniocervical junction (CCJ) disorders to analyse outcomes and demonstrate the importance and feasibility of anterior C1 arch preservation or its reconstruction. Between January 2009 and December 2013, 10 patients underwent an endoscopic endonasal approach for different CCJ pathologies at our Institution. In 8 patients we were able to preserve the anterior C1 arch, while in 2 post-traumatic cases we reconstructed it. The CCJ disorders included 4 cases of irreducible anterior bulbo-medullary compression secondary to rheumatoid arthritis or CCJ anomalies, 4 cases of inveterate fractures of C1 and/or C2 and 2 tumours. Pre- and postoperative neuroradiological evaluation was always obtained by magnetic resonance imaging (MRI), computed tomographic (CT) scanning and dynamic cranio-vertebral junction x-ray. Pre- and postoperative neurologic disability assessment was obtained by Ranawat classification for patients with rheumatoid arthritis and by Nurick classification for the others. At a mean follow-up of 31 months (range: 14-73 months), an improvement of at least one Ranawat or Nurick classification level was observed in 6 patients, while in another 4 patients neurological conditions were stable. Radiological follow-up revealed an adequate bulbo-medullary decompression in all patients and a regular bone fusion in cases of C1 and/or C2 fractures. In all patients spinal stability was preserved and none required subsequent posterior fixation. The endoscopic endonasal surgery provided adequate exposure and a low morbidity minimally invasive approach to the antero-medial located lesions of the CCJ, resulting in a safe, effective and well-tolerated procedure. This approach allowed preservation of the anterior C1 arch and the avoidance of a posterior fixation in all patients of this series, thus preserving the rotational movement at C0-C2 segment and reducing the risk of a subaxial instability development.

Minimally Invasive Supraorbital Key-hole Approach for the Treatment of Anterior Cranial Fossa Meningiomas

The most important target of minimally invasive surgery is to obtain the best therapeutic effect with the least iatrogenic injury. In this background, a pivotal role in contemporary neurosurgery is played by the supraorbital key-hole approach proposed by Perneczky for anterior cranial base surgery. In this article, it is presented as a possible valid alternative to the traditional craniotomies in anterior cranial fossa meningiomas removal. From January 2008 to January 2012 at our department 56 patients underwent anterior cranial base meningiomas removal. Thirty-three patients were submitted to traditional approaches while 23 to supraorbital key-hole technique. A clinical and neuroradiological pre- and postoperative evaluation were performed, with attention to eventual complications, length of surgical procedure, and hospitalization. Compared to traditional approaches the supraorbital key-hole approach was associated neither to a greater range of postoperative complications nor to a longer surgical procedure and hospitalization while permitting the same lesion control. With this technique, minimization of brain exposition and manipulation with reduction of unwanted iatrogenic injuries, neurovascular structures preservation, and a better aesthetic result are possible. The supraorbital key-hole approach according to Perneckzy could represent a valid alternative to traditional approaches in anterior cranial base meningiomas surgery.

The technological development of minimally invasive spine surgery

Minimally invasive spine surgery has its roots in the mid-twentieth century with a few surgeons and a few techniques, but it has now developed into a large field of progressive spinal surgery. A wide range of techniques are now called "minimally invasive," and case reports are submitted constantly with new "minimally invasive" approaches to spinal pathology. As minimally invasive spine surgery has become more mainstream over the past ten years, in this paper we discuss its history and development.

Cervical spine epidural abscess: experience with microsurgical treatment in eight cases

OBJECT

The authors report a series of eight consecutive cases in which epidural abscesses in the cervical spine were treated by microsurgery without arthrodesis, including two cases of concomitant pyogenic and tubercular infection.

METHODS

The authors used a minimally invasive surgical approach consisting of single-level anterior microsurgical discectomy and drainage of the epidural abscess via a silicone catheter, and then initiated antibiotic therapy. At follow-up examination (mean duration 39 months), six patients exhibited complete recovery and two suffered from minor residual deficits. In all cases, spontaneous vertebral fusion occurred. Sagittal alignment was maintained in seven patients, and in one there was slight asymptomatic kyphosis. In two patients, tubercular and pyogenic infections were found. Prior intervention for dental infection was recorded in four cases.

