Mercan Sarier

Osteotomies/spinal column resections in adult deformity

Osteotomies may be life saving procedures for patients with rigid severe spinal deformity. Several different types of osteotomies have been defined by several authors. To correct and provide a balanced spine with reasonable amount of correction is the ultimate goal in deformity correction by osteotomies. Selection of osteotomy is decided by careful preoperative assessment of the patient and deformity and the amount of correction needed to have a balanced spine. Patient’s general medical status and surgeon’s experience levels are the other factors for determining the ideal osteotomy type. There are different osteotomy options for correcting deformities, including the Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), bone-disc-bone osteotomy (BDBO) and vertebral column resection (VCR) providing correction of the sagittal and multiplanar deformity. SPO refers to a posterior column osteotomy in which the posterior ligaments and facet joints are removed and a mobile anterior disc is required for correction. PSO is performed by removing the posterior elements and both pedicles, decancellating vertebral body, and closure of the osteotomy by hinging on the anterior cortex. BDBO is an osteotomy that aims to resect the disc with its adjacent endplate(s) in deformities with the disc space as the apex or center of rotational axis (CORA). VCR provides the greatest amount of correction among other osteotomy types with complete resection of one or more vertebral segments with posterior elements and entire vertebral body including adjacent discs. It is also important to understand sagittal imbalance and the surgeon must consider global spino-pelvic alignment for satisfactory long-term results. Vertebral osteotomies are technically challenging but effective procedures for the correction of severe adult deformity and should be performed by experienced surgeons to prevent catastrophic complications.

Simultaneous Surgical Treatment in Congenital Scoliosis and/or Kyphosis Associated With Intraspinal Abnormalities

Study Design. Retrospective clinical study. Objective. To show retrospective analysis of 21 consecutive patients who underwent simultaneous surgical treatment for progressive spinal deformity and coexisting intraspinal pathologies (tethered cord and/or diastematomyelia). Summary of Background Data. The classic advocated approach in patients with congenital spine deformity associated with intraspinal anomalies is first to perform surgery for the intraspinal pathologies and then surgery for correction and stabilization of the deformity 3 to 6 months later. To our knowledge, there is no study on simultaneous surgical treatment for these 2 associated conditions. Methods. In the surgery; after the exposure of the determined levels, placement of all pedicle screws was performed as the initial part of surgical procedure. Then surgical treatment for intraspinal pathology was performed by the neurosurgical team and then followed by completion of instrumentation and correction of the deformity. Additional anterior surgery was done later to prevent pseudarthrosis and crankshaft phenomenon. Results. The mean age of the patients at presentation ranged from 3 to 19 years (mean, 13 years). There were 17 female patients and 4 male patients. Four patients had neurologic deficits at the time of presentation, and all 4 had associated kyphosis. The mean operation time was 9.3 hours (range, 7–12 hours) and the mean blood loss was 1980 mL (range, 1500–3000 mL). The average follow-up was 6.8 years (2–12 years). None of the patients experienced deterioration in their neurologic status after surgery. None of the patients had infection, pseudarthrosis, or loss of correction during the follow-up visits. Conclusion. The simultaneous surgical treatment for congenital deformity and intraspinal abnormality does not involve significant complications and seems to be an alternative and safe treatment option.

Cervical brucellosis mimicking cervical disc herniation

Brucellar spondylitis may be difficult to diagnose. Initial plain radiographs of the spine may show mild degenerative lesions. Although, magnetic resonance imaging of spine is mostly helpful to establish the disease, in some cases, it may lead to misdiagnosis. The aim of this report was to present a case of brucella infection involving the cervical spine that was falsely diagnosed and underwent to surgery for cervical disc herniation. Since the spinal form of brucellosis has no specific symptomatology, a patient has symptoms with mimicking the cervical hernia, with a history of disabling pain more severe than radicular pain, and especially who reside in countries where the disease is endemic, the brucella infection should be kept in mind in the differential diagnosis and specific diagnostic investigations such as brucella agglutination tests should be made before any treatment procedure.RésuméIl peut être difficile de diagnostiquer la spondylodiscite brucellienne. Les radiographies standard initiales du rachis peuvent montrer des lésions dégénératives seulement légères. Bien que l’IRM du rachis soit le plus souvent déterminante dans l’établissement du diagnostic, elle peut parfois aussi conduire à un diagnostic erroné. Le but de ce rapport est de présenter un cas de brucellose impliquant le rachis cervical qui a été faussement diagnostiquée et a été opérée avec un diagnostic de hernie discale cervicale. Etant donné que la forme vertébrale de la brucellose n’a aucune symptomatologie spécifique, un patient peut avoir les signes imitant ceux de la hernie cervicale, avec une histoire de douleur invalidante plus grave que la douleur radiculaire. En particulier pour des patients qui résident dans les pays où la maladie est endémique, l’on devrait toujours avoir à l’esprit la brucellose dans le diagnostic différentiel et des investigations diagnostiques spécifiques telles que les séro-tests d’agglutination devraient être faits avant toute décision thérapeutique.

