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Bai J, Li J, Lv J, Yang W, Wang Y, Feng Y, Lv Z. The new clinical classification of metastatic spinal malignancies serves as a vital reference for surgical management: a retrospective case-control study. BMC Musculoskelet Disord 2023; 24:956. [PMID: 38066483 PMCID: PMC10704627 DOI: 10.1186/s12891-023-07092-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 12/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND It is commonly accepted that surgical treatment is an essential component of the comprehensive management of metastatic spinal malignancies. However, up until now, the clinical classification of metastatic spinal malignancies has not been well-structured. METHODS After IRB approval, 86 patients with metastatic spinal malignancies were adopted. According to the vascular distribution, stability of vertebrae, and degree of nerve compression, metastatic spinal malignancies can be classified into five types. Tumors classified as type I typically appear in the vertebral body. Type II tumors are those that develop in the transverse processes, superior and inferior articular processes, and spinal pedicles. Type III denotes malignancies that are present in the spinous process and vertebral plate. Types IVa and IVb are included in type IV. Type IVa combines type I and type II, whereas type IVb combines type II and type III. Type V tumors are those of types I, II, and III that co-occur and spread in different directions into the spinal canal. 20 of included 86 patients who did not receive segmental arterial embolization were set as the non-embolization group. The embolization group included 24 patients who received segmental arterial embolization on both sides of the diseased vertebrae. 42 patients were included in the offending embolization group after receiving responsible arterial embolization. A surgical intervention was performed within 24 h following an embolization. Surgical intervention with the purpose of removing as much of the tumor as possible and providing an effective reconstruction of the spinal column. RESULTS In comparison with the non-embolization group and embolization group, the offending embolization group presented unique advantages in terms of bleeding volume (p<0.001), operation time (p<0.001), and local recurrence rate within 12 months (p=0.006). CONCLUSION By significantly reducing surgical trauma and local recurrence rate (12 months), responsible arterial vascular embolization procedures together with associated surgical protocols developed on the basis of the clinical classification of metastatic spinal malignancies, are worthy of clinical dissemination.
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Affiliation(s)
- Junjun Bai
- Department of Orthopaedics, Second Hospital of Shanxi Medical University, Taiyuan, 030001, China
| | - Jian Li
- Department of Orthopaedics, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Jia Lv
- Department of Orthopaedics, Second Hospital of Shanxi Medical University, Taiyuan, 030001, China
| | - Wangzhe Yang
- Department of Orthopaedics, Second Hospital of Shanxi Medical University, Taiyuan, 030001, China
| | - Yushan Wang
- Department of Orthopaedics, Second Hospital of Shanxi Medical University, Taiyuan, 030001, China
| | - Yi Feng
- Department of Orthopaedics, Second Hospital of Shanxi Medical University, Taiyuan, 030001, China.
| | - Zhi Lv
- Department of Orthopaedics, Second Hospital of Shanxi Medical University, Taiyuan, 030001, China.
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Shlobin NA, Raz E, Shapiro M, Clark JR, Hoffman SC, Shaibani A, Hurley MC, Ansari SA, Jahromi BS, Dahdaleh NS, Potts MB. Spinal neurovascular complications with anterior thoracolumbar spine surgery: a systematic review and review of thoracolumbar vascular anatomy. Neurosurg Focus 2020; 49:E9. [PMID: 32871559 DOI: 10.3171/2020.6.focus20373] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal cord infarction due to interruption of the spinal vascular supply during anterior thoracolumbar surgery is a rare but devastating complication. Here, the authors sought to summarize the data on this complication in terms of its incidence, risk factors, and operative considerations. They also sought to summarize the relevant spinal vascular anatomy. METHODS They performed a systematic literature review of the PubMed, Scopus, and Embase databases to identify reports of spinal cord vascular injury related to anterior thoracolumbar spine procedures as well as operative adjuncts and considerations related to management of the segmental artery ligation during such anterior procedures. Titles and abstracts were screened, and studies meeting inclusion criteria were reviewed in full. RESULTS Of 1200 articles identified on the initial screening, 16 met the inclusion criteria and consisted of 2 prospective cohort studies, 10 retrospective cohort studies, and 4 case reports. Four studies reported on the incidence of spinal cord ischemia with anterior thoracolumbar surgery, which ranged from 0% to 0.75%. Eight studies presented patient-level data for 13 cases of spinal cord ischemia after anterior thoracolumbar spine surgery. Proposed risk factors for vasculogenic spinal injury with anterior thoracolumbar surgery included hyperkyphosis, prior spinal deformity surgery, combined anterior-posterior procedures, left-sided approaches, operating on the concavity side of a scoliotic curve, and intra- or postoperative hypotension. In addition, eight studies analyzed operative considerations to reduce spinal cord ischemic complications in anterior thoracolumbar surgery, including intraoperative neuromonitoring and preoperative spinal angiography. CONCLUSIONS While spinal cord infarction related to anterior thoracolumbar surgery is rare, it warrants proper consideration in the pre-, intra-, and postoperative periods. The spine surgeon must be aware of the relevant risk factors as well as the pre- and intraoperative adjuncts that can minimize these risks. Most importantly, an understanding of the relevant spinal vascular anatomy is critical to minimizing the risks associated with anterior thoracolumbar spine surgery.
