Journal articles: 'Decompression failures' – Grafiati (2024)

Abstract:

Background: In patients with symptomatic lumbar stenosis undergoing lateral transpsoas approach for lumbar interbody fusion (LLIF) surgery, it is not always clear when indirect decompression is sufficient in order to achieve symptom resolution. Indirect decompression failure (IDF), defined as “postoperative persistent symptoms of nerve compression with or without a second direct decompression surgery to reach adequate symptom resolution,” is not widely reported. This information, however, is critical to better understand the indications, the potential, and the limitations of indirect decompression. Objective: The purpose of this study was to systematically review the current literature on IDF after LLIF. Methods: A literature search was performed on PubMed. We included randomized controlled trials and prospective, retrospective, case-control studies, and case reports. Information on sample size, demographics, procedure, number and location of involved levels, follow-up time, and complications were extracted. Results: After applying the exclusion criteria, we included 9 of the 268 screened articles that reported failure. A total of 632 patients were screened in these articles and detailed information was provided. Average follow-up time was 21 months. Overall reported incidence of IDF was 9%. Conclusion: Failures of decompression via LLIF are inconsistently reported and the incidence is approximately 9%. IDF failure in LLIF may be underreported or misinterpreted as a complication. We propose to include the term “IDF” as described in this article to differentiate them from complications for future studies. A better understanding of why IDF occurs will allow surgeons to better plan surgical intervention and will avoid revision surgery.

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✓ One-hundred patients who had undergone decompressive surgery for lumbar stenosis between 1980 and 1985 were evaluated as to their long-term outcome. Four patients with postfusion stenosis were included. A 5-year follow-up period was achieved in 88 patients. The mean age was 67 years, and 80% were over 60 years of age. There was a high incidence of coexisting medical diseases, but the principal disability was lumbar stenosis with neurological involvement. Results were categorized as either a surgical success or a failure. depending upon the achievement of preset goals within the context of lifestyle and needs. There were no perioperative complications. Initially there was a high incidence of success, but recurrence of neurological involvement and persistence of low-back pain led to an increasing number of failures. By 5 years this number had reached 27% of the available population pool, suggesting that the failure rate could reach 50% within the projected life expectancies of most patients. Of the 26 failures, 16 were secondary to renewed neurological involvement, which occurred at new levels of stenosis in eight and recurrence of stenosis at operative levels in eight. Reoperation was successful in 12 of these 16 patients, but two required a third operation. The incidence of spondylolisthesis at 5 years was higher in the surgical failures (12 of 26 patients) than in the surgical successes (16 of 64). Spondylolisthetic stenosis tended to recur within a few years following decompression. To forestall recurrences, it is suggested that stabilization be carried out at levels of spondylolisthetic stenosis and the initial decompression include adjacent levels of threatening symptomatic stenosis. However, the heterogenicity of this patient population, with varying patterns and levels of symptomatic stenosis, precludes application of rigid surgical protocols.

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Abstract A study has been made of gas decompression failures in elastomeric seals using a fracture mechanics approach and considerations of gas permeation. An equation is proposed for the tearing energy associated with crack growth from internal gas bubbles in a finite thickness elastic media. When applied to a model experiment where an internal flaw of known size was pressurized up to failure, the equation agreed with experimental results. A series of seals were then subjected to high gas pressures (up to 69 MPa or 10,000 psi) for a range of temperatures between 20 and 230°C and the amount of crack growth was measured after decompression. The trends in crack growth were correctly accounted for when values for tearing energy and modulus were used that were appropriate for the temperature of decompression. The effect of mechanical boundary constraint was studied by varying the compression on the seal in specially designed test holders. The effect of decompression rate is also considered. The conditions under which failure will occur are created by a complex balance of the available tearing energy and the gas permeation kinetics. A fundamental problem is the unknown size of the initial flaw from which crack growth and rupture occurs. This is discussed in the light of the experimental results and it is proposed that effective surfaces of weakness form in the elastomer phase of size to provide initiation sites for crack growth.

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Hard-and-software integrated systems such as command and control systems (C4ISR systems) are typical systems that are comprised of both software and hardware, the failures of such devices result from complicated common cause failures and common (or shared) signals that make classical reliability analysis methods will be not applicable. To this end, this paper applies the Goal-Oriented (GO) methodology to detailed analyze the reliability of a C4ISR system. The reliability as well as the failure probability of the C4ISR system, are reached based on the GO model constructed. At the component level, the reliability of units of the C4ISR system is computed. Importance analysis of failures of such a system is completed by the qualitative analysis capability of the GO model, by which critical failures of hardware failures like communication module failures and motherboard module failures as well as software failures like network module application software failures and decompression module software failures are ascertained. This method of this paper contributes to the reliability analysis of all hard-and-software integrated systems.

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At present, the common surgical procedures for the Chiari malformation type I are comprised of posterior fossa decompression, duraplasty and tonsillectomy. Some neurosurgeons prefer these so called minimally invasive surgeries. However, there are still some failures for patients undergoing the above surgeries in clinical practice. Analyzing causes of many surgical failures, the author put forward the anatomical concept of occipitocervical dura angulation (ODA). The ODA is defined as the included angle between the cerebral dura mater and spinal dura mater at the posterior foramen magnum on the median sagittal plane. For Chiari malformation type I without atlantoaxial instability, the selection of appropriate surgeries and accurate evaluation on the effect of the decompression can be realized after the comprehensive analysis both on the severity of tonsil herniation and the ODA. Tonsillectomy may be needed to add to posterior fossa decompression (PFD) and duraplasty for Chiari malformation type I with the ODA being the larger obtuse angle and/or the tonsil herniation to the level of arcus posterior atlantis.

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OBJECT Pathological compression fractures in cancer patients cause significant pain and disability. Spinal metastases affect quality of life near the end of life and may require multiple procedures, including medical palliative care and open surgical decompression and fixation. An increasingly popular minimally invasive technique to treat metastatic instabilities is kyphoplasty. Even though it may alleviate pain due to pathological fractures, it may fail. However, delayed kyphoplasty failures with retropulsed cement and neural element compression have not been well reported. Such failures necessitate open surgical decompression and stabilization, and cement inserted during the kyphoplasty complicates salvage surgeries in patients with a disease-burdened spine. The authors sought to examine the incidence of delayed failure of structural kyphoplasty in a series of cement augmentations for pathological compression fractures. The goal was to identify risk predictors by analyzing patient and disease characteristics to reduce kyphoplasty failure and to prevent excessive surgical procedures at the end of life. METHODS The authors retrospectively reviewed the records of all patients with metastatic cancer from 2010 to 2013 who had undergone a procedure involving cement augmentation for a pathological compression fracture at their institution. The authors examined the characteristics of the patients, diseases, and radiographic fractures. RESULTS In total, 37 patients underwent cement augmentation in 75 spinal levels during 45 surgeries. Four patients had delayed structural kyphoplasty failure necessitating surgical decompression and fusion. The mean time to kyphoplasty failure was 2.88 ± 1.24 months. The mean loss of vertebral body height was 16% in the patients in whom kyphoplasty failed and 32% in patients in whom kyphoplasty did not fail. No posterior intraoperative cement extravasation was observed in the patients in whom kyphoplasty had failed. The mean spinal instability neoplastic score was 10.8 in the patients in whom kyphoplasty failed and 10.1 in those in whom kyphoplasty did not fail. Approximately 50% of the kyphoplasty failures occurred at junctional spinal levels. All the patients in whom kyphoplasty failed had fractures in 3 or more cortical walls before treatment, whereas 46% of patients in the nonfailure group had fractures with breaching of 3 or more walls. CONCLUSIONS Although rare, delayed failures of structural augmentation with cement during kyphoplasty do occur and can lead to additional surgeries. A possible predictive index may include wall integrity of the vertebral body, competency of the posterior tension band, and location of the kyphoplasty at a junctional spinal level. Additional studies are required to confirm these findings.