Radiologic and Clinical Outcome of the Operated and Adjacent Segments Following Prodisc-C Cervical Arthroplasty After a Minimum 24-month Follow-up: A Single Surgeon-center Experience

Study Design:This was a retrospective study. Objective:The purpose of this retrospective study was to determine the radiologic outcome at the index and adjacent levels and clinical outcome of cervical total disk arthroplasty (TDA) using Prodisc-C after a minimum 24 months follow-up at a single center. Methods:Eighty-six levels of 59 (28 female, 31 male) cases with minimum 2 years follow-up were included in this study. Radiologic parameters including disk level height at the operated and adjacent levels, global cervical lordosis, segmental lordosis, range of motion, subsidence, facet arthrosis, adjacent segment degeneration (ASD), and heterotopic ossification were analyzed. All surgeries were performed by a single surgeon. Results:Average age was 39.5 (range, 27 to 56) years and average follow-up was 33.6 (range, 24 to 81) months. Operated levels were C3-4 (%4.6), C4-5 (%16.3), C5-6 (%48.8), C6-7 (%26.8), and C7-T1 (%3.5). All patients had clinical improvement. NDI was improved from 46 to 9. There was a significant improvement in segmental kyphosis, global lordosis, and disk height at the operated level with no significant change at the final follow-up. There was no radiographic facet joint arthrosis at the index and adjacent levels, 4 (%6.7) patients had radiographic signs of ASD at the cranial adjacent level, whereas 5 (%8.4) patients had ASD at the caudal adjacent level. Heterotopic ossification (HO) was observed in 4 patients (%6.7) with a complete fusion in 1 patient. Conclusions:This study demonstrates a satisfactory radiographic and clinical outcome after prodisc-C TDA with a minimum 24-month follow-up.

Thoracic spinal stenosis above severe thoracolumbar kyphosis a report of three cases

The neurological deficit can be seen in severe thoracolumbar kyphosis caused by spinal tuberculosis (early or late onset), fracture and congenital deformities. It is commonly believed that spinal cord compression at the severe kyphotic segment is mainly responsible for the neurological deficit. The purpose of this paper was to describe here a new entity of neurological deficit mechanism due to the thoracic spinal stenosis produced above the severe thoracolumbar kyphosis (transition zone from severe kyphosis to compensatory or structural lordosis). Three patients who were presented with this problem are described. The appropriate surgical treatment revealed the disappearance of the symptoms. We believe in that facet orientation change and direction of them towards spinal canal cause spinal canal stenosis and foraminal stenosis in the compensatory lordotic segment, which eventually becomes structural lordosis above the severe kyphotic segment. These changes result in shearing stresses in long period and cause facet hypertrophy and spinal canal narrowing.RésuméUn déficit neurologique peut être constaté dans les hypercyphoses thoraco-lombaires sévères causées par la tuberculose vertébrale (début précoce ou tardif), les fractures et les déformations congénitales. L’on pense habituellement que c’est la compression médullaire qui est responsable des déficits neurologiques. Le but de ce travail est de mettre en évidence un autre mécanisme de déficit neurologique produit par une sténose sus-jacente à une sévère hypercyphose thoraco-lombaire (zone transitionnelle entre l’hypercyphose et la lordose compensatrice ou structurelle). Trois patients présentant une telle lésion sont présentés. Le traitement chirurgical approprié a permis la disparition des symptômes. Nous pensons que c’est le changement d’orientation et de direction des facettes qui est responsable de la sténose canalaire et foraminale dans le segment lordotique compensateur, qui peut éventuellement se transformer en lordose structurelle au dessus du segment cyphotique. Ces changements résultent de stress en cisaillement pendant une longue période, qui entraînent une hypertrophie des facettes articulaires et un canal étroit.