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Journal of Craniovertebral Junction and Spine
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   Table of Contents - Current issue
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July-September 2018
Volume 9 | Issue 3
Page Nos. 133-217

Online since Monday, October 8, 2018

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EDITORIALS  

Prolapsed, herniated, or extruded intervertebral disc-treatment by only stabilization Highly accessed article p. 133
Atul Goel
DOI:10.4103/jcvjs.JCVJS_84_18  PMID:30443129
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Diaphragma sellae: Anatomical and surgical implication in surgery for pituitary adenomas – Highlighting contributions by Goel p. 135
Abhidha Shah, Mohamed Said Mohamed Elsanafiry
DOI:10.4103/jcvjs.JCVJS_85_18  PMID:30443130
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ORIGINAL ARTICLES Top

Cervical fusion for degenerative disease: A comprehensive cost analysis of hospital complications in the United States from 2002 to 2014 p. 140
Hansen Deng, John K Yue, Angel Ordaz, Ernesto J Rivera, Catherine G Suen, David C Sing
DOI:10.4103/jcvjs.JCVJS_62_18  PMID:30443131
Purpose: Recent data suggest great variability in costs for surgical hospitalization for spinal surgery. However, the magnitude of expenditures attributable to complications is unknown. The purpose of this study is to describe cost of care associated with surgical and medical complications after cervical spine surgery. Materials and Methods: A retrospective cohort study utilizing the National Inpatient Sample years 2002–2014 was conducted. A weighted sample of 901,508 adults undergoing elective cervical fusion for degenerative indications was extracted using diagnostic and procedure codes. Twelve categories of major complications were identified, and patient/hospital variables were evaluated as predictors of the overall reimbursed cost using multivariate regression. Mean differences (B) and 95% confidence intervals were reported. Results: The mean age was 52.2 ± 11.4 years, with 5.2% of patients experiencing a complication. Mean overall increase in inflation-adjusted cost associated with complication was $16,435 ± 10,358, varying significantly by type of complication, surgical approach, and number of levels fused. The most common complications and their attributed costs were dysphagia (1.6%, B = $2624 [2476–2771], P < 0.001), pulmonary complications (1.0%, B = $9334 [9110–9558], P < 0.001), and device-related complications (0.9%, B = $3125 [2927–3324], P < 0.001). The costliest complications were infection (0.1%, B = $25359 [24723–25994], P < 0.001), thromboembolism (0.1%, B = $17480 [16808–18153], P < 0.001), and neurological complications (0.2%, B = $10098 [9629–10567], P < 0.001). Conclusions: Although complications are rare after elective cervical fusion, they are associated with dramatically increase costs of care as high as $25,359 in the setting of postoperative infection. Improved understanding of the economic magnitude of complications may help guide efforts in reducing health care spending and improving perioperative care.
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Management of occipitocervical junction and upper cervical trauma p. 148
Ahmet Dagtekin, Emel Avci, Vural Hamzaoglu, Hakan Ozalp, Derya Karatas, Kaan Esen, Celal Bagdatoglu, Mustafa K Baskaya
DOI:10.4103/jcvjs.JCVJS_72_18  PMID:30443132
Objective: The treatment modality of occipitocervical junction (OCJ) and upper cervical traumas carries great importance because of unique form of bone, complex ligamentous, and neurovascular structure. Materials and Methods: Eighty-eight patients were admitted to Mersin University Department of Neurosurgery between January 2007 and January 2017 for injuries of the OCJ and upper cervical spine and evaluated retrospectively. In the group, there were 60 male, 28 female patients in the mean age of 42.9 (18–87) years. Among those, 2 occipital condyle fractures, 28 C1 fractures (26 isolated and 2 with transverse ligament injury), 9 combined C1/C2 fractures, 6 rotatory C1/C2 dislocations, and 43 C2 fractures (32 odontoid, 5 Hangman's, and 6 miscellaneous fractures) were diagnosed. In addition to clinical cases, ten cadavers were used to study the OCJ in a step-wise manner. Results: Occipital condyle fractures, isolated C1 fractures, and rotatory C1/C2 dislocations were treated conservatively. Two patients with C1 fracture including transverse