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Journal of Craniovertebral Junction and Spine
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   Table of Contents - Current issue
Coverpage
April-June 2018
Volume 9 | Issue 2
Page Nos. 81-132

Online since Tuesday, June 19, 2018

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EDITORIAL  

Is the symptom of cervical or lumbar radiculopathy an evidence of spinal instability? p. 81
Atul Goel
DOI:10.4103/jcvjs.JCVJS_52_18  
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ORIGINAL ARTICLES Top

Interlaminar lumbar device implantation in treatment of Baastrup disease (kissing spine) p. 83
Keyvan Mostofi, Babak Gharaei Moghadam, Morad Peyravi
DOI:10.4103/jcvjs.JCVJS_139_17  
Background: Baastrup disease (BD) is characterized by the degenerative changes of spinous processes and interspinous soft tissues. It is more common among aged persons. This disorder is a relatively common cause of low back pain. Its incidence is underestimated. A few studies have investigated BD epidemiology and proposed treatment efficacy. The aim of this paper is to establish impact and outcome evaluations of managing the patients with Baastrup disease who have been treated by implementing of floating interlaminar device (FID). Materials and Methods: Between January 2015 and September 2017, 47 patients have been operated by implementing of FID for BD in our Department of Neurosurgery. Results: Of the 47 patients, 20 were female and 27 were male with an average age of 51.78. On average, we followed the cases up to 11 months. The most frequent level of disorder was L4–L5 followed by L3–L4 level. The condition of 45 patients improved after surgery according to Oswestry low back pain score and 39 patients could return to their work. Conclusion: The results from our study corroborate that implementing of FID is a good alternative treatment for patient chronic low back pain due to BD This technique contributes to improving a better living situation for the patients given the correct indications.
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Long-term clinical and radiological outcomes following anterior cervical discectomy and fusion by zero-profile anchored cage p. 87
Giovanni Grasso, Alessandro Landi
DOI:10.4103/jcvjs.JCVJS_36_18  
Objectives: The purpose of this study was to extend the results of our previous study providing a minimum of 4-year follow-up results of a prospective study following implantation of a cervical cage with an integrated fixation system. Summary of Background Data: The use of cervical intersomatic cages with an integrated fixation system for anterior cervical discectomy and fusion (ACDF) has increased rapidly in this last decade. In addition to immediate stabilization, these implants allow avoidance of anterior plating and iliac crest bone-grafting. Methods: Patients were studied prospectively, and data were collected and analyzed. Intersomatic cages with an integrated fixation system were used in consecutive 100 patients operated on for ACDF. Intraoperative parameters, clinical, and outcome scores were recorded. Radiographs were taken to evaluate implant positioning and fusion rate, disc height (DH), and changes in adjacent disc spaces. All the patients had a minimum 4-year follow-up. Results: A total of 127 cages were implanted in the 100 patients. Compared to preoperatively, the visual analog scale, 36-item short-form health survey, the Japanese Orthopedic Association, and the Neck Disability Index scores were significantly improved at 1-year follow-up without change during subsequent follow-up. At 4 years, the fusion rate was 97%. Two patients complained about minor dysphagia-related symptoms, which resolved rapidly. DH index and cervical Cobb angle were significantly restored after surgery, and the results were maintained during the whole follow-up. Conclusions: This is a prospective, independently conducted study on cages with an integrated fixation system with 4-year long follow-up. Findings of this study seem to be interesting regarding outcomes and low complications rates compared to recent series using other implants with integrated fixation system. Larger, randomized controlled trials are warranted.
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Late appearance of low back pain relating to modic change after lumbar discectomy p. 93
Keyvan Mostofi, Babak Gharaei Moghaddam, Morad Peyravi
DOI:10.4103/jcvjs.JCVJS_25_18  
Background: In practice of neurosurgery, we find that a wide number of patients referred for refractory low back pain have a history of lumbar discectomy. In a large number of them, magnetic resonance imaging (MRI) studies detect Modic changes (MCs). The aim of this study is to determine the relationship between emergence of MC and low back after lumbar discectomy. Materials and Methods: Three hundred and fifty-eight patients with a medical history of discectomy had a MC at the level of the operated disc without any other discopathy. They have been selected from among the 1154 patients operated for lumbar disc herniation over 5 years. Results: Two hundred and fourteen patients (67.30%) had not presented MCs on preoperative MRI. Conclusion: Our study awakens a strong presumption about the relationship between emergence of MC after lumbar discectomy.
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Application and use of subcutaneous stay sutures in anterior cervical spine surgeries with a transverse neck incision: A technical report p. 96
Ashok Keshav Rathod, Rakesh Padmakar Dhake, Mohit Navinchand Muttha, Amit Indrasan Singh, Dattatray Vilas Thakur
DOI:10.4103/jcvjs.JCVJS_153_17  