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Affiliation(s)
| | - Eytan Raz
- 3Departments of Radiology and Neurological Surgery, New York University Grossman School of Medicine, Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Maksim Shapiro
- 3Departments of Radiology and Neurological Surgery, New York University Grossman School of Medicine, Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | | | | | - Ali Shaibani
- Departments of1Neurological Surgery and.,2Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; and
| | - Michael C Hurley
- Departments of1Neurological Surgery and.,2Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; and
| | - Sameer A Ansari
- Departments of1Neurological Surgery and.,2Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; and
| | - Babak S Jahromi
- Departments of1Neurological Surgery and.,2Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; and
| | | | - Matthew B Potts
- Departments of1Neurological Surgery and.,2Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; and
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Tan T, Rutges J, Marion T, Fisher C, Tee J. The Safety Profile of Intentional or Iatrogenic Sacrifice of the Artery of Adamkiewciz and Its Vicinity's Spinal Segmental Arteries: A Systematic Review. Global Spine J 2020; 10:464-475. [PMID: 32435568 PMCID: PMC7222674 DOI: 10.1177/2192568219845652] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES There is paucity of consensus on whether (1) the artery of Adamkiewicz (AoA) and (2) the number of contiguous segmental spinal arteries (SSAs) that can be safely ligated without causing spinal cord ischemia. The objective of this review is to determine the risk of motor neurological deficits from iatrogenic sacrifice of the (1) AoA and (2) its vicinity's SSAs. METHODS Systematic review of the spine and vascular surgery was carried out in accordance to PRISMA guidelines. Outcomes in terms of risk of postoperative motor neurological deficit with occlusion of the AoA, bilateral contiguous SSAs, or unilateral contiguous SSAs were analyzed. RESULTS Ten articles, all retrospective case series, were included. Three studies (total N = 50) demonstrated a postoperative neurological deficit risk of 4.0% when the AoA is occluded. When 1 to 6 pairs of SSAs (without knowledge of AoA location) were ligated, the postoperative neurological deficit risk was 0.6%, as compared with 5.4% when more than 6 bilateral pairs of SSAs were ligated (relative risk [RR] = 0.105, 95% CI 0.013-0.841, P = .0337). For unilateral ligation of SSAs of two to nine levels, the risk of postoperative neurological deficit does not exceed 1.3%. CONCLUSION The current best evidence indicates that (1) occlusion of the AoA and (2) occlusion of up to 6 pairs of SSAs is associated with a low risk of postoperative neurological deficit. This limited number of low quality studies restrict the ability to draw definitive conclusions. Ligation of AoA and SSAs should only be undertaken when absolutely required to mitigate the small but devastating risk of paralysis.
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Affiliation(s)
- Terence Tan
- The Alfred Hospital, Melbourne, Victoria, Australia,National Trauma Research Institute Melbourne, Victoria, Australia
| | | | - Travis Marion
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Charles Fisher
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jin Tee
- The Alfred Hospital, Melbourne, Victoria, Australia,National Trauma Research Institute Melbourne, Victoria, Australia,Jin Tee, Department of Neurosurgery, Level 1, Old Baker Building, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.
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Patel SA, McDonald CL, Reid DBC, DiSilvestro KJ, Daniels AH, Rihn JA. Complications of Thoracolumbar Adult Spinal Deformity Surgery. JBJS Rev 2020; 8:e0214. [PMID: 32427777 DOI: 10.2106/jbjs.rvw.19.00214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Adult spinal deformity (ASD) is a challenging problem for spine surgeons given the high risk of complications, both medical and surgical.
