Mootaz Shousha

Surgical treatment of cervical spondylodiscitis: a review of 30 consecutive patients.

Study Design. A retrospective study of 30 consecutive cases of pyogenic cervical spine infection, excluding postoperative infections. Objective. To establish a real incidence of the disease and the risk factors associated with its occurrence. Furthermore, to evaluate the different surgical approaches dealing with this condition as well as the complications associated with the disease itself and with the different lines of treatment undertaken. Summary of Background Data. Cervical spondylodiscitis is a quite rare finding regarding the common location of spinal abscesses in the lumbar and thoracic regions. Methods. Between January 2004 and December 2009, 30 patients suffering from cervical spondylodiscitis underwent surgical debridement and reconstruction in our institution. The mean age at presentation was 64.5 years, and 19 patients were male (63.3%). Clinically, 24 patients (80%) had neck pain. Neurological deficit was found in 12 patients (40%), while septicemia was one of the presenting pictures in 12 patients (40%). Radiologically, epidural abscess was found in 24 patients (80%). Another concomitant noncontiguous discitis in the thoracic and/or lumbar spine was found in 14 patients (47%). All patients in this series underwent surgical debridement followed by antibiotic therapy for 8 to 12 weeks. Mean period of follow-up was 28.4 months. Results. Healing of the inflammation was the rule. From the 12 patients with neurological deficit, 7 (58%) improved clinically after surgery. Three patients (10%) died postoperatively due to septicemia. Metal failure occurred in 1 patient in whom corpectomy, grafting, and ventral plating were performed. Esophagus perforation occurred in 1 patient with history of cancer pharynx and total neck dissection. Conclusion. Radical surgical debridement and appropriate antibiotic provide a reliable approach to achieve complete healing of the inflammation in cervical spondylodiscitis. Magnetic resonance imaging of the whole spine is recommended in all cases so as not to miss another infection in the spinal column. Regarding the surgical options, ventral plating after corpectomy for spondylodiscitis should be avoided.

Infection rate after transoral approach for the upper cervical spine.

Study Design. A retrospective review of prospectively collected databases of 139 consecutive patients who underwent transoral surgery for lesions of the upper cervical spine. Objective. To analyze the incidence and risk factors of local infection after transoral surgery for the craniocervical junction in a single institution and to compare the findings with the literature. Summary of Background Data. One of the primary risks associated with transoral approach for lesions in the upper cervical spine is postoperative surgical wound infection. Methods. From April 1994 to December 2012, 139 consecutive transoral surgical procedures were performed at a single referral center. The mean age at presentation was 53.6 years (range: 5–87 yr), and more than half of the patients were males (58.3%). The majority of cases were experiencing rheumatic diseases (43.9%), whereas tumor destruction was the indication for surgery in 23.7% of the cases. A total of 23% had fracture of the upper cervical spine and primary infection was found in 7 patients (5%). The mean follow-up period was 4.5 years. Results. Infection of the pharyngeal wound occurred in 5 patients (3.6%), solely in the rheumatic and tumor groups. The presentation was mostly in the first 4 months. A single patient with cage reconstruction after giant cell tumor C2 presented with a late infection 5 years postoperatively. Debridement and primary closure was possible in 2 patients, whereas flap coverage of the pharyngeal wall was necessary in 3 patients. The presence of implant did not have a statistically significant effect on the occurrence of infection. However, infection in the presence of titanium cage mostly necessitated flap coverage of the pharyngeal wall after removal of the cage. Conclusion. The transoral route has proved to be an invaluable method of approaching pathological lesions in the upper cervical spine. The infection rate in this work was 3.6%. Patients with rheumatic diseases and patients presenting with tumors were more susceptible to postoperative surgical wound infection. Level of Evidence: 4

Infection rate after minimally invasive noninstrumented spinal surgery based on 4350 procedures.

Study Design. Retrospective review of a prospectively collected database. Objective. To assess the rate of postoperative infection associated with minimally invasive noninstrumented spinal surgery. Summary of Background Data. Infection after spinal surgery results in significant morbidity, extended hospital stay, and significant costs. Minimally invasive spinal techniques require smaller incisions and less dissection, minimizing the risk of postoperative infection. Methods. Inclusion criteria were patients undergoing posterior spinal surgery using a tubular retractor system with the aid of operative microscope between June 1998 and November 2013. The analysis revealed a total number of 4350 procedures performed in 4037 patients (mean age = 53.2 yr). Sixty percent of the patients were male. The majority of procedures were performed in the lumbar spine (98.4%), and the indication was mostly degenerative in nature (96.9%). The databases were then reviewed for any infectious complications. Results. Postoperative infection was recorded in 4 patients (0.09%). All of them occurred in the lumbar region after discectomy. These patients presented with discitis and underwent revision in the form of open debridement and fusion. The time lapse between the index surgery and revision was 56 days. All 4 patients recovered, with a mean follow-up of 7.5 years. Conclusion. Infection rate after posterior transtubular microscopic assisted spinal surgery is very low (0.09%). Surgical debridement with fusion was the method of choice in treating such complications. This minimally invasive technique reduces markedly the risk of postoperative infection when compared with other large series published in the literature. Level of Evidence: 4

Corpectomy of the fifth lumbar vertebra, a challenging procedure.