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✓ The authors report the results of 782 microvascular decompression procedures for hemifacial spasm in 703 patients (705 sides), with follow-up study from 1 to 20 years (mean 8 years). Of 648 patients who had not undergone prior intracranial procedures for hemifacial spasm, 65% were women; their mean age was 52 years, and the mean preoperative duration of symptoms was 7 years. The onset of symptoms was typical in 92% and atypical in 8%. An additional 57 patients who had undergone prior microvascular decompression elsewhere were analyzed as a separate group. Patients were followed prospectively with annual questionnaires. Kaplan-Meier methods showed that among patients without prior microvascular decompression elsewhere, 84% had excellent results and 7% had partial success 10 years postoperatively. Subgroup analyses (Cox proportional hazards model) showed that men had better results than women, and patients with typical onset of symptoms had better results than those with atypical onset. Nearly all failures occurred within 24 months of operation; 9% of patients underwent reoperation for recurrent symptoms. Second microvascular decompression procedures were less successful, whether the first procedure was performed at Presbyterian-University Hospital or elsewhere, unless the procedure was performed within 30 days after the first microvascular decompression. Patient age, side and preoperative duration of symptoms, history of Bell's palsy, preoperative presence of facial weakness or synkinesis, and implant material used had no influence on postoperative results. Complications after the first microvascular decompression for hemifacial spasm included ipsilateral deaf ear in 2.6% and ipsilateral permanent, severe facial weakness in 0.9% of patients. Complications were more frequent in reoperated patients. In all, one operative death (0.1%) and two brainstem infarctions (0.3%) occurred. Microvascular decompression is a safe and definitive treatment for hemifacial spasm with proven long-term efficacy.

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OBJECT Chiari I malformation is the most common craniocervical malformation. Its combination with basilar invagin*tion in a significant proportion of patients is well established. This study presents surgical results for patients with Chiari I malformation with and without additional basilar invagin*tion. METHOD Three hundred twenty-three patients underwent 350 operations between 1985 and 2013 (mean age 43 ± 16 years, mean history of symptoms 64 ± 94 months). The clinical courses were documented with a score system for individual neurological symptoms for short-term results after 3 and 12 months. Long-term outcomes were analyzed with Kaplan-Meier statistics. The mean follow-up was 53 ± 58 months (the means are expressed ± SD). RESULTS Patients with (n = 46) or without (n = 277) basilar invagin*tion in addition to Chiari I malformation were identified. Patients with invagin*tion were separated into groups: those with (n = 31) and without (n = 15) ventral compression by the odontoid in the foramen magnum. Of the 350 operations, 313 dealt with the craniospinal pathology, 28 surgeries were undertaken for degenerative diseases of the cervical spine, 3 were performed for hydrocephalus, and 6 syrinx catheters were removed for cord tethering. All craniospinal operations included a foramen magnum decompression with arachnoid dissection, opening of the fourth ventricle, and a duraplasty. In patients without invagin*tion, craniospinal instability was detected in 4 individuals, who required additional craniospinal fusion. In patients with invagin*tion but without ventral compression, no stabilization was added to the decompression. In all patients with ventral compression, craniospinal stabilization was performed with the foramen magnum decompression, except for 4 patients with mild ventral compression early in the series who underwent posterior decompression only. Among those with ventral compression, 9 patients with caudal cranial nerve dysfunctions underwent a combination of transoral decompression with posterior decompression and fusion. Within the 1st postoperative year, neurological scores improved for all symptoms in each patient group, with the most profound improvement for occipital pain. In the long term, late postoperative deteriorations were related to reobstruction of CSF flow in patients without invagin*tion (18.3% in 10 years), whereas deteriorations in patients with invagin*tion (24.9% in 10 years) were exclusively related either to instabilities becoming manifest after a foramen magnum decompression or to hardware failures. Results for ventral and posterior fusions for degenerative disc diseases in these patients indicated a trend for better long-term results with posterior operations. CONCLUSIONS The great majority of patients with Chiari I malformations with or without basilar invagin*tion report postoperative improvements with this management algorithm. There were no significant differences in short-term or long-term outcomes between these groups. Chiari I malformations without invagin*tion and those with invagin*tions but without ventral compression can be managed by foramen magnum decompression alone. The majority of patients with ventral compression can be treated by posterior decompression, realignment, and stabilization, reserving anterior decompressions for patients with profound, symptomatic brainstem compression.

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OBJECTIVESpine stereotactic radiosurgery (SRS) is a safe and effective treatment for spinal metastases. However, it is unknown whether this highly conformal radiation technique is suitable at instrumented sites given the potential for microscopic disease seeding. The authors hypothesized that spinal decompression with instrumentation is not associated with increased local failure (LF) following SRS.METHODSA 2:1 propensity-matched retrospective cohort study of patients undergoing SRS for spinal metastasis was conducted. Patients with less than 1 month of radiographic follow-up were excluded. Each SRS treatment with spinal decompression and instrumentation was propensity matched to 2 controls without decompression or instrumentation on the basis of demographic, disease-related, dosimetric, and treatment-site characteristics. Standardized differences were used to assess for balance between matched cohorts.The primary outcome was the 12-month cumulative incidence of LF, with death as a competing risk. Lesions demonstrating any in-field progression were considered LFs. Secondary outcomes of interest were post-SRS pain flare, vertebral compression fracture, instrumentation failure, and any Grade ≥ 3 toxicity. Cumulative incidences analysis was used to estimate LF in each cohort, which were compared via Gray’s test. Multivariate competing-risks regression was then used to adjust for prespecified covariates.RESULTSOf 650 candidates for the control group, 166 were propensity matched to 83 patients with instrumentation. Baseline characteristics were well balanced. The median prescription dose was 16 Gy in each cohort. The 12-month cumulative incidence of LF was not statistically significantly different between cohorts (22.8% [instrumentation] vs 15.8% [control], p = 0.25). After adjusting for the prespecified covariates in a multivariate competing-risks model, decompression with instrumentation did not contribute to a greater risk of LF (HR 1.21, 95% CI 0.74–1.98, p = 0.45). The incidences of post-SRS pain flare (11% vs 14%, p = 0.55), vertebral compression fracture (12% vs 22%, p = 0.04), and Grade ≥ 3 toxicity (1% vs 1%, p = 1.00) were not increased at instrumented sites. No instrumentation failures were observed.CONCLUSIONSIn this propensity-matched analysis, LF and toxicity were similar among cohorts, suggesting that decompression with instrumentation does not significantly impact the efficacy or safety of spine SRS. Accordingly, spinal instrumentation may not be a contraindication to SRS. Future studies comparing SRS to conventional radiotherapy at instrumented sites in matched populations are warranted.

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Object Adjuvant radiation following epidural spinal cord decompression for tumor is a powerful tool used to achieve local disease control and preserve neurological function. To the authors' knowledge, only 1 published report addresses adjuvant stereotactic radiosurgery after this procedure, but that study used significantly lower doses than are currently prescribed. The authors review their experience using high-dose single-fraction radiosurgery as a postoperative adjuvant following surgical decompression and instrumentation to assess long-term local tumor control, morbidity, and survival. Methods A retrospective chart review identified 21 patients treated with surgical decompression and instrumentation for high-grade, epidural, spinal cord compression from tumor, followed by single-fraction high-dose spinal radiosurgery (dose range 18–24 Gy, median 24 Gy). Spinal cord dose was limited to a cord maximal dose of 14 Gy. Tumor histologies, time between surgery and radiosurgery, time to local recurrence after radiosurgery as assessed by serial MR imaging, and time to death were determined. Competing risk analysis was used to evaluate these end points. Results In this series, 20 tumors treated (95%) were considered highly radioresistant to conventional external beam radiation. The planning target volume received a high dose (24 Gy) in 16 patients (76.2%), and a low dose (18 or 21 Gy) in 5 patients (23.8%). During the study, 15 (72%) of 21 patients died, and in all cases death was due to systemic progression as opposed to local failure. The median overall survival after radiosurgery was 310 days (range 37 days to not reached). One patient (4.8%) underwent repeat surgery for local failure and 2 patients (9.5%) underwent spine surgery for other reasons. Local control was maintained after radiosurgery in 17 (81%) of 21 patients until death or most recent follow-up, with an estimated 1-year local failure risk of 9.5%. Of the failures, 3 of 4 were noted in patients receiving low-dose radiosurgery, equaling an overall failure rate of 60% (3 of 5 patients) and a 1-year local failure estimated risk of 20%. Those patients receiving adjuvant stereotactic radiosurgery with a high dose had a 93.8% overall local control rate (15 of 16 patients), with a 1-year estimated failure risk of 6.3%. Competing risk analysis showed this to be a significant difference between radiosurgical doses. One patient experienced a significant radiation-related complication; there were no wound-related issues after radiosurgery. Conclusions Spine radiosurgery after surgical decompression and instrumentation for tumor is a safe and effective technique that can achieve local tumor control until death in the vast majority of patients. In this series, those patients who received a higher radiosurgical dose had a significantly better local control rate.

