Navigation for Tubular Decompression of the L5 Nerve Root Ganglion after Cement Leakage via a Wiltse Approach

Osteoporotic vertebral fractures are a widespread problem in the elderly population. In experienced hands, treatment procedures are safe and can be done in a minimally invasive fashion. Nevertheless, in rare cases, severe complications may occur. We present a case report of cement leakage after vertebroplasty of L5 compressing the nerve root with neurological signs and radiculopathy. An 86-year-old female patient was introduced to our department with severe L5 nerve root radiculopathy and a foot flexion paresis after vertebroplasty of L5. Computed tomography (CT) of the lumbar spine revealed extraforaminal extravasation of cement around the nerve root causing significant compression. The patient underwent surgical revision using spinal navigation for skin incision, retractor placing, and verification of the cement extravasation. The cement plombage was removed, and the patient improved immediately. Sufficient decompression of the nerve root after cement leakage can be achieved using a spinal navigation setup in combination with intraoperative CT.

Clinical and radiological effect of medialized cortical bone trajectory for lumbar pedicle screw fixation in patients with degenerative lumbar spondylolisthesis: study protocol for a randomized controlled trial (mPACT)

Background

Spinal fusion with pedicle screw fixation represents the gold standard for lumbar degenerative disc disease with instability. Although it is an established technique, it is nevertheless an invasive intervention with high complication rates. Therefore, minimally invasive approaches have been developed, the medialized bilateral screw pedicel fixation (mPACT) being one of them. The study objective is to evaluate prospectively the efficacy and safety of the mPACT technique compared with the traditional trajectory for degenerative lumbar spondylolisthesis.

Methods/design

This is a single-center, randomized, controlled, parallel group, superiority trial. A total of 154 adult patients are allocated in a ratio of 1:1. Sample size and power calculation were performed to detect the minimal clinically important difference of 10%, with an expected standard deviation of 20% in the primary outcome parameter, the Oswestry Disability Index, with power of 80%, based on an assumed maximal dropout rate of 20%. Secondary outcome parameters include the EuroQoL 5-Dimension questionnaire, the Beck Depression Inventory, the painDETECT questionnaire and the “timed up and go” test. Furthermore, radiological and health economic outcomes will be evaluated. Follow up is performed until 5 years after surgery. Major inclusion criteria are lumbar degenerative spondylolisthesis with Meyerding grade I or II, which qualifies for decompression and fusion by medialised posterior screw placement with cortical trajectory (mPACT) or by a traditional trajectory for lumbar pedicle screw placement.

Discussion

This trial will contribute to the understanding of the short-term and long-term clinical and radiological postoperative course in patients with lumbar degenerative disc disease, in which the mPACT technique is used.

Trial registration

ISRCTN registry, ISRCTN99263604. Registered on 3 November 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2504-z) contains supplementary material, which is available to authorized users.

How I do it-optimizing radiofrequency ablation in spinal metastases using iCT and navigation

BACKGROUND

Exact positioning of the radiofrequency ablation (RFA) probe for tumor treatment under fluoroscopic guidance can be difficult because of potentially small inaccessible lesions and the radiation dose to the medical staff in RFA. In addition, vertebroplasty (VP) can be significantly high.

METHOD

Description and workflow of RFA in spinal metastasis using iCT (intraoperative computed tomography) and 3D-navigation-based probe placement followed by VP.

CONCLUSION

RFA and VP can be successfully combined with iCT-based navigation, which leads to a reduction of radiation to the staff and optimal probe positioning due to 3D navigation.

Thoracic corpectomy for neoplastic vertebral bodies using a navigated lateral extracavitary approach-a single-center consecutive case series: technique and analysis