Study Design: A retrospective study of 25 consecutive cases undergoing L5 corpectomy and reconstruction. Summary of Background Data: Corpectomy of L5 is a challenging procedure because of the unique biomechanical and anatomic properties of this level. Objective: To report the clinical and radiographic outcomes and to stress the technical difficulties encountered with L5 corpectomy, reconstruction of the resulting defect together with posterior stabilization. Methods: Between 2003 and 2008 25 consecutive cases (13 females and 12 males, mean age 54.5 y) underwent L5 corpectomy, followed by titanium cage implantation and posterior stabilization. The indications for surgery were fracture (44%), bony destruction by tumor (44%), and spondylodiscitis (12%). Results: The mean amount of intraoperative blood loss was 3.4 L. The cage was implanted through a posterior approach in a single patient with lymphoma. In the remaining 24 patients, an expandable cage was implanted through a ventral approach. Intraoperative complications occurred in 2 patients presenting with fracture. This was in the form of injury to the left common iliac vein in one patient and extensive epidural bleeding reaching 10 L in the other patient. Five patients died within 2 years after surgery: 2 of them were presenting with spondylodiscitis and died later due to sepsis, whereas the remaining 3 patients had advanced malignancy. In the remaining 20 patients, the mean follow-up period was 3.4 years. Local recurrence of infection occurred in 1 patient necessitating change of the cage. Recurrence of metastasis occurred in 2 patients; one of them underwent posterior decompression and the other one was treated successfully with local irradiation. Conclusions: L5 corpectomy is a demanding procedure because of the vascular anatomy at that level. Large amount of blood loss should be expected. In case of complication or recurrence of the pathology, revision surgery is more demanding and necessitates a wide experience.

Abcd Classification System: A Novel Classification for Subaxial Cervical Spine Injuries

Study Design. The classification system was derived through a retrospective analysis of 73 consecutive cases of subaxial cervical spine injury as well as thorough literature review. Objective. To define a new classification system for subaxial cervical spine injuries. Summary of Background Data. There exist several methods to classify subaxial cervical spine injuries but no single system has emerged as clearly superior to the others. Methods. On the basis of a 2-column anatomical model, the first part of the proposed classification is an anatomical description of the injury. It delivers the information whether the injury is bony, ligamentous, or a combined one. The first 4 alphabetical letters have been used for simplicity. Each column is represented by an alphabetical letter from A to D. Each letter has a radiological meaning (A = Absent injury, B = Bony lesion, C = Combined bony and ligamentous, D = Disc or ligamentous injury). The second part of the classification is represented by 3 modifiers. These are the neurological status of the patient (N), the degree of spinal canal stenosis (S), and the degree of instability (I). For simplicity, each modifier was graded in an ascending pattern of severity from zero to 2. The last part is optional and denotes which radiological examination has been used to define the injury type. Results. The new ABCD classification was applicable for all patients. The most common type was anterior ligamentous and posterior combined injury “DC” (37.9%), followed by “DD” injury in 12% of the cases. Conclusion. Through this work a new classification for cervical spine injuries is proposed. The aim is to establish criteria for a common language in description of cervical injuries aiming for simplification, especially for junior residents. Each letter and each sign has a meaning to deliver the largest amount of information. Both the radiological as well as the clinical data are represented in this scheme. However, further evaluation of this classification is needed. Level of Evidence: 3

Adjacent segment disease after cervical spine fusion: Evaluation of a 70 patient long term follow-up

Study Design. A retrospective study of 70 patients undergoing surgical treatment for adjacent segment disease (ASD) after anterior cervical decompression and fusion (ACDF). Objective. To analyze the risk factors for the development of ASD in patients who underwent ACDF. Summary of Background Data. ACDF has provided a high rate of clinical success for the cervical degenerative disc disease; nevertheless, adjacent segment degeneration has been reported as a complication at the adjacent level secondary to the rigid fixation. Methods. Between January 2005 and December 2012, 70 consecutive patients underwent surgery for ASD after ACDF in our institution. In all patients thorough clinical and radiological examination was performed preoperatively, postoperatively, and at the final follow-up. The clinical data included the Neck Disability Index (NDI) and the Visual Analogue Scale (VAS). The radiological evaluation included x-rays and magnetic resonance imaging (MRI) for all patients. The duration of follow up after the adjacent segment operation ranged from 3 to 10 years. Results. Surgery for ASD was performed after a mean period of 32 months from the primary ACDF. ASD occurred after single level ACDF in 54% of cases, most commonly after C5/6 fusion (28%). Risk factors for ASD were found to be preexisting radiological signs of degeneration at the primary surgery (74%) and bad sagittal profile after the primary ACDF (90%). Conclusion. ASD occurred predominantly in the middle cervical region (C4–6); especially in patients with preexisting evidence of radiological degeneration in the adjacent segment at the time of primary cervical fusion, notably when this surgery failed to restore or maintain the cervical lordosis. Level of Evidence: 4

What an orthopaedic surgeon should know about vertebral cement augmentation

In the past 3 decades percutaneous vertebroplasty and percutaneous kyphoplasty have widely gained acceptance as a line of treatment in symptomatic osteoporotic vertebral compression fractures and osteolytic primary or secondary lesions in the spinal column. With an ever aging world population these minimal invasive techniques are expected to gain more importance in improving the medical care and quality of life. This review deals with the current techniques and advances of vertebral cement augmentation, their complications, cost efficiency, and effect on pain control.