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Abstract The Review first describes the general features of gas induced rupture in elastomers, induced by a reduction in the ambient gas pressure, and introduces the main variables such as the gas-polymer transport and equilibrium properties. The phenomenologieal nature of the failure processes are also described and the characteristics of the failures encountered are summarized. It is proposed that the failure processes, which involve bubble expansion and subsequent tearing of the interior and exterior of the elastomer, arise from the action of at least two stress fields; one is provided by a simple triaxial tension and the other by an evolving gas concentration gradient. Various routes to model this process are described in the Review. In addition, the importance of the main system variables, on these rupture processes, is assessed and means of deducing, and directly measuring the parameters which may influence the rupture process are described. These include various equilibrium and transient properties such as the extent of the gas mass sorption, the associated volume change and the variation of the mechanical and thermal properties of the polymer-gas system at elevated pressures.

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Objective. To assess the effectiveness of various therapeutic hip preservation strategies on patients with nontraumatic osteonecrosis of the femoral head (ONFH). Design. This is a systematic review of previous literature and in-depth Bayesian network meta-analysis of randomized controlled trials (RCTs) to compare the clinical effect of various operation methods and one physical intervention (extracorporeal shockwave). Data Sources. Electronic literature, for studies published up to December 2017, was collected from PubMed, Medline, and the Cochrane Library. Study Selection. We selected RCTs on patients with ONFH. Treatment methods included extracorporeal shockwave (ESW), core decompression (CD), multiple drilling decompression (DD), vascularized fibular grafting (VFG), free-vascularized fibular grafting (FVFG), inverted femoral head grafting (IFHG), vascular iliac pedicle bone grafting (VIPBG), osteotomy, and tantalum implantation (TI). Outcome. The primary outcome was Harris score; the secondary outcome was Harris hip score (HHS), including total hip arthroplasty requirement (THA) and progression to collapse. Results. A total of 14 randomized controlled trials were investigated. ESW had the highest improvement on Harris score (probability best 52%), followed by VFG (probability was 38%). In the meanwhile, VFG also proved to be superior in reducing the failure rates of treatment (probability lowest 59%), followed by ESW (probability lowest 24%). In femoral necrosis stage-II, VFG achieved the highest probability in preventing treatment failures (52%) and showed better performance in reducing treatment failure rates than CD. Conclusion. ESW therapy (ESWT) is the most effective intervention to improve HHS, and VFG shows superior effect on reducing treatment failure rates.

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Object The purpose of this study was to report the results of a survey of the American Society of Pediatric Neurosurgeons (ASPN) on treatment of Chiari malformation Type I (CM-I) with syringomyelia. Methods A questionnaire was circulated during the 2006 meeting of the ASPN, in which surgeons were surveyed on their management of patients with CM-I and syringomyelia. The survey consisted of questions about 4 clinical scenarios, common causes of surgical failures, and complications. Results There were 72 respondents, representing more than 90% of attendees at the 2006 ASPN meeting and approximately half of the society's members. The majority of respondents (85%) reported that they perform posterior fossa decompression as first-line treatment for CM-I with syringomyelia. Seven percent perform bony decompression alone, 36% open the dura, and 27% shrink the tonsils. Very few respondents indicated that they offer syrinx drainage as first-line therapy (< 3%). Although all respondents reported that they treat symptomatic CM-I/syringomyelia patients surgically, 15% of respondents indicated that they do not operate on asymptomatic patients. Finally, respondents stated that their most common complications are pseudomeningocele and chemical meningitis. Conclusions This survey, given to a representative group of experienced North American pediatric neurosurgeons, confirms that posterior fossa decompression is still the preferred treatment modality in children with CM-I and syringomyelia, regardless of symptoms. Although most surgeons open the dura, preferred techniques for decompression vary. In contrast to the results of past surveys, conservative follow-up is now only used by a minority of respondents and only in the asymptomatic patient, and primary syrinx drainage seems to have lost popularity. A multicenter trial of surgical outcomes has been designed based on the information from this survey.

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Background: Transforaminal endoscopic lumbar disc decompression (TELD) has emerged as a treatment alternative to open lumbar discectomy, but rates of herniated lumbar disc (HLD) recurrence after TELD are higher by comparison. Objectives: We conducted this study to identify factors correlating with early HLD recurrence after TELD. Study Design: Retrospective study. Setting: The Department of Anesthesiology and Pain Medicine, Neurosurgery at Spine Health Wooridul Hospital. Methods: As a retrospective review, we examined all patients undergoing TELD between 2012 and 2017, analyzing the following in terms of time to recurrence: age, gender, body mass index (BMI), comorbid conditions (diabetes mellitus [DM], hypertension [HTN]), smoking status, nature of disc herniation (central, paramedian, or foraminal), Modic changes, migration grade (rostral vs. caudal track + degree), herniated disc height (Dht) and base size (Dbase), and the presence of spondylolisthesis on magnetic resonance imaging. Results: During the 5-year study period, 1,900 patients underwent TELD procedures, resulting in 209 recurrences (11.0%). In 27 of these patients (12.9%), herniation recurred within 24 hours after surgery. Recurrences most often developed within 2-30 days (n = 76). The smaller the size of a herniated disc, the earlier it recurred. Recurrences were unrelated to gender, BMI, DM or HTN, smoking status, migration grade, nature (Dht or Dbase of herniated disc), or the presence of spondylolisthesis. Limitations: In addition to variables assessed herein, other clinical and radiologic parameters that may be important in recurrent disc herniation should be included. Furthermore, only univariate analyses were performed, making no adjustments for potential confounders, therefore, independent risk factors could not be assessed. A prospective study would likely generate more precise results, especially in terms of standardized sampling and data classification. Finally, multiple causes for primary discectomy failures may have rendered our patient groups nonhom*ogeneous, and inequalities in surgical options or physician-dictated surgical choices may have had an effect. Conclusions: In patients undergoing TELD procedures, smaller-sized herniated discs are linked to early recurrences. Key words: Disc herniation, lumbar, endoscopic, recurrence, early

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Object. The authors sought to determine whether the results of trigeminal microvascular decompression (MVD) are influenced by prior gamma knife surgery (GKS). Methods. Gamma knife surgery is an established procedure for treating medically intractable trigeminal neuralgia but failures do occur. The authors assessed six patients (two men and four women; mean age 52 years) who experienced pain recurrence after GKS and elected to undergo trigeminal MVD via retrosigmoid craniotomy. Three patients underwent a single GKS to a maximal dose of 80 Gy, whereas three others underwent a second GKS to total of 120 to 135 Gy. At surgery, none of the six patients demonstrated excess arachnoid thickening, grossly apparent changes in the nerve itself, or any other tissue alterations that made successful mobilization of a blood vessel from the trigeminal root entry zone technically more difficult. A single individual had a small atherosclerotic plaque in the superior cerebellar artery near its contact point with the trigeminal nerve. Follow up at a mean of 25.4 months (range 7.5–42 months) indicated that five patients were pain free. One patient had improved but still relied on medications for pain control. Conclusions. In the authors' experience, trigeminal MVD can be performed without added difficulty in patients who have previously undergone GKS. The success rates seem similar to those normally associated with MVD. Patients who elect the less invasive option of GKS can be assured that trigeminal MVD remains a viable alternative at a later date if further surgery is required.

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Object. The authors sought to determine whether the results of trigeminal microvascular decompression (MVD) are influenced by prior gamma knife surgery (GKS). Methods. Gamma knife surgery is an established procedure for treating medically intractable trigeminal neuralgia but failures do occur. The authors assessed six patients (two men and four women; mean age 52 years) who experienced pain recurrence after GKS and elected to undergo trigeminal MVD via retrosigmoid craniotomy. Three patients underwent a single GKS to a maximal dose of 80 Gy, whereas three others underwent a second GKS to total of 120 to 135 Gy. At surgery, none of the six patients demonstrated excess arachnoid thickening, grossly apparent changes in the nerve itself, or any other tissue alterations that made successful mobilization of a blood vessel from the trigeminal root entry zone technically more difficult. A single individual had a small atherosclerotic plaque in the superior cerebellar artery near its contact point with the trigeminal nerve. Follow up at a mean of 25.4 months (range 7.5–42 months) indicated that five patients were pain free. One patient had improved but still relied on medications for pain control. Conclusions. In the authors' experience, trigeminal MVD can be performed without added difficulty in patients who have previously undergone GKS. The success rates seem similar to those normally associated with MVD. Patients who elect the less invasive option of GKS can be assured that trigeminal MVD remains a viable alternative at a later date if further surgery is required.