Thoracic myelopathy is often caused by vertebral body fractures resulting from neoplastic conditions, traumatic events, or infectious diseases. One of the preferred procedures for treating it is the lateral extracavitary approach (LECA) with single-level or multilevel decompressive corpectomy and reconstruction. The aim of this retrospective study was to analyze the thoracic lateral extracavitary approach with corpectomy using vertebral body replacement systems (VBR-S) and dorsal reconstruction. Twenty-four patients with metastatic or primary lesions of thoracic vertebrae T2-T12 underwent spinal decompression and ventral column reconstruction with correction of spinal deformity via a LECA. One-level to four-level corpectomies were performed with additional navigated dorsal pedicle screw fixation at an average of two levels above and below the corpectomy lesion. None of the patients received preoperative spinal embolization, and the majority of the patients were admitted to radiotherapy postoperatively. Their mean age was 56 years (± 15), with a female-to-male sex ratio of 8 to 16. Patients with a minimum follow-up period of 16 months were included. The Karnofsky index, preoperative and postoperative numeric rating scale (NRS), and Frankel scale were measured. In addition, intraoperative loss of blood (LOB), units of packed red blood cell (PRBC) transfusions, the duration of the operation, and the hospitalization period were evaluated and correlated with preoperative and postoperative values. The majority of the patients were suffering from metastatic lesions and were treated with a 1 level corpectomy (median 1 level, range 1 to 4). The mean duration of surgery was 288 min (± 121) and the mean LOB was 1626 mL (± 1486 mL), with approximately two PRBC units per patient used. All patients were transferred to the intensive care unit (ICU) postoperatively, with a mean ICU stay of 2.0 days (± 1 day). The mean hospitalization period was 13 days (± 7 days). No implant-related failures or procedure-related deaths were observed. Significant differences were noted between the preoperative and postoperative Karnofsky index (74 vs. 84%) and NRS (4 vs. 2). One patient required revision surgery due to a superficial wound infection, and another needed revision surgery due to a dural tear. In another patient, an iatrogenic dural tear was repaired during the same surgical procedure and did not lead to postoperative complications. Four pleural effusions and one pneumothorax were observed, so that the overall complication rate was approximately 33%. Four of the patients died within 2 years of the operation due to progression of the primary disease. Lateral corpectomy and sagittal reconstruction of the thoracic spine using VBR-S conducted via a navigated LECA approach yields favorable results, despite the burden of neoplastic disease. These challenging procedures are accompanied by increased LOB and hospitalization periods, with moderate transfusion requirements. Surgery-related complications are low and local tumor control is satisfactory, despite the progression of the underlying neoplastic disease. However, optimal surgical therapy does not ensure long-term survival.Study design Retrospective analysis of thoracic corpectomiesLevel of evidence 4.

Asymmetric pedicle subtractionosteotomy (aPSO) guided by a 3D-printed model to correct a combined fixed sagittal and coronal imbalance

Surgical correction of fixed thoracolumbar deformity is usually achieved by estimating the preoperatively planned correction angles during surgery and is therefore prone to inaccuracy. This is particularly problematic in biplanar deformities. To overcome these difficulties, 3D model for planning, preparation, and simulation of an asymmetric pedicle subtraction osteotomy (aPSO) was printed and used to realign coronal and sagittal balance in case of rigid degenerative kyphoscoliosis. A 59-year-old woman presented with severe back pain and spinal claudication and was diagnosed with a rigid kyphoscoliosis with multilevel spinal stenosis. Spino-pelvic parameters were measured preoperatively (pelvic incidence 47° [PI], lumbar lordosis 18° [LL]; pelvic tilt 42° [PT], T1 pelvic angle 40° [TPA], Cobb angle 33°, sagittal vertical axis 10.5 cm [SVA]). To aid the complex deformity in the sagittal and coronal plane, a 1:1 3D model of the spine was printed according to the preoperative computed tomography (CT). With the use of a rebalancing software, the spine was prepared in vitro as a model for intraoperative realignment and the correction was preoperatively simulated. Surgery was accomplished according to the preoperative software-guided plan. Asymmetric pedicle subtraction osteotomy (aPSO) of L3 identical to the 3D model was performed. Additionally, a Smith-Peterson osteotomy of L4/5 with transforaminal lumbar interbody fusion (TLIF) and laminectomy of L2-S1 with pedicle screw instrumentation TH12-S1 was accomplished. Postoperative radiological parameters revealed good success (LL 40°, SVA 6 cm, PT 19°, TPA 22°, and a Cobb angle of 8°). Improvement of the Oswestry disability index (ODI) of 42 to 18, the visual analog scale (VAS) of 8 to 1, and walking distance 100 to 8000 m compared to preoperatively resulted at 24 months follow-up. The precise coronal and sagittal correction of a rigid degenerative kyphoscoliosis presents a major challenge. Asymmetric PSO is able to realign the thoracolumbar spine in both the coronal and sagittal planes. The creation of an in vitro 3D-printed model of a patient's spinal deformity in combination with a software to calculate the correction angles facilitates preoperative planning and implementation of aPSO.

