Daniel Serban

Genitofemoral nerve protection during the lateral retroperitoneal transpsoas approach.

BACKGROUND: The minimally invasive lateral retroperitoneal approach for lumbar fusions is a novel technique with good results, but also with significant sensory and motor complications. OBJECTIVE: To present the early results of a modified surgical technique, in which the psoas muscle is dissected under direct visualization. METHODS: Thirteen consecutive patients with L4-5 or L3-4 pathology were prospectively followed after being treated using a minimally invasive lateral approach with direct exposure of the psoas muscle before dissection. There were 7 woman and 6 men with a mean age of 52.3 years. Perioperative parameters like operative time, estimated blood loss, and length of stay, were noted. Pain, paresthesia, and motor weakness, as well as any other complications, were evaluated at 2 weeks and 3 months postoperatively. RESULTS: The mean operative time, estimated blood loss, and length of stay were 163 minutes, 126 mL, and 3 days, respectively. One patient exhibited anterior thigh pain and paresthesia at 2 weeks, both of which resolved by 3 months. Two patients experienced superficial wound infections that healed with antibiotics. The genitofemoral nerve was identified and protected in 7 patients; in 4 patients, it had a more posterior anatomic location than expected. The femoral nerve was not exposed or detected in the operative field by neuromonitoring, nor were there any symptoms related to a femoral nerve injury in any patient. CONCLUSION: Dissection of the psoas muscle under direct visualization during the minimally invasive lateral approach may provide increased safety to the genitofemoral and femoral nerves.

Primary cervical spine carcinoid tumor in a woman with arm paresthesias and weakness: a case report

IntroductionCarcinoid tumors are neuroendocrine neoplasms derived from the enterochromaffin cells. Central nervous system involvement is rare and has been reported either as metastases to the brain and spine or primary tumors involving the sacrococcygeal spine. We report the first case of a primary carcinoid tumor of the cervical spine.Case presentationA 50-year-old African-American woman presented with a 4-month history of numbness, paresthesias, and mild left-hand weakness. Magnetic resonance imaging of her cervical spine revealed a homogenously enhancing extradural mass, indenting the cervical cord and expanding the left neural foramen at C7–T1. A C7 corpectomy, en bloc resection of the tumor, and anterior C6–T1 fusion were performed to decompress the spinal cord and nerves and provide stability. Postoperative histopathologic examination and immunohistochemical analysis were consistent with carcinoid tumor. There has been no recurrence at the 6-year follow-up visit.ConclusionsPrimary cervical carcinoid tumor is extremely rare, but should be included in the differential diagnosis of enhancing expansile extradural masses compressing the spinal cord and nerves. Surgical resection may provide a definitive cure.

Standard versus Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Prospective Randomized Study

Symptomatic spondylolisthesis patients may benefit from surgical decompression and stabilization. The standard (S) technique is a transforaminal lumbar interbody fusion (TLIF). Newer, minimally invasive (MI) techniques seem to provide similar results with less morbidity. We enrolled patients with at least 6 months of symptoms and image-confirmed low-grade spondylolisthesis, at a single academic institution, between 2011 and 2015. The patients were randomized to either S or MI TLIF. The primary outcome measure was the Oswestry Disability Index (ODI) improvement at 1 year. Secondary outcome measures included length of operation, estimated blood loss, length of hospitalization, and fusion rates at 1 year. Forty patients were enrolled in each group. The differences in mean operative time and estimated blood loss were not statistically significant between the two groups. The patients were discharged after surgery at 4.12 days for the S TLIF group and 1.92 days for the MI TLIF group. The ODI improvement was similar and statistically significant in both groups. The fusion was considered solid in 36 (90%) of patients at 1 year in both groups. In conclusion, the two techniques provided similar clinical and radiological outcomes at 1 year. The patients undergoing MI TLIF had a shorter hospital stay. This trial is registered with NCT03155789.