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✓ An ideal spinal construct should immobilize only the unstable spinal segments, and thus only the segments fused. Pedicle fixation techniques have provided operative stabilization with the instrumentation of a minimal number of spinal segments; however, some failures have been observed with pedicle instrumentation. These failures are primarily related to excessive preload forces and limitations caused by the size and orientation of the pedicles. To circumvent these problems, a new technique, the crossed-screw fixation method, was developed and is described in this report. This technique facilitates short-segment spinal fixation and uses a lateral extracavitary approach, which provides generous exposure for spinal decompression and interbody fusion. The technique employs two large transverse vertebral body screws (6.5 to 8.5 mm in diameter) to bear axial loads, and two unilateral pedicle screws (placed on the side of the exposure) to restrict flexion and extension deformation around the transverse screws and to provide three-dimensional deformity correction. The horizontal vertebral body and the pedicle screws are connected to rods and then to each other via rigid crosslinking. The transverse vertebral body screws are unloaded during insertion by placing the construct in a compression mode after the interbody bone graft is placed, thus optimizing the advantage gained by the significant “toe-in” configuration provided and further decreasing the chance for instrumentation failure. The initial results of this technique are reported in a series of 10 consecutively treated patients, in whom correction of the deformity was facilitated. Follow-up examination (average 10.1 months after surgery) demonstrated negligible angulation. Chronic pain was minimal. The crossed-screw fixation technique is biomechanically sound and offers a rapid and safe form of short-segment three-dimensional deformity correction and solid fixation when utilized in conjunction with the lateral extracavitary approach to the unstable thoracic and lumbar spine. This approach also facilitates the secure placement of an interbody bone graft.

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Abstract BACKGROUND: Reconstruction of the thoracolumbar spine after corpectomy is a challenge for fractures, infections, and tumors. OBJECTIVE: To analyze fusion rates, clinical outcomes, and the percent of vertebral body coverage achieved by using stackable carbon fiber–reinforced polyetheretherketone cages in thoracolumbar corpectomies, and to measure the actual size of the cages and compare this measurement with the size of the vertebra(e) replaced by the cage. METHODS: A retrospective study of 40 patients who underwent thoracolumbar corpectomies was performed. Preoperative imaging included plain films, computed tomography scans, and magnetic resonance imaging. Postoperatively, plain films and computed tomography scans were obtained, and the width of decompression and cross-sectional area of the cage were measured. The ratio of the area of the cage to the calculated area of the replaced vertebral body was used to determine the percent of vertebral body coverage. RESULTS: The mean follow-up period was 43 months. Successful fusion was observed in 39 patients. One patient experienced cage subsidence with kyphosis. One additional patient incurred a neurological complication that was corrected without long-term consequence. The mean correction of sagittal alignment was 10°, and the mean width of bony decompression was 20 mm. The mean ratio of the area of the carbon fiber cage to the area of the resected vertebral body was 60%. CONCLUSION: Stackable carbon fiber cages are effective devices for achieving thoracolumbar fusions. No failures of the cages occurred over long-term follow-up. Excellent clinical and radiographic results were achieved by covering a mean of 60% of the vertebral body with the cage.

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Abstract Purpose Surgical treatment failures or strategies for the reoperation of residual thoracic disc herniations are sparsely discussed. We investigated factors that led to incomplete disc removal and recommend reoperation strategies. Methods As a referral centre for thoracic disc disease, we reviewed retrospectively the clinical records and imaging studies before and after the treatment of patients who were sent to us for revision surgery for thoracic disc herniation from 2013 to 2018. Results A total of 456 patients were treated from 2013 to 2018 at our institution. Twenty-one patients had undergone previously thoracic discectomy at an outside facility and harboured residual, incompletely excised and symptomatic herniated thoracic discs. In 12 patients (57%), the initial symptoms that led to their primary operation were improved after the first surgery, but recurred after a mean of 2.8 years. In seven patients (33%) they remained stable, and in two cases they were worse. All patients were treated via all dorsal approaches. In all 21 cases, the initial excision was incomplete regarding medullar decompression. All of the discs were removed completely in a single revision procedure. After mean follow-up of 24 months (range 12–57 months), clinical neurological improvement was demonstrated in seven patients, while three patients suffered a worsening and 11 patients remained stable. Conclusion Our data suggest that pure dorsal decompression provides a short relief of the symptoms caused by spinal cord compression. Progressive myelopathy (probably due to mechanical and vascular deficits) and scar formation may cause worsening of symptoms. Graphic abstract These slides can be retrieved under Electronic Supplementary Material.

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Intrahepatic stones are prevalent in the Far East, whereas they are infrequently seen in Western countries. Hepatolithiasis can cause recurrent attacks of cholangitis, with a risk of liver abscesses, sepsis or hepatic failure. Immediate biliary decompression can usually be achieved by endoscopic or percutaneous transhepatic drainage. Definitive treatment should aim for complete elimination of bile stasis and removal of all stones. Hepatic resection promises the best long term results when the disease is limited to segments or the left liver lobe. Endoscopic retrograde choledochopancreatography is not well established for intrahepatic stones because of frequent failures due to associated biliary strictures, angulated ducts or peripherally impacted concrements. In contrast, percutaneous procedures can be easily performed through a T tube tract for residual stones after surgery. Establishment of a transhepatic fistula allows a targeted approach to liver segments with catheters or miniscopes, without the need for laparotomy. Biliary strictures can be dilated with balloons, and intrahepatic stones can be removed with baskets under fluoroscopic or cholangioscopic control. These techniques can be combined with electrohydraulic lithotripsy or laser lithotripsy for disintegration of impacted calculi. The risk of stone recurrence is particularly high in patients with associated biliary stenoses. Temporary or long term transhepatic intubation is a promising approach in these cases. The optimal management of intrahepatic stones remains a challenging task that requires an experienced team of gastroenterologists, surgeons and radiologists.

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Abstract OBJECTIVE Instrumentation of the osteoporotic spine may result in bone failure because of pedicle screw loosening and pullout. A clinical evaluation of a novel fenestrated bone tap used in pedicle screw augmentation was performed to determine the performance and safety of this technique. METHODS Over a 2.5-year period, the clinical and radiographic results of 119 consecutive patients who underwent instrumented arthrodesis were reviewed. Of these patients, 23 had bone softening secondary to osteoporosis and/or metastatic spinal tumor involvement. These patients underwent surgical decompression and spinal instrumentation. RESULTS Six patients (26%) had metastatic spine disease (squamous cell lung carcinoma, renal cell carcinoma, bladder carcinoma, breast, prostate, and uterine adenocarcinoma); five patients (22%) had a degenerative spondylolisthesis; and 12 patients (52%) had burst fractures, eight as a result of benign causes and four as a result of metastatic disease. Four (17%) patients underwent revision surgery of previous pedicle screw failure resulting from bone softening and pseudarthrosis. A total of 98 levels were fused using 158 polymethylmethacrylate-augmented screws. None of the patients experienced operative death, myocardial infarction, hypoxemia, intraoperative hypotension, radiculopathy, or myelopathy. Asymptomatic anterior cement extravasation was observed in nine patients (39%). There was one asymptomatic polymethylmethacrylate pulmonary embolus and one wound infection. There was no significant relationship between cement extravasation and the quantity used, levels augmented, or location (P &gt; 0.05). There were no construct failures. CONCLUSION Polymethylmethacrylate-augmented pedicle screw fixation reduces the likelihood of pedicle screw loosening and pullout in patients with osteoporosis requiring instrumented arthrodesis.

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Abstract OBJECTIVE Developmental remnants around the foramen magnum, or proatlas segmentation abnormalities, have been recorded in postmortem studies but very rarely in a clinical setting. Because of their rarity, the pathological anatomy has been misunderstood, and treatment has been fraught with failures. The objectives of this prospective study were to understand the correlative anatomy, pathology, and embryology and to recognize the clinical presentation and gain insights on the treatment and management. METHODS Our craniovertebral junction (CVJ) database started in 1977 and comprises 5200 cases. This prospective study has retrieval capabilities. Neurodiagnostic studies changed with the evolution of imaging. Seventy-two patients were recognized as having symptomatic proatlas segmentation abnormalities. RESULTS Ventral bony masses from the clivus or medial occipital condyle occurred in 66% (44/72), lateral or anterolateral compressive masses in 37% (27 of 72 patients), and dorsal bony compression in 17% (12 of 72 patients). Hindbrain herniation was associated in 33%. The age at presentation was 3 to 23 years. Motor symptoms occurred in 72% (52 of 72 patients); palsies in Cranial Nerves IX, X, and XII in 33% (24 of 72 patients); and vertebrobasilar symptoms in 25% (18 of 72 patients). Trauma precipitated symptoms in 55% (40 of 72 patients). The best definition of the abnormality was demonstrated by 3-dimensional computed tomography combined with magnetic resonance imaging. Treatment was aimed at decompression of the pathology and stabilization. CONCLUSION Remnants of the occipital vertebrae around the foramen magnum were recognized in 72 of 5200 CVJ cases (7.2%). Magnetic resonance imaging with 3-dimensional computed tomography of the CVJ provides the best definition and understanding of the lesions. Brainstem myelopathy and lower cranial nerve deficits are common clinical presentations in the first and second decades of life. Treatment is aimed at decompression of the pathology and CVJ stabilization.

