Patrick Guérin

Incidental durotomy during spine surgery: Incidence, management and complications. A retrospective review

STUDY DESIGN Retrospective review of a series of patients who underwent spinal surgery at a single spine unit during a 1 year period. OBJECTIVES To assess the incidence, treatment, clinical consequence, complications of incidental durotomy during spine surgery and results of 37 months clinical follow-up. SUMMARY OF BACKGROUND DATA Incidental durotomy is an underestimated and relatively adverse event during spinal surgery. Several consequences of inadequately treated dural tears have been reported. METHODS A retrospective review was conducted on 1326 consecutive patients who underwent spinal surgery performed in one French spine unit from January 2005 to December 2005. We excluded from this study patients treated for emergency spine cases. RESULTS Fifty-one dural tears were identified (3.84%). Incidental durotomies were associated with anterior cervical approach in 1 case, with posterior cervical approach in 1 case, with anterior retroperitoneal approach in 1 case and with posterior thoracolumbar approach in 48 cases. In addition, any clinically significant durotomy unrecognised during surgical procedure were included. Thirteen patients presented postoperative complications including 7 cerebrospinal fluid leaks, 2 wound infections, 2 postoperative haematomas, and 2 pseudomeningoceles. Nine of these 13 patients required a revision procedure. A mean follow-up of 37 months showed good long-term clinical results. CONCLUSIONS Incidental durotomy is a common complication of spine surgery. All incidental durotomies must be repaired primarily. Dural tears that were immediately recognised and treated accordingly did not lead to any significant sequelae at a mean follow-up of 37 months. However, long-term follow-up studies will be needed to confirm this finding. The risks associated with dural tears and cerebrospinal fluid leaks are serious and should be discussed with any patients undergoing spine surgery.

The lumbosacral plexus: anatomic considerations for minimally invasive retroperitoneal transpsoas approach

PurposeThe minimally invasive transpsoas approach can be employed to treat various spinal disorders, such as disc degeneration, deformity, and lateral disc herniation. With this technique, visualization is limited in comparison with the open procedure and the proximity of the lumbar plexus to the surgical pathway is one limitation of this technique. Precise knowledge of the regional anatomy of the lumbar plexus is required for safe passage through the psoas muscle. The primary objective of this study was to determine the anatomic position of the lumbar plexus branches and sympathetic chain in relation to the intervertebral disc and to define a safe working zone. The second objective was to compare our observations with previous anatomical studies concerning the transpsoas approach.MethodsA total of 60 lumbar plexus in 8 fresh cadavers from the Department of Anatomy were analyzed in this study. Coronal and lateral X-Ray images were obtained before dissection in order to eliminate spine deformity or fracture. All cadavers were placed in a lateral decubitus position with a lateral bolster. Dissection of the lumbar plexus was performed. All nerve branches and sympathetic chain were identified. Intervertebral disc space from L1L2 to L4L5 was divided into four zones. Zone 1 being the anterior quarter of the disc, zone 2 being the middle anterior quarter, zone 3 the posterior middle quarter and zone 4 the posterior quarter. Crossing of each nervous branch with the disc was reported and a safe working zone was determined for L1L2 to L4L5 disc levels. A safe working zone was defined by the absence of crossing of a lumbar plexus branch.ResultsNo anatomical variation was found during blunt dissection. As described previously, the lumbar plexus is composed of the ventral divisions of the first four lumbar nerves and from contributions of the sub costal nerve from T12. The safe working zone includes zones 2 and 3 at level L1L2, zone 3 at level L2L3, zone 3 at level L3L4, and zone 2 at level L4L5. No difference was observed between right and left sides as regards the relationships between the lumbar plexus and the intervertebral disc.ConclusionWe observed some differences concerning the safe working zone in comparison with other cadaveric studies. The small number of cadaveric specimens used in anatomical studies probably explains theses differences. The minimally invasive transpsoas lateral approach was initially developed to reduce the complications associated with the traditional procedure. The anatomical relationships between the lumbar plexus and the intervertebral disc make this technique particularly risky a L4L5. Alternative techniques, such as transforaminal interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF) or anterior interbody fusion (ALIF) should be used at this level.

Posterior spinal fusion from T2 to the sacrum for the management of major deformities in patients with Parkinson disease: a retrospective review with analysis of complications.