Surgeons should have a high index of suspicion for medical complications, including cardiac, pulmonary, thromboembolic, genitourinary and gastrointestinal, renal, cognitive and psychiatric, and skin conditions, in the perioperative period and have a low threshold for involving specialists.
Surgical complications, including neurologic injuries, vascular injuries, proximal junctional kyphosis, durotomy, and pseudarthrosis and rod fracture, can be devastating for the patient and costly to the health-care system. Mortality rates have been reported to be between 1.0% and 3.5% following ASD surgery. With the increasing rate of ASD surgery, surgeons should properly counsel patients about these risks and have a high index of suspicion for complications in the perioperative period.
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Preoperative CT Angiography Informs Instrumentation in Anterior Spine Surgery for Idiopathic Scoliosis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:JAAOSGlobal-D-19-00123. [PMID: 32377614 PMCID: PMC7188266 DOI: 10.5435/jaaosglobal-d-19-00123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 01/30/2020] [Indexed: 11/18/2022]
Abstract
The objective of this study is to evaluate whether the artery of Adamkiewicz localization with preoperative CT angiography influences anterior spinal instrumentation. Methods Children with idiopathic scoliosis who underwent anterior instrumentation and with a preoperative CT angiography were evaluated retrospectively. Data included curve type, artery of Adamkiewicz level/laterality, surgical approach laterality, number of instrumented levels and segmental vessels ligated, intraoperative neuromonitoring changes, and postoperative neural complications. Results Thirty-nine girls and eight boys (mean age 12 years [6.7 to 16.8 years]) were analyzed. Instrumented curves indicate 28 thoracic, 14 thoracolumbar, and seven double major. The artery of Adamkiewicz: T6 (left-1), T8 (left-1), T9 (left-4/right-2), T10 (left-11/right-4), T11 (left-4/right-4), T12 (left-1/right-2), L1 (left-2/right-1), and L2 (left-3/right-2). Four had bilateral dominant segmentals, whereas in nine patients, none was identified. T10 (32%) and left side (57%) were most frequent. On average, 7.1 (4 to 11) segmentals were ligated per case (total 355). Dominant vessels were ipsilateral to/within instrumentation levels in 30%. Discussion In children with idiopathic scoliosis who underwent anterior instrumentation, the artery of Adamkiewicz was identified on the left in >50% and at T10 in 32%. In one-third of the patients, the artery was within intended surgical levels and resulted in instrumentation modification.
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Origins, Courses, and Distributions of the Lumbar Arterial Branches in Relation to the Spinal Nerves: An Anatomical Study. Spine (Phila Pa 1976) 2019; 44:E808-E814. [PMID: 30817735 DOI: 10.1097/brs.0000000000003000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Observational, anatomical, cadaveric study. OBJECTIVE To investigate the origins, courses, and distributions of the lumbar arterial branches in relation to the spinal nerves using Japanese cadavers. SUMMARY OF BACKGROUND DATA Lumbar arterial branches to the spinal nerves can be damaged during posterior lumbar column osteotomy, leading to neurological complications. Spinal cord ischemia via arterial ligation has been reported to be a major cause of neurological complications in anterior thoracolumbar surgery. Although neurological deficits have been considered the most common complications in lumbar pedicle subtraction osteotomy, there is little information on the possible neurological deficits due to spinal nerve ischemia caused by damage to the lumbar arterial branches. METHODS In total, 111 lumbar arteries (1 lumbar artery was damaged) from 14 embalmed cadavers (28 sides, L1-L4) were investigated. We examined the branching patterns and measured their diameter and length. Branches to the spinal nerves were classified as follows: radicular branch (Rb), spinal nerve branch (SNb), and plexus branch (Pxb). RESULTS The Rb was identified most frequently at L1 (21.4%) and included the main branch to supply the spinal cord. The SNb diverged from the dorsal branch (59.4%) and was mainly detected at L2 (85.7%) and L3 (85.2%). The Pxb originated from the lumbar artery (56.1%) and was found most frequently at L4 (75%). The Pxb had a larger diameter and a longer length at L3 and L4 than the SNb. Both the L3 and L4 Pxbs were the main blood suppliers to the femoral nerve. CONCLUSION The L3 and L4 Pxbs mainly supplied the femoral nerve. The Pxb is likely to exist in the medial side of the spinal nerve in the extraforaminal region. Thus, the Pxb should be recognized as a very important arterial branch during operation procedures. LEVEL OF EVIDENCE 5.