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Abstract BACKGROUND Treatment failures of artificial disc implantation are well-described, but posterior herniation of the arthroplasty core is rare. We present a case of posterior herniation of the arthroplasty core resulting in cauda equina syndrome in a 36-yr-old woman. Preoperative imaging studies including computed tomography (CT), magnetic resonance imaging (MRI), and CT Myelogram were performed; only the CT Myelogram demonstrated the severe compression well. This report highlights the radiographic findings on multiple imaging modalities, clinical implications, and management considerations of posterior arthroplasty failures. OBJECTIVE To demonstrate a rare complication of lumbar arthroplasties. The biomechanical considerations, surgical management, and thorough radiographic work-up demonstrate successful diagnosis and treatment of this unusual complication. METHODS The patient's chart was reviewed for medical history, laboratory and radiographic studies, and outpatient clinical follow-up. RESULTS After imaging work-up, this patient was found to have a herniation of the arthroplasty core at L5-S1. She was taken emergently to the operating room for a decompression at L5-S1 and arthroplasty core removal. She made some recovery neurological, but over 3 mo time, she developed a spondylolisthesis with new back pain and radiculopathy. This ultimately responded well to an L5-S1 instrumented posterior fusion. CONCLUSION Posterior herniation of the lumbar arthroplasty core is a rare complication from implantation of an artificial lumbar disc. Confirmation of the diagnosis is best confirmed with a CT Myelogram. Furthermore, this case underscores the biomechanical importance of the artificial disc given the development of the spondylolisthesis after removal, and fusion after arthroplasty core removal should be considered.

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A 31-year-old male was transferred to our hospital with severe heart failure due to viral myocarditis. He progressed to multiorgan failure requiring intubation and maximal doses of multiple vasopressors. Circulatory support was provided with an Impella device as a bridge to an extracorporeal membrane oxygenation (ECMO) system. On full mechanical cardiovascular support, the patient's hemodynamic status improved and ECMO and Impella were explanted after 48 hours. Three days later, he was extubated and continued on to a full recovery. There are no specific therapies for fulminant myocarditis but first-line treatment is supportive care. ECMO is commonly used in patients with severe heart failure. In severe systolic dysfunction, left ventricular decompression is required to reduce myocardial wall stress, decrease myocardial oxygen requirements, and enhance the chances of recovery. The Impella, an active support system, is less invasive than classical decompressive techniques and is associated with lower requirements for blood products with fewer thromboembolic complications. This is the only case reported of the contemporary use of Impella and ECMO as a bridge to full recovery in an adult with myocarditis. It also presents a novel use of the Impella device in decompressing the left ventricle of an adult patient on ECMO.

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Abstract Avascular necrosis (AVN) of the hips affects half of sickle cell anemia (SCA) patients and can rapidly lead to total collapse of the hip. Treatment with supportive therapy alone is unsuccessful and results in half of all patients requiring hip surgery within 2 years of diagnosis. Prognosis in advanced cases is dismal, with surgery eventually required in all patients. Alternative therapies including aggressive physical therapy (PT) and hip coring decompression (HCD) may improve the natural history of AVN but neither have been evaluated prospectively in SCD. The goal of the prospective randomized National AVN Trial in SCA is to evaluate the safety of HCD and PT for AVN. 46 patients were randomized to have either HCD of their study hip followed by 6 weeks of an aggressive PT protocol, or to undergo only the PT protocol. Both treatment arms are balanced for Ficat stage and patient age. Outcome measures include clinical improvement as measured by the Children’s Hospital Oakland Hip Evaluation Scale (CHOHES), a 100 point validated scale that assesses hip function and pain associated with AVN in SCA. Additional measures include X-ray progression and the need for surgical intervention. This report presents hip survival rates in 39 study patients: 17 patients underwent HCD and 22 were treated in the PT arm. Average patient age was 26 (range 10 to 50). 67% had bilateral disease. The average follow-up is currently 40 months. In the survival graph, treatment failure was defined as additional hip surgery. 4 of the 39 study hips (10%) were treatment failures: 1/9 (11%) of Stage I, 3/19 (16%) of Stage II, and 0/11 (0%) of Stage III hips. Figure Figure In addition to a low treatment failure rate, hips in each Ficat stage show evidence of clinical improvement. CHOHES scores improved 17 points at 1 year and 22 points at 2 years; even Stage III shows a 20 point improvement at 1 year and 21 points at 2 years. Our data indicates that both HCD and aggressive PT are beneficial in the treatment of AVN in SCA. PT may be effective in the treatment of even fairly advanced Stage III AVN. The AVN Trial in SCA is ongoing; patients will be followed for 3 to 5 years, and a comparison of HCD to aggressive PT will be made upon completion.

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La compresión mecánica de un nervio periférico en dos sitios diferentes a lo largo de su trayecto se define como síndrome de doble compresión. Esta enfermedad se basa en la teoría de la mayor susceptibilidad que tendría un nervio a nivel distal cuando este también se encuentra comprimido, en forma asintomática, a nivel proximal, debido a una alteración en el flujo axonal. Si bien la descompresión del túnel carpiano es una cirugía con resultados previsibles, hay pacientes operados por síndrome de túnel carpiano que no mejoran después de una cirugía, como cabría esperar. Si se excluye de este análisis a las comorbilidades, como diabetes, casos avanzados con atrofia muscular o descompresiones insuficientes, muchos de estos fracasos terapéuticos podrían estar fundamentados por el escaso diagnóstico de un segundo sitio de compresión concomitante. No obstante, existe gran controversia alrededor del síndrome de doble compresión que involucran no solo a su existencia, sino también a su incidencia y fisiopatología. El objetivo de esta publicación es presentar una revisión bibliográfica crítica del síndrome de doble compresión centrada en el compromiso del nervio mediano tanto en la muñeca como en el codo. AbstractThe mechanical compression of a peripheral nerve at two different sites is defined as double compression syndrome. This concept is based on the theory of the higher susceptibility that a nerve would present at a distal level when it is also compressed asymptomatically at a more proximal site. While carpal tunnel release is a surgery with predictable results, there are patients undergoing carpal tunnel decompression who do not have the expected improvement after surgery. Excluding from this analysis comorbidities such as diabetes, advanced cases with thenar atrophy, or incomplete decompressions, many of these therapeutic failures could be explained on the sub diagnosis of a second concomitant compression site. Despite this, there exists a big controversy around the double compression syndrome involving not only its existence but also its incidence and pathophysiology. Our objective is to perform a critical literature review of the double compression syndrome focused on the entrapment of the median nerve in the wrist and elbow.

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✓ Hypertrophy of the posterior spinal elements leading to compromise of the spinal canal and its neural elements is a well-recognized pathological entity affecting the lumbar or cervical spine. Such stenosis of the thoracic spine in the absence of a generalized rheumatological, metabolic, or orthopedic disorder, or a history of trauma is generally considered to be rare. Over a 2-year period the authors have treated six cases of thoracic myelopathy associated with thoracic canal stenosis. In four patients the deficits developed gradually and painlessly. The three older patients had a clinical profile characterized by complaints of pseudoclaudication, spastic lower limbs, and evidence of posterior column dysfunction. Two patients were younger adults with low thoracic myelopathy associated with local back pain after minor trauma. Both patients also had congenital narrowing of the thoracic spinal canal. Oil and metrizamide contrast myelography in the prone position were of limited value in diagnosing this condition; in fact, myelography may be misleading and result in erroneous diagnosis of thoracic disc protrusion, when the principal problem is dorsal and lateral compression from hypertrophied facets. Magnetic resonance imaging and computerized tomography sector scanning were more useful in the diagnosis of this disorder than was myelography. Thoracic canal stenosis may be more common than is currently recognized and account for a portion of the failures in anterior and lateral decompression of thoracic disc herniations.

