BackgroundMinimally invasive surgery is a promising new tool in treatment of spinal disorders. Mi... more BackgroundMinimally invasive surgery is a promising new tool in treatment of spinal disorders. Minimally invasive laminectomy provides an efficacious means of achieving lumbar decompression. Present single-tube approaches may entail significant facet injury. We explore the feasibility of a dual-tube minimally invasive laminectomy approach in a cadaver model.
Clinical and radiographic outcomes using local bone shavings as autograft in minimally invasive transforaminal lumbar interbody fusion
World neurosurgery, 2012
Transforaminal lumbar interbody fusion (TLIF) augmented with pedicle screw instrumentation has be... more Transforaminal lumbar interbody fusion (TLIF) augmented with pedicle screw instrumentation has become a favored surgical treatment for management of lumbar degenerative disease and spondylolisthesis. Iliac crest bone graft has traditionally been used for interbody arthrodesis. Many substitutes for autograft have been suggested to reduce iliac crest graft morbidity. The present study was aimed to determine fusion rate and clinical outcome with local bone autograft drill shavings harvested during minimally invasive (MI) TLIF. A retrospective study of 40 patients who underwent MI-TLIF using a cage filled with local bone shavings and pedicle screw fixation with a minimum 1-year imaging follow-up was performed. Bone shavings were collected during surgery by use of a simple specimen trap device. Fusion was assessed with computed tomography scan with sagittal and coronal reconstructions. Clinical assessment was performed using patient-filled preoperative and postoperative Oswestry Disabili...
Idiopathic spinal cord herniation is a rare but potentially treatable cause of thoracic myelopath... more Idiopathic spinal cord herniation is a rare but potentially treatable cause of thoracic myelopathy. The rarity and variable clinical presentation often results in missed diagnosis and delay in treatment. Posterior midline approach with laminectomy has been the most common approach performed for spinal cord herniation in cases described in the literature. A posterior approach is limited by the danger of retracting the spinal cord and difficulty visualizing the dural defect. Considering the anterior location of the dural defect, a posterolateral allows for a more ventral view without spinal cord manipulation. We report a rare case of idiopathic spinal cord herniation which was managed by unilateral paramedian transpedicular approach with an excellent clinical outcome.
Laminoplasty is well described in the Japanese literature as a surgical option for treating ossif... more Laminoplasty is well described in the Japanese literature as a surgical option for treating ossification of the posterior longitudinal ligament (OPLL). The open door technique has gained increasing popularity in the United States and Europe to treat not only OPLL but also cervical stenotic myelopathy. An obstacle to its widespread use is the lack of a suitable fixation plate to adequately secure the fractured lamina to the lateral mass. Our objective was to demonstrate the advantages of a novel miniplate (Ti-Mesh LP system; Medtronic Sofamor Danek, Memphis, TN, USA) that is ideally suited for fixing the lamina to the lateral mass. We used the Ti-Mesh LP miniplate system to perform laminoplasties on five patients, all male, with a mean preoperative Nurick score of 2.8. Four patients had congenital cervical stenosis with myelopathy and one had OPLL. Open door laminoplasties were performed on all patients. The plates were implanted with a claw positioned on the trapdoor lamina and a flat plate on the lateral mass. The system was implanted successfully in all patients. The mean number of levels fixated was 4.4. There were no intraoperative or postoperative complications after >5 months follow-up. The new Ti-Mesh LP cranial miniplate and screw system facilitates posterior cervical laminoplasty procedures by eliminating the need to contour cranial miniplates for use in the cervical spine. Its unique claw construct and angled design are ideal for holding a trapdoor laminoplasty in the open position. We have used this system successfully and without complications to perform decompressive posterior cervical laminoplasties in five patients.