Study Design: Description of the surgical management of major spinal deformities in patients with Parkinson disease (PD). Objective: To evaluate the effectiveness of the construct, the incidence and types of complications, and patient satisfaction. Summary of Background Data: The association of degenerative, neuromuscular, and osteoporotic diseases in PD can lead to major complications after spine surgery. We treated PD patients with major spinal deformities by a posterior-only approach for spinal fusion from T2 to the sacrum. Methods: This retrospective study reviews 12 consecutive patients with PD undergoing this surgery in a 2-year span at a single institution. Radiographs were taken with the EOS low-dose system (EOS Imaging, Paris, France) before and 3 months after surgery and at the last follow-up visit and were evaluated by a spine surgeon not involved in the surgery. Complications were analyzed. The functional outcome was assessed with the SRS-30 questionnaire. Results: The patients’ mean age was 68±6.2 years, the mean duration of PD 10±4.9 years, and the mean follow-up 32.8±6.9 months. Six patients had first surgeries, and 6 revisions. Statistically significant improvement was observed in all patients in the frontal and the sagittal planes after surgery. The sagittal vertical axis improved from 15.2±9.3 cm preoperatively to 0.5±3.2 cm at the last follow-up. Six patients had revision, 3 times for instrumentation failure, twice for proximal junctional kyphosis at T1–T2, and once for an epidural hematoma. The SRS-30 questionnaire indicated strong patient satisfaction, with 11 patients who would have the same procedure again if they had the same condition. Conclusions: This is the first reported series of PD patients undergoing posterior spinal fusion from T2 to the sacrum for major deformities. This study indicates that good correction of sagittal and frontal balance enables good clinical and radiologic results that remain stable over time even when complications occur.

Regression of giant cell tumor of the cervical spine with bisphosphonate as single therapy.

Study Design. A case report. Objective. To describe a case of regression of a giant cell tumor (GCT) of the cervical spine, which was treated with zoledronic acid as single therapy. Summary of Background Data. Bisphosphonates are antiresorptive drugs used in patients with myeloma and bone metastases to treat pain and skeletal events. Despite the emerging evidence of antitumoral effects in adjuvant therapy for GCT of bone, the use of bisphosphonates as a single agent has not been described. Methods. Case study with follow-up examination and radiological control 36 months after the beginning of therapy. A review of the literature is also provided. Results. The imaging data at admission evidenced an extensive osteolytic lesion on C5 and C6 vertebral bodies. An open biopsy confirmed the diagnosis of GCT. It was decided to immobilize the cervical spine with rigid collar and to start monthly intravenous zoledronic acid. The subsequent clinical and radiological follow-up during 3 years revealed a marked regression of the lesion. Conclusion. The use of a bisphosphonate agent for GCT of the cervical spine showed potential therapeutic benefits as previously described for other osteolytic disorders. This finding could lead to further investigation on the role and true value of these drugs as possible adjuvants in the management of GCT of bone.

Sagittal alignment after single cervical disc arthroplasty.

Study Design Prospective study. Objectives To analyze the sagittal balance after single-level cervical disc replacement (CDR) and range of motion (ROM). To define clinical and radiologic parameters those have a significant correlation with segmental and overall cervical curvature after CDR. Summary of Background Data Clinical outcomes and ROM after CDR with Mobi-C (LDR, Troyes, France) prosthesis have been documented in few studies. No earlier report of this prosthesis has studied correlations between static and dynamic parameters or those between static parameters and clinical outcomes. Methods Forty patients were evaluated. Clinical outcome was assessed using the Short Form-36 questionnaire, Neck Disability Index, and a Visual Analog Scale. Spineview software (Surgiview, Paris, France) was used to investigate sagittal balance parameters and ROM. The mean follow-up was 24.3 months (range: 12 to 36 mo). Results Clinical outcomes were satisfactory. There was a significant improvement of Short Form-36, Neck Disability Index, and Visual Analog Scale scores. Mean ROM was 8.3 degrees preoperatively and 11.0 degrees postoperatively (P=0.013). Mean preoperative C2C7 curvature was 12.8 and 16.0 degrees at last follow-up (P=0.001). Mean preoperative functional spinal unit (FSU) angle was 2.3 and 5.3 degrees postoperatively (P<0.0001). Mean postoperative shell angle was 5.5 degrees. There was a significant correlation between postoperative C2C7 alignment and preoperative C2C7 alignment, change of C2C7 alignment, preoperative and postoperative FSU angle, and prosthesis shell angle. There was also a significant correlation between postoperative FSU angle and preoperative C2C7 alignment, preoperative FSU angle, change of FSU angle, and prosthesis shell angle. Regression analysis showed that prosthesis shell angle and preoperative FSU angle contributed significantly to postoperative FSU angle. Moreover, preoperative C2C7 alignment, preoperative FSU angle, postoperative FSU angle, and prosthesis shell angle contributed significantly to postoperative C2C7 alignment. No significant correlation was observed between ROM and sagittal parameters. Few correlations were found between sagittal alignment and clinical results. Conclusions CDR with this prosthesis provided favorable clinical outcomes and maintains ROM of the FSU, overall and segmental cervical alignment. Long-term follow-up will be needed to assess the effectiveness and advantages of this procedure.