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Object The cervical spine in a patient with ankylosing spondylitis (AS) (Bechterew disease) is exposed to maximal risk due to physical load. Even minor trauma can cause fractures because of the spine’s poor elasticity (so-called bamboo spine). The authors conducted a study to determine the characteristics of cervical fractures in patients with AS to describe the standard procedures in the treatment of this condition at two trauma centers and to discuss complications of and outcomes after treatment. Methods Between 1990 and 2006, 37 patients were surgically treated at two institutions. All patients were examined preoperatively and when being discharged from the hospital for rehabilitation. Single-session (11 cases) and two-session anterior–posterior (13 cases), anterior (11 cases), posterior (two cases), and laminectomy (one case) procedures were performed. The injury pattern, segments involved, the pre- and postoperative neurological status, and complications were analyzed. Preoperative neurological deficits were present in 36 patients. All patients experienced improvement postoperatively, and there was no case of surgery-related neurological deterioration. In patients in whom treatment was delayed because of late diagnosis, preoperative neurological deficits were more severe and improvement worse than those treated earlier. The causes of three deaths were respiratory distress syndrome due to a rigid thorax and cerebral ischemia due to rupture of the vertebral arteries. There were 12 perioperative complications (32%), three infections, one deep venous thrombosis, five early implant failures, and the three aforementioned fatalities. There were no cases of epidural hematoma. In all five cases in which early implant failure required revision surgery, the initial stabilization procedure had been anterior only. A comparison of complications and the outcomes at the two centers revealed no significant differences. Conclusions The standard intervention for these injuries is open reduction, anterior decompression and fusion, and anterior–posterior stabilization; these procedures may be conducted in one or two stages. Based on the early implant failures that occurred exclusively after single-session anterior stabilizations (five of 10—a failure rate of 50%), the authors have performed only posterior and anterior procedures since 1997 at both centers. Diagnostic investigations include computed tomography scanning or magnetic resonance imaging of the whole spine, because additional injuries are common. The causative trauma may be very slight, and diagnosis may be delayed because plain radiographs can be initially misinterpreted. In cases in which diagnosis is delayed, patients present with more severe neurological deficits, and postoperative improvement is less pronounced than that in patients in whom a prompt diagnosis is established. Because of postoperative pulmonary and ischemic complications, the mortality rate is high. In the present series the mortality rate was lower than the mean rate reported in the literature.

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The objective of the study was to compare clinical efficiency of the fusion after reconstruction with an anatomically shaped PEEK cage associated with a iliac crest autograft or MBCP in the treatment of cervical disc disease in randomized clinical trial. A multicente randomized, comparative and prospective study on 58 patients, with a 12 months follow up are reported. They underwent anterior cervical decompression and fusion being randomized for autologous graft or MBCP. Patients presenting purely degenerative disc disease were implanted with a PEEK cage filled with iliac crest autograft or MBCP. Pain and functionality as well as patients satisfaction were assessed through VAS, Neck Disability Index (NDI) and Patient Satisfaction index were recorded until 24 month follow-up. Radiological evaluation included plain and dynamic short X-rays at each stage of the follow up. The patients satisfaction rates was of 82% in the autograft group versus 96% in the MBCP group. Pain at the donor site was significantly more important in the autograft group at 3 weeks, 3 months and 1 year follow-up. No implant failures were recorded. Previously goat preclinical study was performed. Micro CT, light microscopy and shistomorphometry were related to the high performance of the MBCP insert for filling cage fusion, completing the clinical assessment of our clinical study. The use of MBCP insert is safe and avoids potential graft site morbidity and pain in comparison with an autologous graft procedure.

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Abstract BACKGROUND: Transorbital neuroendoscopic surgery (TONES) pathways attempt to address some of the technical challenges of accessing laterally placed anterior skull base lesions or paramedian lesions that cross neurovascular structures. TONES approaches allow simultaneous coplanar visualization and working space above and below the skull base. OBJECTIVE: To present an anatomic study, a description of the surgical techniques, and an analysis of the safety and efficacy of 20 consecutive procedures using TONES for a variety of pathological conditions. METHODS: Sixteen patients underwent 20 TONES procedures for anterior skull base pathology, including repair of cerebrospinal leak, optic nerve decompression, repair of cranial base fractures, and removal of 3 skull base tumors. Ten patients were male, and 6 were female. The mean age at presentation was 44 years. Follow-up was 6 to 18 months with a mean of 9 months. RESULTS: There were no significant complications or treatment failures in any of the 20 procedures. A variety of pathological conditions were treated, including cerebrospinal fluid leaks, fractures, mass lesions, and tumors. The TONES approach provided up to 4 separate access ports with ample exposure for manipulation and correction of the pathology. CONCLUSION: This anatomic and prospective outcome study demonstrates that TONES provides safe and effective coplanar endoscopic access to the anterior and middle cranial base. These novel TONES approaches may be added to the wide range of published minimally invasive armamentarium when approaching challenging skull base pathology.

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OBJECTIVEAs patients with metastatic cancer live longer, an increased emphasis is placed on long-term therapeutic outcomes. The current study evaluates outcomes of long-term cancer survivors following surgery for spinal metastases.METHODSThe study population included patients surgically treated at a tertiary cancer center between January 2010 and December 2015 who survived at least 24 months postoperatively. A retrospective chart and imaging review was performed to collect data regarding patient demographics; tumor histology; type and extent of spinal intervention; radiation data, including treatment dose and field; long-term sequelae, including local tumor control; and reoperations, repeat irradiation, or postoperative kyphoplasty at a previously treated level.RESULTSEighty-eight patients were identified, of whom 44 were male, with a mean age of 61 years. The mean clinical follow-up for the cohort was 44.6 months (range 24.2–88.3 months). Open posterolateral decompression and stabilization was performed in 67 patients and percutaneous minimally invasive surgery in 21. In the total cohort, 84% received postoperative adjuvant radiation and 27% were operated on for progression following radiation. Posttreatment local tumor progression was identified in 10 patients (11%) at the index treatment level and 5 additional patients had a marginal failure; all of these patients were treated with repeat irradiation with 5 patients requiring a reoperation. In total, at least 1 additional surgical intervention was performed at the index level in 20 (23%) of the 88 patients: 11 for hardware failure, 5 for progression of disease, 3 for wound complications, and 1 for postoperative hematoma. Most reoperations (85%) were delayed at more than 3 months from the index surgery. Wound infections or dehiscence requiring additional surgical intervention occurred in 3 patients, all of which occurred more than a year postoperatively. Kyphoplasty at a previously operated level was performed in 3 cases due to progressive fractures.CONCLUSIONSDurable tumor control can be achieved in long-term cancer survivors surgically treated for symptomatic spinal metastases with limited complications. Complications observed after long-term follow-up include local tumor recurrence/progression, marginal tumor control failures, early or late hardware complications, late wound complications, and progressive spinal instability or deformity.

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AbstractThe 1972 AAOO committee (Alford, 1972) guidelines brought some uniformity into the evaluation of therapy for Meniere's Disease. We have adhered to its recommendations in this long-term follow-up report of 21 saccus decompressions and 29 vestibular nerve sections performed on 46 patients between 1968 and 1977. Comparisons between these and other groups have been possible with regard to: 1. control of vertigo; 2. hearing; 3. tinnitus; and 4. development of hydrops in the contralateral ear. All the vestibular nerve section group have enjoyed sustained relief from vertigo. Class D results (recurrent vertigo) account for 14 per cent of the saccus decompression group at one year and 29 per cent at eight to 10-year follow-up. Hearing levels in both groups deteriorated in parallel as time progressed but tinnitus became less noticeable. Nineteen per cent of the long-term review patients showed evidence of developing cochlear hydrops in the contralateral ear. Conservative surgical procedures should be employed whilst any useful hearing exists, though the emphasis remains on controlling vertigo. Saccus decompression, despite its controversial therapeutic basis, will remain the first-line surgical procedure for many otologists. However, in the fit young Meniere's cripple or saccus decompression failure with serviceable hearing, vestibular nerve section remains the treatment of choice.