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The effect of resuscitative endovascular balloon occlusion of the aorta, partial aortic occlusion and aggressive blood transfusion on traumatic brain injury in a swine multiple injuries model. J Trauma Acute Care Surg 2017. [PMID: 28632582 DOI: 10.1097/ta.0000000000001518] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite clinical reports of poor outcomes, the degree to which resuscitative endovascular balloon occlusion of the aorta (REBOA) exacerbates traumatic brain injury (TBI) is not known. We hypothesized that combined effects of increased proximal mean arterial pressure (pMAP), carotid blood flow (Qcarotid), and intracranial pressure (ICP) from REBOA would lead to TBI progression compared with partial aortic occlusion (PAO) or no intervention. METHODS Twenty-one swine underwent a standardized TBI via computer Controlled cortical impact followed by 25% total blood volume rapid hemorrhage. After 30 minutes of hypotension, animals were randomized to 60 minutes of continued hypotension (Control), REBOA, or PAO. REBOA and PAO animals were then weaned from occlusion. All animals were resuscitated with shed blood via a rapid blood infuser. Physiologic parameters were recorded continuously and brain computed tomography obtained at specified intervals. RESULTS There were no differences in baseline physiology or during the initial 30 minutes of hypotension. During the 60-minute intervention period, REBOA resulted in higher maximal pMAP (REBOA, 105.3 ± 8.8; PAO, 92.7 ± 9.2; Control, 48.9 ± 7.7; p = 0.02) and higher Qcarotid (REBOA, 673.1 ± 57.9; PAO, 464.2 ± 53.0; Control, 170.3 ± 29.4; p < 0.01). Increases in ICP were greatest during blood resuscitation, with Control animals demonstrating the largest peak ICP (Control, 12.8 ± 1.2; REBOA, 5.1 ± 0.6; PAO, 9.4 ± 1.1; p < 0.01). There were no differences in the percentage of animals with hemorrhage progression on CT (Control, 14.3%; 95% confidence interval [CI], 3.6-57.9; REBOA, 28.6%; 95% CI, 3.7-71.0; and PAO, 28.6%; 95% CI, 3.7-71.0). CONCLUSION In an animal model of TBI and shock, REBOA increased Qcarotid and pMAP, but did not exacerbate TBI progression. PAO resulted in physiology closer to baseline with smaller increases in ICP and pMAP. Rapid blood resuscitation, not REBOA, resulted in the largest increase in ICP after intervention, which occurred in Control animals. Continued studies of the cerebral hemodynamics of aortic occlusion and blood transfusion are required to determine optimal resuscitation strategies for multi-injured patients.
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Zhao Z, Xie J, Wang Y, Bi N, Li T, Zhang Y, Shi Z. The effect from different numbers of segmental arteries ligation to the spinal cord in the clinical practice of posterior vertebral column resection correction. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:1937-1944. [PMID: 28364333 DOI: 10.1007/s00586-017-5067-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 03/01/2017] [Accepted: 03/24/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE In using posterior vertebral column resection (PVCR) to treat severe kyphoscoliosis, it is unavoidable to ligate and cut off several segmental arteries (SAs) of the spinal cord for exposure and hemostasis, but which would raise the neurological risks. The aim of this study is to explore the changes of intraoperative spinal cord monitoring (IOM) following ligating different numbers of SAs in PVCR. METHODS Twenty-one consecutive patients with severe kyphoscoliosis were included and treated by PVCR correction. In operation, according to ligate different numbers of SAs, the IOM changes were recorded, respectively. Examinations of the covariance between different numbers of SAs ligations and IOM changes were performed to reveal the effect to the spinal cord by SAs ligations. RESULTS In all the 21 cases, averaging 1.9 pairs of SAs were ligated. With the increased numbers of ligations, SSEP amplitudes and latencies were changed more obviously: from 1 to 3 pairs ligations, the mean decreased percentages of amplitudes were from 53.20 to 78.15%, the mean increased percentages of latency were from 1.23 to 1.40%, and the mean durations of decreased SSEP amplitudes were from 3.23 to 5.2 min; but without abnormal MEP changes. None occurred postoperative or delayed neurological deficit. Correlation analysis identified significant correlations between the number of SAs ligation and decreased percentage of SSEP amplitude (r = 0.945, P < 0.0001), and between the number of SAs being ligated and the duration of SSEP change (r = 0.945, P = 0.0002). CONCLUSIONS Following the increased number of SAs ligation, the amplitude of SSEP is decreased more obviously with a much longer duration of recovery and the risk to spinal cord will be increased greatly. In the PVCR correction on the basis of spinal shortening, the numbers of SAs ligations should be as less as possible for neurological safety.