Total Vertebrectomy and Spine Shortening in the Management of Acute Thoracic Spine Fracture Dislocation: Technical Note and Report of 3 Cases

Study Design Case report of 3 thoracic spine fracture-dislocations with complete spinal cord section treated by total vertebrectomy—spine shortening through a posterior approach. Objectives To assess the usefulness and safety of this surgical technique in the treatment of acute thoracic spine fracture-dislocation. Summary of Background Total vertebrectomy can be used in different nontraumatic disorders. This surgical procedure has been used in the chronic phase of traumatic thoracolumbar dislocation. To our knowledge, the technique of total vertebrectomy and spine shortening in the acute phase of thoracic spine fracture dislocation has never been reported. Material and Methods Three patients who suffered thoracic spine fracture-dislocation with ASIA A paraplegia underwent complete vertebrectomy and spine shortening through a posterior approach. We report technical details, clinical, and radiologic results at 24 months minimum follow-up. Results Complete vertebrectomy of the fractured vertebra involved T5 in 1 patient, T7 in another, and T10 in the third. There were no perioperative complications. At latest follow-up, fusion was obtained in all 3. Overall sagittal and coronal alignment was restored. Conclusions Complete vertebrectomy and spinal shortening can be used in the acute phase to manage thoracic spine fracture-dislocations.

The use of curare during anesthesia to prevent iatrogenic muscle damage caused by lumbar spinal surgery through a posterior approach.

Study Design. Prospective randomized study of patients undergoing lumbar arthrodesis. Objectives. To evaluate the use of curare during anesthesia to limit muscle lesions caused by surgery. Summary of Background Data. It has been shown that lumbar spine surgery through a posterior approach can induce iatrogenic lesions in the erector spinae. The prevention of these lesions by intraoperative cholinergic blockade has never been evaluated. Methods. Twenty patients scheduled to undergo pedicle-screw enhanced L4–L5 arthrodesis were enrolled in this study. The average age was 48.9 years. Ten patients received curare during anesthesia and 10 patients did not. Postoperative pain was assessed using a visual analog scale (VAS) and the consumption of morphine by patient-controlled analgesia during the first 24 hours. Intramuscular pressure (IMP) in the multifidus was monitored during the intervention. A biopsy of the multifidus muscle was performed at the end of the intervention for histologic study. Serum activity of the MM iso-enzyme of the creatine phosphokinase (CPK-MM) was measured 24 hours after surgery. Results. The average consumption of morphine and the mean value of the VAS at 24 hours were not statistically different between these 2 groups. The use of a self-retaining retractor during lumbar surgery resulted in a substantial increase in IMP, resulting in histologic muscle lesions and an increase in serum CPK-MM activity. There was no significant difference between the 2 groups of patients. Conclusions. The use of curare during anesthesia did not limit the muscle damage caused by surgery.

Vías de acceso de la columna cervical

El acceso de la columna cervical puede realizarse por vias anteriores o posteriores, cuya eleccion depende de la enfermedad que se va a tratar, de la extension de las lesiones y de las costumbres de los equipos quirurgicos. La via posterior es sencilla y directa. Permite acceder a los arcos posteriores. Sin embargo, plantea problemas, como la colocacion del paciente y la infeccion de la herida quirurgica. Las vias anteriores son las mas usadas en la actualidad, pero plantean problemas diversos, dependiendo de los niveles vertebrales expuestos. La via transoral permite un acceso directo del cuerpo del axis, pero sus indicaciones son escasas. La via preesternocleidomastoidea es la mas usada para exponer la columna cervical inferior. Ademas, permite acceder a la porcion suprahioidea de la columna cervical superior. No obstante, plantea el problema del riesgo de lesion del nervio laringeo inferior, sobre todo a nivel C7-T1. Las vias retroesternocleidomastoidea, preesternocleidomastoidea anterolateral y preesternocleidomastoidea retrovascular permiten acceder a la cara anterolateral de la columna cervical y a la arteria vertebral homolateral.

Vie d’accesso al rachide cervicale

Riassunto L’accesso al rachide cervicale puo essere realizzato attraverso vie anteriori o posteriori. La scelta di tali vie e guidata dalla patologia da trattare, dall’estensione delle lesioni e dalle abitudini dell’equipe chirurgica. La via posteriore e semplice e diretta e permette di approcciare gli archi posteriori; tuttavia, pone il problema dell’installazione e dell’infezione del sito operatorio. Le vie anteriori sono attualmente le piu utilizzate, ma pongono problemi variabili a seconda dei livelli vertebrali esposti. La via transorale permette un accesso diretto del corpo dell’epistrofeo, ma presenta indicazioni limitate. La via presternocleidomastoidea, la piu utilizzata per esporre il rachide cervicale inferiore, permette inoltre un accesso al rachide cervicale superiore nella sua porzione sovraioidea; tuttavia presenta il rischio di ledere il nervo laringeo inferiore principalmente a livello C7-T1. Le vie retrosternocleidomastoidea, presternocleidomastoidea anterolaterale, presternocleidomastoidea retrovascolare consentono l’approccio alla faccia anterolaterale del rachide cervicale e all’arteria vertebrale omolaterale.