Transoral vertebroplasty of the lateral mass of C1 using image guidance

BACKGROUND

Osteolytic lesions of the anterior aspects of C1 (lateral mass) are difficult to address in a minimally invasive fashion and are often treated by craniocervical instrumentation.

METHODS

We report the feasibility and technical method of transoral vertebroplasty of the lateral mass of the atlas using image guidance and describe the workflow of the procedure. To our knowledge, there has not yet been a technical description of a transoral vertebroplasty using image guidance.

RESULTS

Adequate positioning of the pedicle access needle using image guidance for addressing the lateral mass of C1 through a transoral, permuceous access can be achieved.

CONCLUSIONS

With the assistance of image guidance, it is safe and feasible to access the lateral mass of the atlas. This constitutes a minimally invasive and fast alternative for introducing the bone needle to C1 rather than using a fluoroscopic device alone.

Driving reaction time before and after surgery for disc herniation in patients with preoperative paresis

BACKGROUND CONTEXT

The effect of many types of surgeries on driving reaction time (DRT) has been reported. Although lumbar disc herniation is one of the most common spinal diseases, the effect on DRT has not been investigated.

PURPOSE

To assess the effect of left- and right-sided pareses caused by lumbar disc herniation on DRT before and after surgery.

STUDY DESIGN

Controlled prospective clinical trial.

PATIENT SAMPLE

Patients undergoing disc surgery.

OUTCOME MEASURES

Impact of paresis caused by lumbar disc herniation and disc surgery on DRT.

METHODS

Forty-two consecutive patients (mean age, 50.3 years) were tested for DRT 1 day before surgery, postoperatively before hospital discharge, and 5 weeks after surgery. Visual analogue scale (VAS) for back and leg pain as well as pain medication and patients' driving frequency were recorded.

RESULTS

Significant improvement of DRT after surgery was seen in patients with left- and right-sided pareses (p<.005). For the right-sided paresis group, the preoperative DRT was 761 ms (median, interquartile range [IQR]: 490), 711 ms (median, IQR: 210) immediately postoperatively, and 645 ms (median, IQR: 150) at follow-up (FU). For the left-sided paresis group, DRT was 651 ms (median, IQR: 270) preoperatively, 592 ms (median, IQR: 260) postoperatively, and 569 ms (median, IQR: 140) at FU. Significant differences between right- and left-sided pareses were identified preoperatively and at FU testing (p<.005). No correlation was found between VAS for leg or back pain and DRT. Historical control subjects had a DRT of 487 (median, IQR: 116), which differed significantly at all three test times (p<.001).

CONCLUSIONS

A significant reduction in DRT in patients with right- and left-sided pareses was found after surgery, indicating a positive effect of surgery. The improvement in DRT seen immediately postoperatively and the lack of a generally accepted threshold for DRT would suggest that for both patient samples, it is safe to continue driving after hospital discharge. However, patients should be informed accordingly.

Pedicle-Based Non-fusion Stabilization Devices: A Critical Review and Appraisal of Current Evidence

Over the last decades, spinal fusion has become one of the most important principles in surgical treatment of spinal pathologies. Despite the undoubted benefits of fusion surgery, there are several drawbacks associated with this technique, including adjacent segment degeneration and pseudoarthrosis. Based on biomechanical data, dynamic stabilization of the spine is intended to ameliorate adjacent level degeneration by stabilizing vertebral motion in defined planes and mimicking natural spine movements.In this paper, we review the literature and discuss past and present pedicle-based non-fusion dynamic stabilization devices. Although there is a paucity of high-quality prospective trials, studies have indicated both promising and disappointing results. In comparison to 360° fusion surgery, the perioperative risk seems to be lower. Other complications like screw loosening, however, have been reported with various systems, while a reduction of adjacent segment disease has not yet been demonstrated. The necessary degree of restabilization to achieve pain-free motion seems to vary greatly between patients and current systems are far from perfection. If these problems can be solved, dynamic stabilization may nevertheless be an important option of spinal surgery in the future.