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Affiliation(s)
- Zhi Zhao
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| | - Jingming Xie
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China.
| | - Yingsong Wang
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| | - Ni Bi
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| | - Tao Li
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| | - Ying Zhang
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| | - Zhiyue Shi
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
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Gao L, Wang L, Su B, Wang P, Ye J, Shen H. The vascular supply to the spinal cord and its relationship to anterior spine surgical approaches. Spine J 2013; 13:966-73. [PMID: 23608560 DOI: 10.1016/j.spinee.2013.03.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Revised: 02/22/2013] [Accepted: 03/07/2013] [Indexed: 02/09/2023]
Abstract
BACKGROUND CONTEXT The understanding of vascular supply to the spinal cord is important given that the evolution of surgical approaches to the spine may bring along the potential for more frequent complications, especially a rare but devastating complication: that of spinal cord ischemia or infarction. To maximally avoid this complication, the relationship between the spinal cord vascularity and the anterior spine surgical approach needs further study. PURPOSE To provide a theoretical basis that will allow the spinal surgeon to take appropriate steps to avoid spinal cord ischemia during anterior spinal surgery through anatomic means. STUDY DESIGN Spinal cord vascular casting assessment with cadaveric specimen. METHODS Twenty adult cadaveric specimens (11 men and 9 women) were obtained for the latex perfusion and vessel dissection. In addition, nine patients (seven men and two women) underwent superselective angiography of the spinal cord. The segmental arterial anastomosis and radiculomedullary vessels in the thoracolumbar region were shown and reviewed. RESULTS There were approximately 21 pairs of segmental arteries in the thoracolumbar region. Adjacent segmental arteries were networked with each other. The latex infusion specimens demonstrated 72 anterior radiculomedullary arteries and 177 posterior radiculomedullary arteries in all 20 samples. The anterior and posterior spinal arteries were also networked with each other at several levels. Superselective spinal angiography was consistent with the latex infusion specimens showing. CONCLUSIONS The variety of anatomy of spinal cord arterial networks is shown, and the relation between the blood supply of certain spinal levels and the potential ischemic complications during the anterior surgical approach is discussed. It is hopefully of benefit to surgeons, after fully understanding the anatomy of these spinal vascular supply structures, that there may be even greater avoidance of vascular compromise in these challenging operations.
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Affiliation(s)
- Liangbin Gao
- Institute of Orthopaedics and Traumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiangxi Rd, Guangdong 510120, People's Republic of China
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Arslan M, Comert A, Acar HI, Ozdemir M, Elhan A, Tekdemir I, Tubbs RS, Ugur HC. Surgical view of the lumbar arteries and their branches: an anatomical study. Neurosurgery 2011; 68:16-22; discussion 22. [PMID: 21304330 DOI: 10.1227/neu.0b013e318205e307] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although injury to the lumbar arteries during anterior spinal approaches is often encountered, there are few published articles regarding the relationship between the lumbar arteries and spinal cord ischemia. OBJECTIVE To examine the morphology of the lumbar arteries and to emphasize their clinical importance. METHODS With the aid of a surgical microscope, 80 lumbar arteries in 10 formalin-fixed male cadavers were studied. Measurements of these structures were made and relationships observed. RESULTS The spinal artery was usually the first branch of the lumbar artery. The greatest lumbar artery diameter was at L4 and had a mean diameter of 3.25 mm; the smallest diameter was identified at L2 and had a mean diameter of 2.05 mm. The largest spinal artery diameter was at L3 (mean, 0.56 mm) and the smallest at L1 (mean, 0.42 mm). The largest anastomotic artery diameter was at L4 (mean, 0.42 mm) and the smallest at L1 (mean, 0.32 mm). For the right and left sides, the mean greatest distance between the origin of the lumbar artery and the tendinous arch was at L4 (mean, 40.9 and 31.8 mm, respectively) and the least at L1 (mean, 31.8 and 22.5 mm, respectively). The mean of the greatest distance between the anastomotic branch and the base of the transverse process of the lumbar vertebrae was at L4 (mean, 4.41 and 4.35 mm, respectively) and the smallest at L1 (mean, 4.04 and 4.08 mm, respectively). CONCLUSION These anatomic findings of the lumbar segmental arteries would be useful for emphasizing their surgical importance.