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Background: Despite the evident progress in treating vertebral column degenerative diseases, the rate of a so-called “failed back surgery syndrome” associated with pain and disability remains relatively high. However, this term has an imprecise definition and includes several different morbid conditions following spinal surgery, not all of which directly illustrate the efficacy of the applied technology; furthermore, some of them could even be irrelevant. Objective: To evaluate and systematize the reasons for persistent pain syndromes following surgical nerve root decompression. Study Design: Prospective, nonrandomized, cohort study of 138 consecutive patients with radicular pain syndromes, associated with nerve root compression caused by lumbar disc herniation, and resistant to conservative therapy for at least one month. The minimal period of follow-up was 18 months. Setting: Hospital outpatient department, Russian Federation Methods: Pre-operatively, patients were examined clinically, applying the visual analog scale (VAS), Oswestry Disability Index (ODI), magnetic resonance imaging (MRI), discography and computed tomography (CT). According to the disc herniation morphology and applied type of surgery, all participants were divided into the following groups: for those with disc extrusion or sequester, microdiscectomy was applied (n = 65); for those with disc protrusion, nucleoplasty was applied (n = 46); for those with disc extrusion, nucleoplasty was applied (n = 27). After surgery, participants were examined clinically and the VAS and ODI were applied. All those with permanent or temporary pain syndromes were examined applying MRI imaging, functional roentgenograms, and, to validate the cause of pain syndromes, different types of blocks were applied (facet joint blocks, paravertebral muscular blocks, transforaminal and caudal epidural blocks). Results: Group 1 showed a considerable rate of pain syndromes related to tissue damage during the intervention; the rates of radicular pain caused by epidural scar and myofascial pain were 12.3% and 26.1% respectively. Facet joint pain was found in 23.1% of the cases. Group 2 showed a significant rate of facet joint pain (16.9%) despite the minimally invasive intervention. The specificity of Group 3 was the very high rate of unresolved or recurred nerve root compression (63.0%); in other words, in the majority of cases, the aim of the intervention was not achieved. The results of the applied intervention were considered clinically significant if 50% pain relief on the VAS and a 40% decrease in the ODI were achieved. Limitations: This study is limited because of the loss of participants to follow-up and because it is nonrandomized; also it could be criticized because the dynamics of numeric scores were not provided. Conclusion: The results of our study show that an analysis of the reasons for failures and partial effects of applied interventions for nerve root decompression may help to understand better the efficacy of the interventions and could be helpful in improving surgical strategies, otherwise the validity of the conclusion could be limited because not all sources of residual pain illustrate the applied technology efficacy. In the majority of cases, the cause of the residual or recurrent pain can be identified, and this may open new possibilities to improve the condition of patients presenting with failed back surgery syndrome. Key words: microdiscectomy, nucleoplasty, epidural scar, facet joint pain, recurrent herniation, myofascial pain

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We report two cases of extraperitoneal compression of the intra-abdominal space resulting in abdominal compartment syndrome (ACS) with overt renal failure, which responded to operative decompression of the extra-peritoneal spaces. This discussion includes patient presentation, clinical course, diagnosis, interventions, and outcomes. Data was collected from the patient’s electronic medical record and a radiology database. ACS appears to be a rare but completely reversible complication of both retroperitoneal hematoma (RH) and rectus sheath hematoma (RSH). In patients with large RH or RSH consideration of intra-abdominal pressure (IAP) monitoring combined with aggressive operative drainage after correction of the coagulopathy should be considered. These two cases illustrate how a relatively benign pathology can result in increased IAP, organ failure, and ultimately ACS. Intervention with decompressive laparotomy and evacuation of clot resulted in return to normal physiologic function.

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Object Exposure of the lower cervical and upper thoracic spinal regions through a cervical incision without sternotomy has been described in cases of anterior decompression and methylmethacrylate vertebral body reconstruction. The use of anterior instrumentation and structural bone grafts in this procedure has not been well described. Methods Twenty-one patients underwent anterior cervicothoracic decompression, fusion, and fixation via a low cervical approach. Eight of these patients underwent lower cervical or upper thoracic corpectomy (C7–T4) through the cervical incision. The decompressive procedure was followed by placement of an allograft bone strut and an anterior locking plate system. No patient developed new neurological deficit related to the spinal cord or exiting nerve roots. Three of four patients with preoperative neurological deficits improved dramatically. Two patients developed recurrent laryngeal nerve palsy, of which one was permanent. There was one case of instrumentation-related failure, and two patients developed a superficial wound infection related to a posterior incision made as part of a 360° fusion. Patients were followed for a mean of 18.5 months (range 2–30 months). Two patients died (of metastatic cancer, and a motor vehicle accident, respectively) during the follow-up period. Conclusions Anterior decompression, fusion, and fixation is feasible via a cervical incision. This procedural approach spares the patient the morbidity associated with sternotomy or the lateral extracavitary approach. A thorough preoperative assessment of mediastinal anatomy is essential for the safe execution of these procedures.

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The purpose of this investigation was to determine the failure rate of in situ decompression for cubital tunnel syndrome as determined by the need for additional surgery. We performed a comprehensive chart review of 56 adult patients who had undergone in situ decompression for cubital tunnel syndrome in 69 extremities with more than 1 year follow-up. The patients completed a comprehensive questionnaire concerning preoperative and postoperative pain, numbness, and weakness. After decompression, symptoms were improved substantially or resolved. Five limbs (7%) with persistent symptoms postoperatively were treated successfully with anterior submuscular transposition. These data suggest that in situ decompression of the ulnar nerve is a reliable treatment for cubital tunnel syndrome and has a low failure rate. The uncommon patient with continued symptoms after decompression can be treated effectively with transposition of the ulnar nerve.

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Object There has been increasing interest in spinous process tension band devices, as distinct from spinous process spacers and plates. The purpose of this study was to load spinous processes caudally at L-4 and cranially at L-5 parallel to the long axis of the spine in a biomechanical model of tension band loading. The goal was to provide normative data for the design of a spinous process tension band device after varying degrees of surgical decompression and across varying bone mineral densities (BMDs). Methods Fresh-frozen L4–5 lumbar vertebrae pairs were divided into 3 surgical groups: intact, midline-sparing decompression (laminotomy and medial facetectomy), and midline decompression with foraminotomy (one-half of spinous process resected, laminotomy, and medial facetectomy). After decompression, specimens were disarticulated into isolated L-4 and L-5 vertebrae. Each vertebra was loaded to failure in a caudal (L-4) or cranial (L-5) direction parallel to the long axis of the spine via a 6-mm-wide strap looped around the spinous process. Failure strength and mode were recorded. Results Seventeen L-4 and L-5 lumbar vertebrae were tested from 17 cadavers. There were 10 male (59%) and 7 female (41%) cadavers, with a mean age of 66.6 ± 16.5 years (range 41–100 years) and a mean BMD of 1 ± 0.23 g/cm2 (range 0.66–1.34 g/cm2); the mean is expressed ± SD throughout. For data analysis, specimens were grouped into those with no or midline-sparing decompression (Group 1: 11 of 17) and those with midline decompression (Group 2: 6 of 17). At L-4, the mean failure strength for Group 1 was 453 ± 162 N, and for Group 2 it was 264 ± 99 N (p = 0.02; Cohen's d = 1.4). At L-5, the mean failure strength for Group 1 was 517 ± 190 N, and for Group 2 it was 269 ± 184 N (p = 0.02; Cohen's d = 1.3). There was no significant difference in failure strength between the intact and midline-sparing decompression groups at L-4 (p = 0.91) or L-5 (p = 0.41). Conclusions Across specimens with a wide range of BMDs, midline-sparing decompression was not found to decrease the mean failure strength of the L-4 and L-5 spinous processes (453 and 517 N, respectively), whereas midline surgical decompression decreased the failure strength of these processes (264 and 269 N, respectively) in a biomechanical model of tension band loading relevant to the design of a tension band device.

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The study objective is to demonstrate our experience of employment of O-Arm intraoperative portable сomputed tomography scanner combined with navigation system Stealth Station Treon Plus (Medtronic Navigation) during decompressive-stabilizing surgeries for patients with primary and metastatic spinal tumors.Materials and methods. We have reviewed results of surgical treatment of 44 patients (24 males and 20 females, average age is 54.3 ± 1.8), who were hospitalized and operated in the department of spinal neurosurgery in Federal Centre of Neurosurgery (Tyumen). All surgeries were performed by one surgical team in the period of April 2011 to June 2017. All patients underwent full clinical examination according to diagnostic algorithm, including assessment of general condition, degree of bone and visceral dissemination, neurological status, quality of life, pain syndrome intensity. The most common cause of vertebral lesions was plasma cell myeloma (15 patients, 34.1 %), metastatic spinal lesions (12 patients, 27.3 %). Patients were subjected to posterior decompression and stabilization with total and subtotal excision of mass lesions. Assessment of degree of decompression and transpedicular fixation were carried out visually using O-Arm combined with navigation station.Results. In 6 to 12 months after surgery 79.5 % of patients demonstrated significant improvement of neurological status, specifically a decrease of conduction and sensory disorders. Degree of pain syndrome was reduced by 3.6 times. Using O-Arm combined with navigation station we placed screws adequately in 99.6 % of the cases. The main technical problem that occurred during the surgery was the failure of navigation system caused by: defect of reflective spheres, distant installation and shift of referential frame, aging of Jamshidi needle, malfunction of navigation camera, failure of data transfer from navigation station.Conclusion. The use of O-Arm combined with navigation station for decompressive and stabilizing surgeries in patients with spine and spinal cord tumors let us perform surgeries with 3D control and navigation, conduct surgeries in areas where it is hard to determine surgical landmarks, ensure precision of transpedicular screw implantation, accomplish total resection of mass lesions with minimal blood loss and less aggressive surgical intervention and properly decompress the spinal canal which, eventually, result in positive anatomical and functional characteristics, and contribute to good general outcome of surgical intervention.Conflict of interest. The authors declare no conflict of interest.Informed consent. All patients gave written informed consent to participate in the study and to the publication of their data.