Driving reaction time before and after surgery for lumbar disc herniation in patients with radiculopathy

PURPOSE

Although patients scheduled to undergo lumbar disc surgery often ask when they are allowed to drive a motor vehicle again, there are no published recommendations on this subject.

METHODS

We conducted a prospective study in 46 consecutive patients (mean age 48.9 years) to determine driving reaction time (DRT) before and after surgery in patients with lumbar disc herniation. Of the patients 23 had left-side radiculopathy and 23 right-side radiculopathy. Driving reaction time as well as back and leg pain were evaluated preoperatively, on the day of discharge from hospital and at the 5-week follow-up examination (FU). 31 healthy subjects were tested as controls.

RESULTS

Significant improvement in DRT was seen for both patient samples (p < 0.05). For patients with a right-side radiculopathy preoperative DRT was 664 ms (median, IQR: 241), which was reduced to 605 ms (median, IQR: 189) immediately postoperatively and to 593 ms (median, IQR: 115) at FU. For patients with a left-side radiculopathy DRT was 675 ms (median, IQR: 247) preoperatively, 638 ms (median, IQR: 242) postoperatively and 619 ms (median, IQR: 162) at FU. Pain was moderately correlated to DRT. Control subjects had a driving reaction time of 487 (median, IQR: 116), which differed significantly from patients at all three testing times (p < 0.001).

CONCLUSION

Our data indicate a positive effect of the surgery on driving ability. Therefore, we would suggest that for both patient samples it is safe to continue driving after hospital discharge. However, patients have to be informed about increased DRT caused by radiculopathy already before surgery.

Lung function after total intravenous anaesthesia or balanced anaesthesia with sevoflurane

BACKGROUND

We investigated the effects of total i.v. anaesthesia (TIVA) and balanced anaesthesia (BAL) with sevoflurane on postoperative lung function in patients undergoing surgery in the prone position.

METHODS

Sixty patients, aged 21-60 yr, undergoing elective lumbar disc surgery in the prone position were randomly allocated to undergo TIVA (propofol-remifentanil) or BAL (fentanyl-nitrous oxide-sevoflurane). Forced vital capacity (FVC), forced expiratory volume in 1 s, mid-expiratory flow (MEF 25-75), and peak expiratory flow were measured before and after general anaesthesia.

RESULTS

Both groups were similar with respect to patient characteristic data and preoperative lung function parameters. Irrespective of the type of anaesthesia administered, lung function parameters decreased after operation, with the decrease in FVC being greater after TIVA than after BAL with sevoflurane.

CONCLUSIONS

In patients emerging from general anaesthesia, postoperative reduction in FVC is greater after TIVA than after BAL with sevoflurane.

Effect of total intravenous anaesthesia and balanced anaesthesia on the frequency of coughing during emergence from the anaesthesia

BACKGROUND

The effects of total intravenous anaesthesia (TIVA) and balanced anaesthesia (BAL) on coughing during emergence from the general anaesthesia have not yet been compared.

METHODS

Fifty patients, aged 18-60 yr, undergoing elective lumbar disk surgery were randomly allocated to undergo TIVA (propofol-remifentanil) or BAL (fentanyl-nitrous oxide-sevoflurane). Extubation was performed in the knee-elbow position, documented on video, and subsequently evaluated by blinded examiners.

RESULTS

There was no difference between TIVA and BAL patients with respect to patient characteristics, proportion of smokers, surgical time, or time of emergence. The median number of coughs was significantly lower in the TIVA group (1, range 0-9) than in the BAL group (4, range 0-20, P = 0.007). Mean maximal heart rate and mean maximal arterial pressure measured during emergence were also significantly lower in the TIVA group (P = 0.009 and P = 0.006, respectively).

CONCLUSIONS

During emergence from anaesthesia in the knee-elbow position, TIVA is associated with significantly less coughing and reduced haemodynamic response when compared with BAL.