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Affiliation(s)
- Mehmet Arslan
- Department of Neurosurgery, Yuzuncu Yıl University, Faculty of Medicine, Van, Turkey
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Hougan O, Zihai D, Ouyang Z. Vascular components of the posterior mediastinum: applications for video-assisted thoracoscopic surgery. Surg Radiol Anat 2010; 33:117-22. [PMID: 20697710 DOI: 10.1007/s00276-010-0710-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 07/24/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE This study introduced an anatomical basis for thoracoscope-assisted thoracolumbar spinal anterior approach. METHODS This work was carried out in terms of 29 corpse specimens anatomizing and the CT three-dimensional images of 25 normal adults observing. RESULTS The observation by the thoracolumbar spine side of the adult corpse specimens showed that the segmental arteries and veins constantly existed and ran in the central supersulcus of the corresponding vertebral body's side; the segmental artery had several branches; the zone between the upper and lower segmental arteries formed a relative non-vascular nerve safe zone, where the intervertebral space(disc) located. And the observation of the three-dimensional CT image indicated that the segmental arteries were visible and ran in the central supersulcus of the corresponding vertebral body's side, while the branches were invisible. Besides, the arrangement and distribution of the segmental arteries on the three-dimensional CT images and the result were basically consistent with that on corpse specimens. CONCLUSIONS The safe zone, with the intervertebral disc as the reference mark, could provide enough operation space for surgeries such as thoracoscope-assisted anterior interbody fusion and reduce damage to blood vessels as well as surgical complications.
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Affiliation(s)
- OuYang Hougan
- Anatomy Education and Research Institute, Southern Medical University, GuangZhou, China,
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Cheung KMC, Al Ghazi S. Approach-related complications of open versus thoracoscopic anterior exposures of the thoracic spine. J Orthop Surg (Hong Kong) 2008; 16:343-7. [PMID: 19126903 DOI: 10.1177/230949900801600315] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This article reviews the approach-related complications of open versus thoracoscopic anterior exposures of the thoracic spine and suggests possible ways to avoid them.
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Affiliation(s)
- K M C Cheung
- Department of Orthopaedics and Traumatology, University of Hong Kong, Hong Kong.
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Tsirikos AI, Howitt SP, McMaster MJ. Segmental vessel ligation in patients undergoing surgery for anterior spinal deformity. ACTA ACUST UNITED AC 2008; 90:474-9. [PMID: 18378922 DOI: 10.1302/0301-620x.90b4.20011] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Segmental vessel ligation during anterior spinal surgery has been associated with paraplegia. However, the incidence and risk factors for this devastating complication are debated. We reviewed 346 consecutive paediatric and adolescent patients ranging in age from three to 18 years who underwent surgery for anterior spinal deformity through a thoracic or thoracoabdominal approach, during which 2651 segmental vessels were ligated. There were 173 patients with idiopathic scoliosis, 80 with congenital scoliosis or kyphosis, 43 with neuromuscular and 31 with syndromic scoliosis, 12 with a scoliosis associated with intraspinal abnormalities, and seven with a kyphosis. There was only one neurological complication, which occurred in a patient with a 127 degrees congenital thoracic scoliosis due to a unilateral unsegmented bar with contralateral hemivertebrae at the same level associated with a thoracic diastematomyelia and tethered cord. This patient was operated upon early in the series, when intra-operative spinal cord monitoring was not available. Intra-operative spinal cord monitoring with the use of somatosensory evoked potentials alone or with motor evoked potentials was performed in 331 patients. This showed no evidence of signal change after ligation of the segmental vessels. In our experience, unilateral segmental vessel ligation carries no risk of neurological damage to the spinal cord unless performed in patients with complex congenital spinal deformities occurring primarily in the thoracic spine and associated with intraspinal anomalies at the same level, where the vascular supply to the cord may be abnormal.