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Object Chiari malformation Type I (CM-I) is often associated with scoliosis. It remains unclear which subgroups of patients are most likely to experience progression of spinal deformity after cervicomedullary decompression. The authors' goal was to determine the time frame of curvature progression and assess which patient subgroups are at greatest risk for progression of spinal deformity after surgery. Methods The authors retrospectively reviewed the records of all pediatric patients with significant scoliosis in whom suboccipital decompression was performed to treat for CM-I during a 10-year period at a single academic institution. Clinical, radiological, and operative variables were assessed as independent factors for failure (worsening of scoliosis) by using a univariate regression analysis. Results Twenty-one children (mean age 9 ± 3 years; 4 male) underwent hindbrain decompression for CM-I–associated scoliosis and were followed for a mean of 39 months. All patients harbored a syrinx. Eight patients (38%) experienced improvement in scoliosis curvature, whereas 10 (48%) suffered a progression. Thoracolumbar junction scoliosis (p = 0.04) and failure of the syrinx to improve (p = 0.05) were associated with 5- and 4-fold respective increases in the likelihood of deformity progression. Each increasing degree of preoperative Cobb angle was associated with an 11% increase in the likelihood of scoliotic curve progression (p < 0.05). Conclusions Over one third of patients with CM-I–associated scoliosis will improve after cervicomedullary decompression alone. Cervicomedullary decompression is a good first-line option, particularly in children with concordant posterior fossa symptoms. Patients presenting with more severe scoliosis (increasing Cobb angle) or scoliosis that crosses the thoracolumbar junction may benefit from earlier orthopedic involvement and should be monitored regularly for curvature progression after cervicomedullary decompression. In cases in which there is a failure of the syrinx to show improvement after suboccipital decompression, the patients are also more likely to develop curvature progression.

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Background:Idiopathic intracranial hypertension (IIH) is a condition that usually affects young, obese women. Management is aimed at controlling symptoms of increased intracranial pressure (ICP) and prevention of visual failure due to papilledema. A common surgical treatment for IIH is the insertion of a lumboperitoneal shunt (LP shunt). Secondary symptomatic tonsillar herniation is an uncommon side effect following lumbar cerebrospinal fluid diversion.Methods:We present two cases of symptomatic secondary tonsillar herniation, one associated with a syrinx, in patients with IIH following valved LP shunting. Treatment options for this side effect may include transplanting the shunt to the ventricular system or decompression of the foramen magnum.Results:In our cases we elected to alter the construct of the LP shunt by inserting a programmable valve which led to clinical and radiological reversal of the tonsillar herniation as well as a dramatic reduction in an associated syrinx.Conclusions:When faced with LP shunt induced symptomatic secondary tonsillar herniation, consideration may be given to altering LP shunt dynamics, prior to inserting a ventricular catheter into normal sized ventricles or decompressing the posterior fossa.

Abstract:

Background Thoracic aortic aneurysm rupture is often a fatal condition. Emergent thoracic endovascular aortic repair (TEVAR) has emerged as a suitable treatment option. Unfortunately, respiratory complications from hemothorax continue to be an important cause of morbidity and mortality even after successful management of the aortic rupture. We hypothesize that early hemothorax decompression after TEVAR for ruptured aneurysms decreases the rate of postoperative respiratory complications. Methods Single-center, retrospective eight-year review of ruptured thoracic aneurysms treated with TEVAR. Results Seventeen patients presented with ruptured degenerative thoracic aortic aneurysms, all of which were successfully treated emergently with TEVAR. The mean age was 74 years among the 12 (70.6%) men and 5 (29.4%) women treated. Inpatient and 30-day mortality rates for the entire cohort were both 17.6% (three patients). The 90-day mortality rate was 47.1% (eight patients). Thirty-day morbidities of the entire cohort included stroke ( n = 1, 5.9%), spinal cord ischemia ( n = 3, 17.6%; only one was temporary), cardiac arrest ( n = 4, 23.5%; 3 were fatal), respiratory failure ( n = 5, 29.4%), and renal failure ( n = 5, 29.4%). A large hemothorax was identified in the majority of patients ( n = 14, 82.4%). While six (42.9% of 14) patients had immediate chest tube decompression on the day of index procedure, three (21.4% of 14) patients had decompression on postoperative day 1, 4, and 7, respectively. Although not statistically significant, there were trends toward higher rates of respiratory failure (50.0% vs. 16.7%, P = 0.198) and 90-day mortality (62.5% vs. 33.3%, P = 0.280) for patients with delayed or no hemothorax decompression when compared to patients with immediate hemothorax decompression. Conclusions The morbidity and mortality of ruptured degenerative thoracic aortic aneurysms remains high despite the introduction of TEVAR. In this single-center experience, there was a trend toward decreased respiratory complications and increased survival with early chest decompression of hemothorax after TEVAR.

Abstract:

Object The authors undertook this study to document the clinical outcomes of microendoscopic laminotomy, a minimally invasive decompressive surgical technique using spinal endoscopy for lumbar decompression, in patients with lumbar spinal stenosis (LSS). Methods A total of 366 patients were enrolled in the study and underwent microendoscopic laminotomy between 2007 and 2010. Indications for surgery were single- or double-level LSS, persistent neurological symptoms, and failure of conservative treatment. Microendoscopy provided wide visualization through oblique lenses and allowed bilateral decompression via a unilateral approach, through partial resection of the base of the spinous process, thereby preserving the supraspinous and interspinous ligaments and contralateral musculature. Clinical symptoms and signs of low-back pain were evaluated prior to and following surgical intervention by applying the Japanese Orthopaedic Association (JOA) scoring system, Roland-Morris Disability Questionnaire (RMDQ), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), and 36-Item Short Form Health Survey (SF-36). These items were evaluated preoperatively and 2 years postoperatively. Results Effective circumferential decompression was achieved in all patients. The 2-year follow-up evaluation was completed for 310 patients (148 men and 162 women; mean age 68.7 years). The average recovery rate based on the JOA score was 61.3%. The overall results were excellent in 34.9% of the patients, good in 34.9%, fair in 21.7%, and poor in 8.5%. The mean RMDQ score significantly improved from 11.3 to 4.8 (p < 0.001). In all categories of both JOABPEQ and SF-36, scores at 2 years' follow-up were significantly higher than those obtained before surgery (p < 0.001). Twelve surgery-related complications were identified: dural tear (6 cases [1.9%]), wrong-level operation (1 [0.3%]), transient neuralgia (4 [1.3%]), and infection (1 [0.3%]). All patients recovered, and there were no serious postoperative complications. Conclusions Microendoscopic laminotomy is a safe and very effective minimally invasive surgical technique for the treatment of degenerative LSS.

Abstract:

Background: Lumbar spinal canal stenosis surgery has recently improved with the use of minimally invasive techniques. Less invasive procedures have emerged, and microendoscopic decompression through smaller incisions is frequently performed. Tubular surgery with the assistance of endoscopic surgery procedures has led to particularly remarkable changes in surgery, with reduced tissue trauma and morbidity. Purpose: The purpose of this study was to compare the clinical outcomes of two different minimally invasive decompressive surgical techniques (microendoscopic bilateral decompression surgery using the unilateral approach [microendoscopic laminectomy (MEL)] and microendoscopy-assisted muscle-preserving interlaminar decompression (MILD; ME-MILD)) using spinal endoscopy for lumbar spinal canal stenosis measured using a visual analog scale (VAS), the Japanese Orthopedic Association (JOA) score, and the JOA Back Pain Evaluation Questionnaire (JOABPEQ), which is based on a patient-oriented scoring system. Study design: This study was a retrospective review of prospectively collected surgical data. Methods: The study included 81 patients (MEL 39 patients, 20 men and 19 women, mean age 68.9 years; and ME-MILD 42 patients, 22 men and 20 women, mean age 73.1 years) with lumbar spinal stenosis (LSS). The indications for surgery were moderate-to-severe stenosis, persistent neurological symptoms, and failure of conservative treatment over 3 months, with a JOA score under 15 points or intermittent claudication at 100 m. This study included patients having LSS at a single vertebral level (L4/5). Results: Low back pain, buttock-leg pain, and numbness were significantly improved in terms of the VAS score from 3 months with both MEL and ME-MILD. In all periods, JOA scores over 3 years of follow-up were significantly higher than those obtained before surgery with both MEL and ME-MILD, and there were improvements of low back pain and walking function. Conclusions: These observations demonstrate that ME-MILD is a safe and very effective minimally invasive technique for degenerative LSS, similar to MEL.