The N-end rule ubiquitin-conjugating enzyme, HR6B, is up-regulated by nerve growth factor and required for neurite outgrowth

Neurite outgrowth is accompanied by increased levels of high molecular weight ubiquitin conjugates and decreased levels of free ubiquitin. The search for enzymes responsible for increased utilization of ubiquitin revealed the ubiquitin-conjugating enzyme, HR6B (yeast UBC2/RAD6), increased on mRNA and protein level in rat pheochromocytoma (PC12) cells after treatment with nerve growth factor (NGF). HR6B participates in 'N-end rule degradation' that is implicated in the cleavage of proteins with destabilizing N-terminal residues (bulky hydrophobic or basic amino acids) and requires UBR1, the ubiquitin ligase binding N-end rule target proteins. Down-regulation of HR6B or UBR1 mRNA by small interfering RNA and treatment with Leu--Ala, a dipeptide-inhibitor of UBR1, inhibit neurite outgrowth of PC12 cells. Furthermore, axonal regeneration of adult sensory neurons, which express prominent nuclear and membrane-associated HR6 immunoreactivity, is reduced by Leu--Ala in vitro. Therefore, N-end rule ubiquitination is required for neuronal differentiation of PC12 cells and may be involved in axonal regeneration of peripheral neurons.

Basic fibroblast growth factor isoforms promote axonal elongation and branching of adult sensory neurons in vitro

Synthesis of the multifunctional cytokine basic fibroblast growth factor (FGF-2) is up-regulated after sciatic nerve lesion. In this study, the effects of low and high molecular weight FGF-2 isoforms on axonal elongation and branching of dissociated rat sensory neurons derived from adult lumbar dorsal root ganglia were investigated. These neurons express FGF receptor (FGFR) type I in the cytoplasmic/membrane compartment and in nuclear speckles. FGF-2 isoforms increase the number of axonal branches in cultures obtained from control rats, but do not promote axonal elongation. In response to a preconditioning lesion, i.e. transection of the sciatic nerve 1 week before culture, the axonal length of ipsilateral lumbar sensory neurons increases two-fold when compared with non-lesioned control rats, and this response is significantly enhanced by FGF-2 isoforms but not by nerve growth factor (NGF). Neurons dissociated from ganglia located contralaterally to the lesion exhibit a smaller increase in axon elongation (30%). The stimulating effects of FGF-2 isoforms on axon growth are fully blocked, and the enhanced regeneration of prelesioned neurons is reduced by the FGFR inhibitor SU5402 suggesting an involvement of endogenous FGF signaling in response to a lesion. The present data support a direct neurotrophic role of the 18 kD and 23 kD FGF-2 isoforms on adult axonal regeneration which may be of therapeutic value in the treatment of peripheral nerve lesions. Furthermore, evidence is provided for an enhanced regenerative capacity not only of preaxotomized neurons but also of homonymous non-axotomized neurons.

Expression of basic fibroblast growth factor isoforms in postmitotic sympathetic neurons: synthesis, intracellular localization and involvement in karyokinesis

Low and high molecular weight isoforms of the mitogen and multifunctional cytokine basic fibroblast growth factor (FGF-2) are up-regulated in neurons and glial cells in response to peripheral nerve lesion. While synthesis, regulation and functions of FGF-2 in non-neuronal cells are well established, the significance of neuronal FGF-2 remains to be investigated in the peripheral nervous system. Therefore, the expression, intracellular localization and possible effects of FGF-2 isoforms were analyzed in primary sympathetic neurons derived from the rat superior cervical ganglion. FGF-2 is detected in the nucleus and in perinuclear Golgi fields of early postnatal neurons which also express mRNA and protein for the FGF receptor type 1. Biolistic transfection of plasmids encoding FGF-2 isoforms fused to fluorescent proteins demonstrates nuclear targeting of 18 kDa FGF-2 and 23 kDa FGF-2 with prominent accumulation in the nucleolus of neurons. Neither overexpression nor treatment with FGF-2 isoforms promotes survival of sympathetic neurons deprived of nerve growth factor; however, neuronal transfection of the high molecular weight FGF-2 isoform in dissociated and slice cultures results in a bi- or multinuclear phenotype. The present study provides evidence for neuronal synthesis and targeting of FGF-2 to the nucleus and Golgi apparatus supporting a dual role of FGF-2 in the nucleus and secretory pathway of sympathetic neurons.