Gunshot wounds to the spine in post-Katrina New Orleans

BACKGROUND Gunshot wounds (GSW) to the spine represent a major health concern within todays society. Our study assessed the epidemiologic characteristics of patients with GSW to the spine treated in New Orleans. PATIENTS AND METHODS A retrospective chart review was performed from January 2007 through November 2011 on all the patients who were seen in the emergency room and diagnosed with a gunshot wound to the spine. Epidemiologic factors, as well as the results of admission toxicology screening, were noted. Outcome analysis was performed on patients undergoing conservative versus operative management for their injuries. Clinical outcomes were assessed using the ASIA classification system. Complications related to initial injury, neurosurgical procedures, and hospital stay were noted. RESULTS A total of 147 patients were enrolled. Of those diagnosed with a GSW to the spine, 88 (59.8%) received an admission toxicology screen. Seventy-three (83%) patients out of those tested had a positive screen, with the most common substances detected being cannabis, cocaine, and alcohol. In regards to management, 127 (87%) patients were treated conservatively and only one (0.7%) patient improved clinically from ASIA D to E. Of the 20 patients who underwent surgery, one (5%) patient had clinical improvement post-operatively from ASIA C to D. CONCLUSIONS This study evaluates the largest number of patients with GSW to the spine per year treated in a single centre, illustrating the violent nature of New Orleans. In this urban population, there was a clear correlation between drug use and suffering a GSW to the spine. Surgical intervention was seldom indicated in these patients and was predominately used for fixation of unstable fractures and decompression of compressive injuries, particularly below T11. Minimally invasive techniques were used successfully at our institution to minimize the risk of post-operative CSF leak.

Traumatic spinal fracture treated by vertebroplasty: a case report

IntroductionSurgical treatment for lumbar burst fractures is complex and typically involves either a retroperitoneal corpectomy and/or a posterior pedicle screw fixation. We describe the case of a patient with a lumbar burst fracture who was cured via a less invasive approach that has not been previously reported as standalone treatment.Case presentationThis 25-year-old Caucasian man presented with excruciating axial low back pain exacerbated by any attempt to elevate the head of the bed after a motor vehicle accident. Computed tomography demonstrated a burst L4 fracture without spinal canal compromise. The patient underwent a bilateral vertebroplasty with an injectable polymer that mimics cortical bone. Postoperatively, the patient was progressively mobilized in a thoracolumbar spinal orthosis brace without any recurrence of pain. Postoperative computed tomography showed no loss of height in the L4 vertebral body. At one-year postoperatively, the patient was symptom free and the computed tomography scan showed good fracture healing.ConclusionRetroperitoneal corpectomy and/or posterior multi-segment fixation for lumbar burst fractures without neural compression in young patients are associated with loss of mobility and potential future adjacent level disease. Our limited vertebroplasty intervention with close postoperative clinical monitoring has not been previously described as standalone treatment, and it offers the advantages of less operative morbidity and maintenance of lumbar mobility in selected patients.

Percutaneous Pedicle Screw/Rod Fixation

Percutaneous instrumented posterior fixation with pedicle screws and rods is frequently used. The insertion of the percutaneous pedicle screws is identical among the various platforms, whereas insertion of the rod can be done in three different ways, depending on the system utilized. The target entry point is at the junction of the lateral facet and the transverse process (or ala, for S1). We prefer to use beveled Jamshidi needles, since they provide better directional insertion.

Minimally Invasive Transforaminal Lumbar Interbody Fusion

Minimally invasive transforaminal lumbar interbody fusion (MI TLIF) is one of the most commonly performed minimally invasive spine operations in the United States. It is also quite difficult to master, since anatomical and pathological variations are common, and the learning surgeon must perform a large number of cases before being able to claim proficiency. Nonetheless, this procedure can be used at all lumbar levels and is probably the most important to learn.

Introduction to Minimally Invasive Spine Surgery

Minimally invasive spine surgery started at the turn of the century and many predicted it would soon become the standard of care. Nonetheless, almost twenty years later, these techniques are used in less than 20% of the procedures performed in the United States. While certainly multifactorial, some of the reasons for this slow adoption include the difficult learning curve, as well as the initially increased operative time (and thus decreased surgical volume and revenue) for the seasoned “open” surgeon who tries to convert to the new minimally invasive techniques. The goal of this book is to share almost 20 years of experience in teaching (and sometimes learning) the minimally invasive spinal surgery techniques to those who understand the benefits and want to embrace a better option for their patients.

Lateral Lumbar Interbody Fusion

Minimally invasive lateral retroperitoneal transpsoas approach for lumbar interbody fusion is the fastest growing type of minimally invasive spinal fusion in the United States. We prefer to perform the psoas dissection under direct visualization, in order to protect sensory nerves not detected by neuromonitoring, and insert the widest cage possible, typically 22 mm. We use either lateral plating or posterior percutaneous instrumentation to increase stability and maximize fusion rates.