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Affiliation(s)
- A I Tsirikos
- Scottish National Spine Deformity Centre, Royal Hospital for Sick Children, Sciennes Road, Edinburgh, UK.
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Bandi S, Davis BJ, Ahmed ENB. Segmental vessel sparing during convex growth arrest surgery--a modified technique. Spine J 2007; 7:349-52. [PMID: 17482120 DOI: 10.1016/j.spinee.2006.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Revised: 01/14/2006] [Accepted: 01/29/2006] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Further evidence of the importance of segmental vessel ligation in the development of neurological complications has been recently published. The more levels the ligation encompasses, the higher the risk of spinal cord damage. Therefore, caution should be taken when several segmental arteries are to be ligated in the clinical setting. PURPOSE To prevent ligation of segmental vessels during convex growth arrest surgery and thus decrease the risk of spinal cord ischemia and neurological injury. STUDY DESIGN A report of a modified technique of convex growth arrest surgery used in two consecutive patients in our unit. METHODS In two consecutive patients the segmental vessels were mobilized, elevated, and protected by using surgical slings. The rib graft was then slid beneath the elevated vessels into the prepared vertebral body channel and punched into place. The pleura then closed over the rib graft and spared vessels. RESULTS Three of the five segmental vessels in the first patient were spared. All five segmental vessels were spared in the second patient. No neurological complications occurred. CONCLUSION We report a straightforward technique, which obviates the need for segmental vessel ligation, and therefore decreases the risk of neurological injury in an already high-risk group.
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Affiliation(s)
- Surendra Bandi
- Hartshill Orthopaedic Unit, University Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK.
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Mirovsky Y, Hod-Feins R, Agar G, Anekstein Y. Avoiding neurologic complications following ligation of the segmental vessels during anterior instrumentation of the thoracolumbar spine. Spine (Phila Pa 1976) 2007; 32:275-80. [PMID: 17224826 DOI: 10.1097/01.brs.0000251967.94423.2a] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective evaluation of anterior instrumentation of the vertebral bodies in the thoracolumbar spine. OBJECTIVE To evaluate the possibility of preserving the segmental vessels following anterior instrumentation. SUMMARY OF BACKGROUND DATA Occlusion of the segmental vessels, routinely performed during anterior spine instrumentation, might cause neurologic injury secondary to cord ischemia. METHODS The medical data of 29 patients following anterior instrumentation of the vertebral bodies at the thoracolumbar spine were reviewed. All underwent surgery recently when we decided to preserve the segmental vessels whenever possible. We sought the reasons that enabled us to do so regarding age, gender, underlying pathology, surgical technique, operation duration, instrumentation type and size, and location in the vertebral body. RESULTS In only 7 patients, fused between T10 and L5, were we able to preserve the segmental vessels. All were instrumented with one 6.25-7-mm wide screw in each vertebral body connected by one rod, approximately half the screws above and half below the segmental vessels. In 22 patients, we were unable to preserve the vessels due to the need to insert 2 screws or a large threaded wide vertebral cage into each vertebra. CONCLUSIONS There is adequate space anteriorly in the vertebral body, above and below the segmental vessels, for the insertion of one screw, even with staples.
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Affiliation(s)
- Yigal Mirovsky
- Spine Unit, Assaf Harofeh Medical Center, Zerifin, Israel.
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Abstract
STUDY DESIGN Review article of medical complications related to adult spinal deformity surgery. OBJECTIVE To identify medical complications related to surgery for adult spinal deformity and suggest ways to minimize their occurrence and to avoid them. SUMMARY OF BACKGROUND DATA Medical complications are a major consideration in adult spinal deformity surgery. Few studies have been done to identify the medical complication rate in relation to these procedures. METHODS We review the literature pertaining to medical complications regarding spinal deformity surgery. RESULTS Urinary tract infections are the most frequently seen complication. Additionally, pulmonary complications are the most common life-threatening complication. Medical complications are a frequent occurrence with adult deformity spinal surgery. CONCLUSIONS Awareness of the presentation, treatment, and prevention of medical complications of deformity surgery may allow minimization of their occurrence and optimize treatment should they occur.
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Affiliation(s)
- Eli M Baron
- Institute for Spinal Disorders, Cedars Sinai Medical Center, Los Angeles, CA, USA
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