The study is a retrospective review of 58 patients who underwent occipitocervical fusion between ... more The study is a retrospective review of 58 patients who underwent occipitocervical fusion between 1997 and 2001. Our objective is to study the clinical results after occipitocervical fixation with long-term follow-up and assess factors contributing to clinical success. Data from patient charts, operative notes, physician office notes, and imaging studies were incorporated in the study. Myelopathy was assessed using a Nurick scale for preoperative and postoperative evaluation. Fusion was assessed using cervical plane films with flexion and extension views. Mean follow-up was 36 months, with all patients having a greater than 1-year follow-up. The most common pathology was congenital cranial settling (41%) followed by trauma (22%) and rheumatoid arthritis (17%). Myelopathy was the most common presentation (62%) followed by pain (28%). A successful fusion occurred in 48 out of 51 patients (94%). Symptoms improved in 86% of patients, whereas 35% improved 1 Nurick grade. Complications occurred in 30% of patients. The cervical wound infection rate was 5%. The rate of adjacent level degeneration was 7%. The mortality rate was 1.7%. Occipitocervical instrumentation allows for very high fusion rates without the need for halo vest immobilization. All patients with successful fixation have pain resolution. Myelopathy improves in most patients, whereas one-third of patients demonstrate dramatic improvement.
Postlaminectomy cervical kyphosis is an important consideration when performing surgery. Identify... more Postlaminectomy cervical kyphosis is an important consideration when performing surgery. Identifying factors predisposing to postoperative deformity is essential. The goal is to prevent postlaminectomy cervical kyphosis while exposing the patient to minimal additional morbidity. When postlaminectomy kyphosis does occur, surgical correction is often required and performed via an anterior, posterior, or combined approach. The authors discuss the indications for surgical approaches as well as clinical results.
Primary tumors of the sacrum are rare. In adults, the most common sacral tumors are metastases. T... more Primary tumors of the sacrum are rare. In adults, the most common sacral tumors are metastases. The most common primary sacral tumor is a chordoma. Chordomas along as well as tumors such as chondrosarcomas, osteosarcomas, myxopapillary ependymomas, myelomas, and Ewing sarcomas are considered malignant. In this article the authors focus on benign sacral tumors.
such a high initial PTH level that the assay saturated and it appeared that the results remained ... more such a high initial PTH level that the assay saturated and it appeared that the results remained static. In 140 operations HPT was identi®ed correctly and excised with a concomitant drop in PTH. Conclusion: The intraoperative PTH levels vary markedly in either direction between induction of anaesthesia and the end of dissection. After excision of hyperparathyroid tissue the PTH level normally falls briskly from the postdissection level. The number of patients with a potentially unfavourable outcome is small; these data suggest that rapid intrapoperative PTH assay would have missed further HPT in ten of 14 instances had the surgical strategy been solely dependent on PTH levels. The routine use of intraoperative PTH assay in surgery for primary HPT is therefore questioned.
Although recent advances in the treatment of carotid artery stenosis have included endovascular a... more Although recent advances in the treatment of carotid artery stenosis have included endovascular angioplasty and stent placement, carotid endarterectomy is still the approach of choice for carotid disease and is one of the most commonly performed operations today. Minimally invasive surgeries involving the neck have recently been performed for thyroid and parathyroid diseases. The purpose of this study was to evaluate the feasibility of an endoscopic approach for carotid artery surgery in a large animal model. Eight 25- to 30-kg pigs were used. Animals underwent endoscopic carotid dissection with carbon dioxide insufflation at 10 mmHg. A 1.5- to 2-cm arteriotomy was made in the common carotid artery. Four animals underwent direct arteriotomy closure, and four animals underwent synthetic patch graft placement using intracorporeal suturing techniques. Open examination of the operative site and carotid angiograms were performed at the end of the procedure. Operative time was recorded in the last four cases. All animals tolerated the procedure well and carotid artery repair was successfully performed in all cases using a four-trocar technique. The entire extent of the cervical common and internal carotid arteries was exposed up to the cranial base. Cranial nerves and cervical structures were clearly visualized and preserved. No bleeding occurred at the end of the procedure. Carotid angiograms confirmed patent, nonstenotic vessels in all cases. Endoscopic approach for carotid surgery is technically feasible in the porcine model. This approach may represent a valuable option for surgery of the carotid artery since it offers the advantages of minimally invasive techniques while maintaining the benefits of surgical arterial repair.
