Gábor Czigléczki

Minimally invasive spine surgery: systematic review

Minimally invasive procedures in spine surgery have undergone significant development in recent times. These procedures have the common aim of avoiding biomechanical complications associated with some traditional destructive methods and improving efficacy. These new techniques prevent damage to crucial posterior stabilizers and preserve the structural integrity and stability of the spine. The wide variety of reported minimally invasive methods for different pathologies necessitates a systematic classification. In the present review, authors first provide a classification system of minimally invasive techniques based on the location of the pathologic lesion to be treated, to help the surgeon in selecting the appropriate procedure. Minimally invasive techniques are then described in detail, including technical features, advantages, complications, and clinical outcomes, based on available literature.

Multiple abscesses with osteomyelitis and destruction of both the atlas and the axis in a 4-week-old infant

Study Design. Case report. Objective. To report an unusual case of a 4-week-old infant with multiple abscesses, which propagated to the cervical region and destroyed the C1–C2 vertebrae. Summary of Background Data. Cervical vertebral osteomyelitis involving the atlas and axis in childhood is distinctly unusual, which may lead to the rapid destruction of the vertebral body. Propagation of a retropharyngeal abscess is the major cause of cervical vertebral osteomyelitis. Only a limited number of infant case reports are published, and no case of osteomyelitis with the destruction of both the atlas and the dens axis has been reported previously. Methods. A 1-month-old infant with multiple craniospinal and thoracic abscesses was surgically treated. Therapy was completed with antibiotics and immobilization. Follow-up was carried out with magnetic resonance imaging, computed tomographic scans, and functional radiographical diagnostics. Results. The retropharyngeal and thoracic abscesses were surgically removed. The infant was placed in a custom-made fixation device for 8 weeks. Two months later, follow-up functional examination revealed no significant instability of the cervical spine. During a 3-year-long follow-up period, no signs of neurological impairment were observed, neck movements were limited but painless. It is assumed that the remnants of the bony elements of C1–C2 vertebrae and the massive interconnecting postinflammatory scar tissue make some degree of neck movements possible. Conclusion. C1–C2 osteomyelitis is a very rare entity even in children. There is limited experience with treatment, but immobilization of the neck, surgical debridement, drainage, and antibiotic treatment can be recommended. Close follow-up is required to check the reconstitution of affected bones and ligaments, any development of instability, and the necessity of surgical stabilization. Level of Evidence: N/A

Long-term effectiveness of an ad hoc tailored titanium implant as a spacer for microvascular decompression in the treatment of trigeminal neuralgia caused by megadolichoectatic basilar artery anomaly: 9-year follow-up

An enlarged, elongated, ectatic, and sclerotic aberration of the vertebrobasilar system is known as a megadolichoectatic basilar artery (BA) anomaly. The anomaly is often involved in the pathological process of trigeminal neuralgia by compressing and distorting the trigeminal nerve. First-line medical treatment includes drug therapy, but a second-line surgical procedure could be effective in medication-resistant cases. The authors report the case of a 65-year-old man with a 12-year history of progressing trigeminal neuralgia who underwent microvascular decompression after the first-line drug treatment had failed. This case is unique because an in situ tailored titanium microplate was used as a spacer to alleviate compression by the BA on the trigeminal nerve. The titanium implant provided durable and sufficient retraction for the sclerotic arterial complex when the trigeminal nerve was placed in the tunnel of the implant. The 9-year follow-up examination proves the safety and long-term efficacy of titanium implants in the treatment of trigeminal neuralgia caused by a megadolichoectatic BA anomaly. The method applied in this case was not intended to be and certainly is not an alternative to routine microvascular decompression-this surgical solution may be reserved for some extreme cases.

Prognostic Factors of Surgical Complications and Overall Survival of Patients with Metastatic Spinal Tumor

OBJECTIVE Oncologic treatments increase the incidence of spinal metastases. Surgical treatment of spinal metastases results in a high complication rate, which must set against the expected benefits. The aim of this article was to study the effect of several prognostic factors on surgical complications and survival time using an extended database of patients with spinal metastases. METHODS This retrospective study comprised 337 patients with spinal metastases who were surgically treated between 2008 and 2015. Demographic and clinical features, oncologic histories, surgical interventions, and end results were collected. Descriptive statistical methods were used to analyze the cohort of patients. Kaplan-Meier formula and log-rank test were used to examine overall survival times. RESULTS Median overall survival time was 222 days (range, 175-274 days). Age, preoperative motor disorders, preoperative Frankel grade categories, Karnofsky performance scale, type of primary tumor, and presence of internal metastasis had a significant negative effect on overall survival. Complications such as bleeding or need for intensive care could be predicted preoperatively based on preoperative performance status, type of primary tumor, affected vertebral levels, and type of surgical interventions. CONCLUSIONS Spinal metastatic disease is a challenging surgical problem. If the exact prognostic factors are known preoperatively, surgical outcome and overall survival can be predicted more precisely. Our results could provide a basis for a future multicenter prospective study to determine the best treatment protocol for patients with spinal metastases.