CONCLUSIONS

In the absence of preoperative spinal instability, microsurgical drainage of the abscess followed by specific antibiotic therapy resulted in spinal cord decompression and neurological recovery, thereby facilitating spontaneous fusion and vertebral stability. The presence of combined tubercular and pyogenic infections of the cervical spine should be considered, especially in patients whose immune systems are depressed.

[Spinal epidural abscess without spondylodiscitis. Description of four cases]

We performed a retrospective study about patients diagnosed of spinal epidural abscess without concurrent spondylodiscitis, collected in the last five years in our hospital. We describe four patients, all of them males, with ages ranged from 59 to 67 years old. All patients presented fever, elevated phase reactants and spinal pain, with cord compression in three of them. Two patients had risk factors: diabetes mellitus and non-Hodgkin lymphoma. S. aureus was isolated in three patients, and S. agalactiae in the other one. The posterior epidural space was the most frequently affected, with variable location along the spinal cord. Three patients required surgical operation, and the other one was treated only with antibiotics. All patients demonstrated a complete clinical, analytical and radiological resolution.

CT guided aspiration of a cervical spinal epidural abscess

The management of spinal epidural abscess has changed over the last few years. Originally treatment was thought to be urgent surgical evacuation. In the more recent literature less invasive techniques have been suggested. We present a case, where a cervical epidural abscess at the C2 level was treated with CT guided aspiration and antibiotic therapy. This has not been previously reported.

Spinal epidural abscess in adults

Spinal epidural abscess is a potentially life-threatening disease that can cause paralysis by the accumulation of purulent material in the epidural space. Although modern diagnostic and management methods have improved the prognosis, morbidity and mortality remain significant. Outcome usually is determined by the rapidity of the diagnosis and initiation of appropriate treatment. A high index of suspicion is warranted when a patient presents with spinal pain or a neurologic deficit in conjunction with fever or an elevated erythrocyte sedimentation rate. Gadolinium-enhanced magnetic resonance imaging should be done in suspected cases to localize and define the abscess. For spinal epidural abscess associated with neurologic compromise, the treatment of choice is emergent surgical decompression and débridement (with or without spinal stabilization), followed by long-term antimicrobial therapy. In the absence of a neurologic deficit, medical management is an alternative to surgery when the risk of neurologic complications is low based on the location and morphology of the abscess, immune status of the patient, and virulence of the organism.

Diagnosis of spinal disease with ultrafine flexible fiberscopes in patients with chronic pain

STUDY DESIGN

Spinal epidural and subarachnoid spaces were observed with the newly developed fine flexible fiberscopes in 55 patients with chronic pain.

OBJECTIVES

To evaluate the fiberscopes as diagnostic tools for spinal canal disease.

SUMMARY OF BACKGROUND DATA

Fine flexible fiberscopes make it possible to visualize the entire length of the spinal subarachnoid space without major complications, and they may be of value for the diagnosis of certain spinal canal diseases.

METHODS

The epidural and subarachnoid spaces were accessed by fine flexible fiberscopes (Purely Fine [PF] types) in the initial 45 patients and by those equipped with a tip-steering function and a working channel (Medical Science [MS] types) in the later 10 patients, respectively. The procedures were based on those of continuous epidural or subarachnoid block.

RESULTS

Normal and abnormal subarachnoid spaces were clearly observed. When the MS types were used, the intended sites of the spinal structures could be more easily approached. In 12 patients, new diagnoses were made (chronic arachnoiditis 9, subarachnoid cyst 2, old subdural hematoma 1) that could not be found by magnetic resonance imaging or computed tomography. Additionally, chronic arachnoiditis was found in 2 patients with spinal trauma. Pathologic changes were confirmed by fiberscopic examination in 16 patients (arachnoiditis 11, spinal trauma 2, arteriovenous malformation 2, subarachnoid cyst 1). No pathologic changes could be detected in 27 patients with spinal canal stenosis, disc herniation, reflex sympathetic dystrophy, or posttraumatic pain syndrome. There were no significant differences in incidence of new diagnoses between the PF and MS types of fiberscopes. There were no major complications. There were 2 cases of light fever in the initial 10 patients and 7 cases of headache in the initial 14 patients. Only 4 cases of headache were observed in the subsequent 41 patients, in whom 20 mL of saline was injected into the epidural space.

CONCLUSION

These fine flexible fiberscopes may provide new diagnostic and interventional tools for spinal canal diseases, provided skilled techniques are applied.