Minimally invasive thoracolumbar costotransversectomy and corpectomy via a dual-tube technique: evaluation in a cadaver model
Minimally invasive surgery (MIS) is a promising new tool in the treatment of a variety of spinal ... more Minimally invasive surgery (MIS) is a promising new tool in the treatment of a variety of spinal disorders. MIS laminectomy techniques provide an effective means of achieving lumbar decompression. MIS corpectomy techniques have not been described. If feasible, such a technique would be optimal in the treatment of spinal metastatic disease, where traditional open techniques can result in a significant burden to a compromised patient. In this study, we explored the feasibility of a dual-tube minimally invasive thoracic corpectomy approach in a cadaver model. A minimally invasive thoracolumbar costotransversectomy and corpectomy were perfumed in eight adult cadavers. A dual-tube technique was used to perform a costotransversectomy followed by a corpectomy on one side, and through the opposite tube a transpedicular approach on the contralateral side. Pre- and postoperative CT scans of all cadavers were obtained to measure the cross-sectional area of the vertebral bodies in each specimen via a CT workstation. Reconstruction of the anterior column was attempted in some cadavers using polymethylmethacrylate (PMMA) cement. A successful costotransversectomy and corpectomy were completed in each cadaver. A percutaneous delivery system was successful in allowing an anterior column reconstruction using PMMA as a strut graft in selected cadavers. We demonstrated that a dual-tube MIS approach to thoracic corpectomy is technically feasible. Additionally, spinal stabilization can be achieved via percutaneous PMMA administration. This approach may provide a minimally invasive option in the treatment of select spinal metastases.
Cervicothoracic kyphotic deformity may inhibit horizontal gaze function, impede activities of dai... more Cervicothoracic kyphotic deformity may inhibit horizontal gaze function, impede activities of daily living, and induce disabling pain. Eventually, some patients develop a chin-on-chest deformity that limits their ability to eat and drink; in the end stage, a few patients also may have difficulty breathing. Progressive kyphosis can stretch the spinal cord leading to myelopathy with progressive lower extremity spasticity and weakness. Indications for surgery include myelopathy, pain, dysphagia or dyspnea owing to kyphosis, and difficulty maintaining a functional horizontal gaze. Patients with unstable cervicothoracic fractures also require surgical fixation. For these patients, surgical goals include deformity correction with restoration of an acceptable forward gaze, re-establishment of sagittal balance, decompression of the spinal cord (if myelopathic), and stable fixation.
BackgroundMinimally invasive surgery is a promising new tool in treatment of spinal disorders. Mi... more BackgroundMinimally invasive surgery is a promising new tool in treatment of spinal disorders. Minimally invasive laminectomy provides an efficacious means of achieving lumbar decompression. Present single-tube approaches may entail significant facet injury. We explore the feasibility of a dual-tube minimally invasive laminectomy approach in a cadaver model.
Clinical and radiographic outcomes using local bone shavings as autograft in minimally invasive transforaminal lumbar interbody fusion
World neurosurgery, 2012
Transforaminal lumbar interbody fusion (TLIF) augmented with pedicle screw instrumentation has be... more Transforaminal lumbar interbody fusion (TLIF) augmented with pedicle screw instrumentation has become a favored surgical treatment for management of lumbar degenerative disease and spondylolisthesis. Iliac crest bone graft has traditionally been used for interbody arthrodesis. Many substitutes for autograft have been suggested to reduce iliac crest graft morbidity. The present study was aimed to determine fusion rate and clinical outcome with local bone autograft drill shavings harvested during minimally invasive (MI) TLIF. A retrospective study of 40 patients who underwent MI-TLIF using a cage filled with local bone shavings and pedicle screw fixation with a minimum 1-year imaging follow-up was performed. Bone shavings were collected during surgery by use of a simple specimen trap device. Fusion was assessed with computed tomography scan with sagittal and coronal reconstructions. Clinical assessment was performed using patient-filled preoperative and postoperative Oswestry Disabili...
Idiopathic spinal cord herniation is a rare but potentially treatable cause of thoracic myelopath... more Idiopathic spinal cord herniation is a rare but potentially treatable cause of thoracic myelopathy. The rarity and variable clinical presentation often results in missed diagnosis and delay in treatment. Posterior midline approach with laminectomy has been the most common approach performed for spinal cord herniation in cases described in the literature. A posterior approach is limited by the danger of retracting the spinal cord and difficulty visualizing the dural defect. Considering the anterior location of the dural defect, a posterolateral allows for a more ventral view without spinal cord manipulation. We report a rare case of idiopathic spinal cord herniation which was managed by unilateral paramedian transpedicular approach with an excellent clinical outcome.