Analysis of Four Scoring Systems for the Prognosis of Patients with Metastasis of the Vertebral Column

OBJECTIVE Metastatic spinal diseases are common health problems and there is no consensus on the appropriate treatment of metastases in several conditions. Using clinical measures (e.g., survival time and functional status), prognosis prediction systems advise on the appropriate interventions. The aim of this article is to assess and compare 4 widely used scoring systems (revised Tokuhashi, Tomita, van der Linden, and modified Bauer scores) on a single-center cohort. METHODS A retrospective study was designed of 329 patients who were subjected to surgery because of metastatic spinal diseases. Subpopulations according to the classifications of the 4 scoring systems were identified. The overall survival was calculated with the Kaplan-Meier formula. The difference between the survival curves of subpopulations was analyzed with log-rank tests. The consistency rates for the 4 scoring systems are calculated as well. RESULTS The follow-up period was 8 years. The median survival time was 222 days. The overall survival of prognostic categories in 3 scoring systems was significantly different from each other, but we found no differences between the categories of the van der Linden system. In this cohort, the revised Tokuhashi system gave the best approximation for survival, with a mean predictive capability 60.5%. CONCLUSIONS The evaluation of 4 standard scoring systems showed that 3 were self-consistent, although none of systems was able to predict the survival in our cohort. Based on the predictive capability, the revised Tokuhashi system may provide the best predictions with careful examination of individual cases.

Management Strategy of Osteoblastomas Localized in the Occipitocervical Junction

OBJECTIVE The aim of this article was to analyze extracted patient data from the literature and highlight the best treatment options and survival outcomes for osteoblastomas in the occipitocervical region. METHODS A systematic literature search method was used to select articles containing information about the demographic features, tumor location, treatment characteristics, adjuvant therapies, and follow-up time. RESULTS From 25 articles, 31 cases of osteoblastoma in the occipitocervical junction were selected for analysis. Average patient age was 17 years (range, 5-57 years); there were 21 male (67%) and 10 female (33%) patients. All patients had cervical pain as the presenting symptom. Other symptoms included torticollis (0.13%) and sensory or motor neurologic deficits (0.16%). The average follow-up time was 41 months, and the local recurrence rate was 0.125%. Recommendations of each article are categorized and discussed in detail. CONCLUSIONS Osteoblastoma is a rare entity in the occipitocervical region, so treatment experiences are limited and mostly based on case reports. To determine the best treatment for these lesions, osteoblastomas should be staged using the Enneking staging system; different methods may be recommended for different stages, and the feasibility of fusion depends on the remaining amount of bony structures and joints. Additional adjuvant therapies may be recommended only in special cases.

Osteomyelitis and Destruction of the Atlas and Axis in a 4-Week-Old Infant: 4-Year Follow-Up

Introduction Neonatal vertebral osteomyelitis is not an uncommon condition, but osteomyelitis simultaneously involving the atlas and the axis is distinctly unusual and no other infant case has been published so far in the literature. We present the case of an infant with retropharyngeal abscess, which led to the destruction of the C1–C2 vertebrae. Materials and Methods MRI examination revealed a multilocular abscess in the right mastoidal area penetrating to the cervical region and causing destruction of the C1 and C2 vertebrae, and an epidural abscess with signs of spinal cord compression at the level of the Th5–Th7 vertebrae. The retropharyngeal and thoracic abscesses were surgically removed and the therapy was completed with antibiotics. The child was placed in a custom-made fixation device for 8 weeks. Follow-up was performed with MRI, CT scans, and functional X-ray diagnostics. Results CT scans with 3D reconstruction demonstrated the absence of normal osseous structures at the craniospinal region, but undamaged ossification centers in the C3 vertebra and below. Functional X-ray diagnostics, performed in general anesthesia showed no significant instability of the cervical spine. Normal motor development and independent walking were allowed. During a 4-year long follow-up period, no signs of neurological impairment were observed, neck movements were limited but painless. It is assumed that the remnants of the bony elements of C1–C2 vertebrae and the massive interconnecting postinflammatory scar tissue make some degree of neck movements possible. His development was undisturbed, similar to his age group. Conclusion C1–C2 osteomyelitis is a very rare entity even in children. There is limited experience with treatment and rehabilitation, but the temporary immobilization of the neck, surgical debridement, antibiotic treatment, and continuous physiotherapy can be recommended. Close follow-up is required to check the reconstitution of affected bones and ligaments, any development of instability, and the necessity of surgical stabilization.

Comparative evaluation of surgical alternatives in the treatment of acute cervical myelopathy and in the decompression of cervical spinal canal

Abstract Symptoms of cervical myelopathy are caused by the compression of the cervical spinal cord in the narrowed spinal canal. Several techniques including less invasive and minimally invasive methods have been developed with the aim of decompressing the cervical spinal canal, preserving posterior motion segments and paraspinal muscles as much as possible, reducing iatrogenic consequences and promoting faster recoveries of patients. The purpose of this article is to summarize these procedures and evaluate their efficacy with comparing them to each other. The applicable methods are presented shortly but the differences between them are discussed in details. Comprehensive examination did not reveal the proven superiority of any techniques and in most cases the less invasive or minimally invasive treatment choices should be individually determined, considering the location and extension of pathology and the familiarity of surgeon with techniques.