Objective/Purpose: The objective of this study is to describe our experience with the use of stay sutures and transverse neck incision for anterior cervical spine surgeries involving multiple levels. Summary of Background Data: Transverse incisions on neck usually heal with minimal fibrosis resulting in cosmetically acceptable scars whereas vertical incision, although provides greater exposure, heals with extensive fibrosis resulting in ugly scars. Transverse incision is thus highly recommended. However, the fear of nonextensibility of transverse incision for multilevel fusion has led to the preference of vertical incision, development of techniques for identifying the optimal level of the incision, or has suggested the usage of two transverse incisions. Materials and Methods: Seventy-six patients underwent anterior cervical spine surgeries using a transverse neck incision for single or multilevel discectomy/corpectomy and fusion. Having divided the platysma, dissection was carried down to the anterior surface of the cervical spine between the carotid sheath laterally and the trachea and esophagus medially. Stay sutures were taken through the platysma and subcutaneous tissue, converting the transverse incision into a quadrilateral window providing access for as much as three-level corpectomy or five levels of fixation. Results: All the wounds healed with no evidence of wound-related complications, leaving a cosmetically acceptable scar. Conclusion: Using appropriately placed stay sutures, a transverse neck incision taken in the middle of the field of work can provide enough of a surgical window to perform multilevel fusion surgeries. Its simplicity and cost-effectiveness make it easily implementable, addressing the underlying pathology adequately with best possible cosmetic results.
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Lumbar fusion for lytic spondylolisthesis: Is an interbody cage necessary? p. 101
Joseph Boktor, Tishi Ninan, Rhys Pockett, Iona Collins, Ahmed Sultan, Wael Koptan
DOI:10.4103/jcvjs.JCVJS_20_18  
Study Design: This study was a retrospective observational study. Purpose: The purpose of the study was to determine the radiological and clinical outcome of using locally sourced autologous bone graft in the surgical management of single-level lumbar lytic spondylolisthesis. Background: Many spinal surgeons supplement pedicle screw fixation of lumbar spondylolisthesis with cages. In developing countries, the high cost of interbody cages has precluded their use, with surgeons resorting to filling the interbody space with different types of bone graft instead. This study reports on the clinical and radiological outcome of posterior lumbar interbody fusions for low-grade lytic spondylolisthesis using locally sourced autologous bone graft. Material and Methods: Posterior interbody fusion was performed in 22 consecutive patients over 18-month period, using (BRAND) pedicle screw system and locally sourced bone graft, i.e., bone removed during neural decompression. There were no postoperative restrictions, and all patients underwent clinical outcome measurements using Oswestry Disability Index (ODI), visual analogue pain score (VAS) at a minimum follow-up of 12 months, and computed tomography (CT) assessment of fusion with intraobserver validation by radiology consultant blinded, at 6 and12 months. Nearly 50% of the population were smokers. Results: There was significant clinical improvement in ODI, VAS back pain, and VAS leg pain (P < 0.001). By contrast, the radiologic fusion rate measured by CT at 12 months was less satisfactory at 64%. There was no difference in clinical outcome between the fused group and nonfused population. Conclusions: These results indicate that the use of locally sourced bone graft in single-level lumbar lytic low-grade spondylolisthesis. Interbody fusion provides good clinical outcomes. The use of an interbody cage may not be clinically necessary. Our radiologic outcome, however, shows inferior fusion rates compared with published data. Future research will focus on long-term outcomes
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Navigated minimally invasive unilateral laminotomy with crossover for intraoperative prediction of outcome in degenerative lumbar stenosis p. 107
Salvatore Massimiliano Cardali, Fabio Cacciola, Giovanni Raffa, Alfredo Conti, Maria Caffo, Antonino Germanò
DOI:10.4103/jcvjs.JCVJS_45_18  
Background: Different surgical techniques have been described for treatment of degenerative lumbar stenosis (DLS). Only postoperative measures have been identified as predictors of efficacy of decompression. The objective of this study is to assess the role of navigated unilateral laminotomy with crossover to achieve and predict a satisfying decompression and outcome in DLS. Materials and Methods: We enrolled patients with DLS who underwent navigation-assisted unilateral laminotomy with crossover. The extent of decompression was evaluated during surgery using neuronavigation. The outcome was assessed through the Oswestry disability index (ODI) and visual analog scale (VAS) for leg pain. Outcome correlation with the extent of the intraoperative bone decompression was analyzed. Finally, the outcome, surgical time, and in-hospital length-of-stay were compared with a control group treated through standard unilateral laminotomy. Results: Twenty-five patients were treated using the navigated technique (Group A), 25 using the standard unilateral laminotomy (Group B). In Group A, a cut-off value ≥0.9 cm for bone decompression revealed to be an intraoperative predictor of good outcome, both regarding the ODI and VAS scores (P = 0.0005; P = 0.002). As compared with Group B, patients operated using the navigated technique showed similar operative times, in-hospital length-of-stay, ODI scores, but improved VAS scores for leg pain (P = 0.04). Conclusions: The intraoperative navigated evaluation of the bone decompression could predict the outcome allowing satisfactory results in unilateral laminotomy for DLS. The navigated technique also could lead to an improved decompression of lateral recesses resulting in better control of leg pain as compared to standard unilateral laminotomy.