Laminoplasty is well described in the Japanese literature as a surgical option for treating ossif... more Laminoplasty is well described in the Japanese literature as a surgical option for treating ossification of the posterior longitudinal ligament (OPLL). The open door technique has gained increasing popularity in the United States and Europe to treat not only OPLL but also cervical stenotic myelopathy. An obstacle to its widespread use is the lack of a suitable fixation plate to adequately secure the fractured lamina to the lateral mass. Our objective was to demonstrate the advantages of a novel miniplate (Ti-Mesh LP system; Medtronic Sofamor Danek, Memphis, TN, USA) that is ideally suited for fixing the lamina to the lateral mass. We used the Ti-Mesh LP miniplate system to perform laminoplasties on five patients, all male, with a mean preoperative Nurick score of 2.8. Four patients had congenital cervical stenosis with myelopathy and one had OPLL. Open door laminoplasties were performed on all patients. The plates were implanted with a claw positioned on the trapdoor lamina and a flat plate on the lateral mass. The system was implanted successfully in all patients. The mean number of levels fixated was 4.4. There were no intraoperative or postoperative complications after >5 months follow-up. The new Ti-Mesh LP cranial miniplate and screw system facilitates posterior cervical laminoplasty procedures by eliminating the need to contour cranial miniplates for use in the cervical spine. Its unique claw construct and angled design are ideal for holding a trapdoor laminoplasty in the open position. We have used this system successfully and without complications to perform decompressive posterior cervical laminoplasties in five patients.
The study is a retrospective review of 58 patients who underwent occipitocervical fusion between ... more The study is a retrospective review of 58 patients who underwent occipitocervical fusion between 1997 and 2001. Our objective is to study the clinical results after occipitocervical fixation with long-term follow-up and assess factors contributing to clinical success. Data from patient charts, operative notes, physician office notes, and imaging studies were incorporated in the study. Myelopathy was assessed using a Nurick scale for preoperative and postoperative evaluation. Fusion was assessed using cervical plane films with flexion and extension views. Mean follow-up was 36 months, with all patients having a greater than 1-year follow-up. The most common pathology was congenital cranial settling (41%) followed by trauma (22%) and rheumatoid arthritis (17%). Myelopathy was the most common presentation (62%) followed by pain (28%). A successful fusion occurred in 48 out of 51 patients (94%). Symptoms improved in 86% of patients, whereas 35% improved 1 Nurick grade. Complications occurred in 30% of patients. The cervical wound infection rate was 5%. The rate of adjacent level degeneration was 7%. The mortality rate was 1.7%. Occipitocervical instrumentation allows for very high fusion rates without the need for halo vest immobilization. All patients with successful fixation have pain resolution. Myelopathy improves in most patients, whereas one-third of patients demonstrate dramatic improvement.
Postlaminectomy cervical kyphosis is an important consideration when performing surgery. Identify... more Postlaminectomy cervical kyphosis is an important consideration when performing surgery. Identifying factors predisposing to postoperative deformity is essential. The goal is to prevent postlaminectomy cervical kyphosis while exposing the patient to minimal additional morbidity. When postlaminectomy kyphosis does occur, surgical correction is often required and performed via an anterior, posterior, or combined approach. The authors discuss the indications for surgical approaches as well as clinical results.
Primary tumors of the sacrum are rare. In adults, the most common sacral tumors are metastases. T... more Primary tumors of the sacrum are rare. In adults, the most common sacral tumors are metastases. The most common primary sacral tumor is a chordoma. Chordomas along as well as tumors such as chondrosarcomas, osteosarcomas, myxopapillary ependymomas, myelomas, and Ewing sarcomas are considered malignant. In this article the authors focus on benign sacral tumors.
such a high initial PTH level that the assay saturated and it appeared that the results remained ... more such a high initial PTH level that the assay saturated and it appeared that the results remained static. In 140 operations HPT was identi®ed correctly and excised with a concomitant drop in PTH. Conclusion: The intraoperative PTH levels vary markedly in either direction between induction of anaesthesia and the end of dissection. After excision of hyperparathyroid tissue the PTH level normally falls briskly from the postdissection level. The number of patients with a potentially unfavourable outcome is small; these data suggest that rapid intrapoperative PTH assay would have missed further HPT in ten of 14 instances had the surgical strategy been solely dependent on PTH levels. The routine use of intraoperative PTH assay in surgery for primary HPT is therefore questioned.
Although recent advances in the treatment of carotid artery stenosis have included endovascular a... more Although recent advances in the treatment of carotid artery stenosis have included endovascular angioplasty and stent placement, carotid endarterectomy is still the approach of choice for carotid disease and is one of the most commonly performed operations today. Minimally invasive surgeries involving the neck have recently been performed for thyroid and parathyroid diseases. The purpose of this study was to evaluate the feasibility of an endoscopic approach for carotid artery surgery in a large animal model. Eight 25- to 30-kg pigs were used. Animals underwent endoscopic carotid dissection with carbon dioxide insufflation at 10 mmHg. A 1.5- to 2-cm arteriotomy was made in the common carotid artery. Four animals underwent direct arteriotomy closure, and four animals underwent synthetic patch graft placement using intracorporeal suturing techniques. Open examination of the operative site and carotid angiograms were performed at the end of the procedure. Operative time was recorded in the last four cases. All animals tolerated the procedure well and carotid artery repair was successfully performed in all cases using a four-trocar technique. The entire extent of the cervical common and internal carotid arteries was exposed up to the cranial base. Cranial nerves and cervical structures were clearly visualized and preserved. No bleeding occurred at the end of the procedure. Carotid angiograms confirmed patent, nonstenotic vessels in all cases. Endoscopic approach for carotid surgery is technically feasible in the porcine model. This approach may represent a valuable option for surgery of the carotid artery since it offers the advantages of minimally invasive techniques while maintaining the benefits of surgical arterial repair.
Minimally invasive thoracolumbar costotransversectomy and corpectomy via a dual-tube technique: evaluation in a cadaver model
Minimally invasive surgery (MIS) is a promising new tool in the treatment of a variety of spinal ... more Minimally invasive surgery (MIS) is a promising new tool in the treatment of a variety of spinal disorders. MIS laminectomy techniques provide an effective means of achieving lumbar decompression. MIS corpectomy techniques have not been described. If feasible, such a technique would be optimal in the treatment of spinal metastatic disease, where traditional open techniques can result in a significant burden to a compromised patient. In this study, we explored the feasibility of a dual-tube minimally invasive thoracic corpectomy approach in a cadaver model. A minimally invasive thoracolumbar costotransversectomy and corpectomy were perfumed in eight adult cadavers. A dual-tube technique was used to perform a costotransversectomy followed by a corpectomy on one side, and through the opposite tube a transpedicular approach on the contralateral side. Pre- and postoperative CT scans of all cadavers were obtained to measure the cross-sectional area of the vertebral bodies in each specimen via a CT workstation. Reconstruction of the anterior column was attempted in some cadavers using polymethylmethacrylate (PMMA) cement. A successful costotransversectomy and corpectomy were completed in each cadaver. A percutaneous delivery system was successful in allowing an anterior column reconstruction using PMMA as a strut graft in selected cadavers. We demonstrated that a dual-tube MIS approach to thoracic corpectomy is technically feasible. Additionally, spinal stabilization can be achieved via percutaneous PMMA administration. This approach may provide a minimally invasive option in the treatment of select spinal metastases.
Cervicothoracic kyphotic deformity may inhibit horizontal gaze function, impede activities of dai... more Cervicothoracic kyphotic deformity may inhibit horizontal gaze function, impede activities of daily living, and induce disabling pain. Eventually, some patients develop a chin-on-chest deformity that limits their ability to eat and drink; in the end stage, a few patients also may have difficulty breathing. Progressive kyphosis can stretch the spinal cord leading to myelopathy with progressive lower extremity spasticity and weakness. Indications for surgery include myelopathy, pain, dysphagia or dyspnea owing to kyphosis, and difficulty maintaining a functional horizontal gaze. Patients with unstable cervicothoracic fractures also require surgical fixation. For these patients, surgical goals include deformity correction with restoration of an acceptable forward gaze, re-establishment of sagittal balance, decompression of the spinal cord (if myelopathic), and stable fixation.
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