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Cadaveric device-injected very high-viscosity cement during vertebroplasty p. 116
Waleed Awwad, Amna Baljoun, Yasir Alabdulkarim, Abdulrahman D Algarni, Chung-Hwan Kim, Demitri Giannitsios, Lorne Beckman, Jean Ouellet, Thomas Steffen
DOI:10.4103/jcvjs.JCVJS_143_17  
Introduction: Cement extravasation during vertebroplasty (VP) is the most commonly reported complication. Cement viscosity is considered the single most important predictor of the risk of extravasation. Certainly, injecting high-viscosity cement (HVC) is difficult to utilize in real practice. We invented a new device capable of injecting high-viscosity with ease and at a distance to avoid radiation. The aim of this study is to confirm the efficacy and safety of the new device on cadaveric vertebrae. Methodology: A 126 osteoporotic vertebral bodies were harvested from cadavers. Eighty vertebrae were included in the study. Computer-randomization software was used to allocate specimens over two main groups, Conventional VP and New Device. Both groups were further subdivided into two subgroups; high-viscosity and low-viscosity. A custom device was used on each vertebra to induce a compression fracture. Results: Injecting HVC was associated with a lower leakage volume compared with low-viscosity cement. HVC was associated with no leakage into the spinal canal. It was also associated with a low incidence of vascular extravasation (P < 0.001). The mean volume of cement leakage in the low-viscosity group was 0.23 and 0.15 cc, for the Conventional VP and New Device, respectively. In both groups, the most common site for leakage was the vertebral end plate, which was exhibited more in the low-viscosity group (71.5%) compared with the high-viscosity group (42.5%). The preset target amount of cement to be injected was reached in 99% of the time when injecting HVC with the New Device, compared with 62% using the Conventional VP. In both groups, there was no correlation between the amount of cement injected and the amount of leakage. Conclusion: The new device is capable of injecting HVC easily, with a lower incidence of cement leakage. It also minimized the risk of radiation exposure to the surgeon.
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Technical pearls and surgical outcome of early transitional period experience in minimally invasive lumbar discectomy: A prospective study p. 122
Suyash Singh, Jayesh C Sardhara, Deepak Khatri, Jeena Joseph, Abhijit N Parab, Kamlesh S Bhaisora, Kuntal Kanti Das, Anant Mehrotra, Arun Kumar Srivastava, Sanjay Behari
DOI:10.4103/jcvjs.JCVJS_47_18  
Background: There is growing indications of minimally invasive spine surgery. The inherent attitude and institutive learning curve limit transition from standard open surgery to minimally invasive surgery demanding understanding of new instruments and correlative anatomy. Materials and Methods: In this prospective study, 80 patients operated for lumbar disc prolapse were included in the study (between January 2016 and March 2018). Fifty patients (Group A) operated by various minimally invasive spine surgery (MISS) techniques for herniated disc disease were compared with randomly selected 30 patients (Group B) operated between the same time interval by standard open approach. Surgical outcome with Oswestry Disability Index (ODI) and patient satisfaction score was calculated in pre- and postoperative periods. Results: Mean preoperative ODI score in Group A was 31.52 ± 7.5 standard deviation (SD) (range: 6–46; interquartile range [IQR]: 8; median: 32.11) and postoperative ODI score was 9.20 ± 87.8 SD (range: 0–38; IQR: 11; median: 6.67). Mean preoperative ODI score in Group B was 26.47 ± 4.9 SD (range: 18–38; IQR: 4; median: 25) and postoperative ODI score was 12.27 ± 8.4 SD (range: 3–34; IQR: 12; median: 10.0). None of the patients was unsatisfied in either group. On comparing the patient satisfaction score among two groups, no significant difference (P = 0.27) was found. Discussion: On comparing the change in ODI and preoperative ODI among both groups, we found a significant difference between the groups. It is worth shifting from open to MISS accepting small learning curve. The satisfaction score of MISS in early transition period is similar to open procedure. Conclusion: The MISS is safe and effective procedure even in transition period for the central and paracentral prolapsed lumbar intervertebral disc treatment. The results are comparable, and patient satisfaction and symptomatic relief are not compromised.
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CASE REPORT Top

De novo syrinx formation in a patient with Type I Chiari malformation: Case report and review of the literature p. 130
David Stewart-Watson, Prynk Sinha, Thomas A Carroll
DOI:10.4103/jcvjs.JCVJS_4_18  
This report highlights the case of a 56-year-old woman with an incidental type I Chiari malformation who on initial presentation had no associated cervical syrinx on magnetic resonance imaging (MRI), but who on subsequent MRI 8 years later was found to have developed a de novo upper cervical cord syrinx.
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