ligament injury were operated in one of the methods of C1–C2 fusion which is posterior sublaminar wiring. Five patients having Type II odontoid fracture were treated surgically. One instable Hangman's fracture patient was treated as anterior cervical discectomy and fusion. Conclusions: Cases with isolated C1 fracture with intact transverse ligament should be conservatively treated without surgical approach. Atlas fractures with transverse ligament rupture, odontoid Type II fractures with dislocation >6 mm, and unstable Hangman's fractures required surgical treatment. Vital neurovascular, ligamentous, and accompanying bone structures should be evaluated for diagnosis and treatment modality. In addition, patient's health status, patient's treatment preference, and surgical team experience are the affecting factors for the decision of surgery.
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Microendoscopic discectomy for lumbar disc herniations p. 156
Anil Patil, Ashish Chugh, Sarang Gotecha, Megha Kotecha, Prashant Punia, Aditya Ashok, Gaurav Amle
DOI:10.4103/jcvjs.JCVJS_61_18  PMID:30443133
Introduction: Lumbar disc herniation is one of the main causes of discogenic low back pain and reported to affect 60%–80% of people during their lifetime. The two main surgical modalities for intervertebral disc surgery are standard open discectomy and minimally invasive discectomy which include percutaneous endoscopic lumbar discectomy and microendoscopic discectomy (MED). We report our experience with the same technique of MED to evaluate the efficacy of MED for lumbar disc pathology. Aims and Objectives: The aims and objectives were to study the efficacy, advantages, and associated limitations and complications of MED in lumbar disc herniations. Materials and Methods: This study was carried out on 300 patients who had single-level herniated disc. The procedure was done by Microscopic Endoscopic Tubular Retraction System. Preoperative assessment of Visual Analog Scale (VAS) and modified Suezawa and Schreiber (MSS) clinical scoring system was documented 1 day prior to surgery. Postoperative results were determined to be excellent, good, fair, or poor according to MacNab criteria and also evaluated by MSS clinical scoring system on postoperative day 7 and after 6 months. Results: A total of 187 patients were males and 113 patients were females and a majority of patients were in the age group of 31–40 years. A total of 192 patients had disc herniations at L4–L5 level. The mean operative time was 82 min and the mean hospital stay was 5.3 days. Eighteen cases (6%) developed postoperative complications including discitis, dysesthesia, recurrent prolapsed intervertebral disc, residual disc, dural tear, and nerve root injury. Mean preoperative VAS score was 8.7 and the mean postoperative VAS scores at postoperative day 7 and at 6 months were 2.25 and 1.12, respectively. The mean preoperative MSS score was 3.27 and the MSS scores at postoperative day 7 and at 6 months were 7.42 and 8.2, respectively. The overall successful outcome of the endoscopic discectomy after 6-month follow-up on the basis of VAS improvement percentage was 87.6%, MSS scoring percentage was 91.6%, and MacNab scoring percentage was 92.67%. Conclusion: MED is a safe and effective technique. It offers decreased blood loss, shorter operative time, shorter in-hospital stay, decreased need for pain medication, decreased rate of infection, and a shorter return to work time. Limitations of this technique include a learning curve which is related to surgery time, complications, conversion to open procedures, and recurrent disc herniation.
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Novel L5-S1 interbody fusion technique for root anomalies or abnormal root configurations of L5-S1 foramens p. 163
Onur Yaman, Ali Fahir Ozer
DOI:10.4103/jcvjs.JCVJS_33_18  PMID:30443134
Purpose: We show in this study that if a root anomaly does not permit access to the disc space in the usual way, the technique we define here can be used. If the patient has a root anomaly or an abnormal root configuration at this level, inevitably, an anterior approach is preferred. Materials and Methods: The patient's previous skin incision was used; the L5-S1 space was reached laterally without entering the midline. The dura in the midline and the L5 and S1 roots on both sides were exposed. They were reached through the adjacent points of both S1 pedicles by going around the upper edge of the sacrum, allowing the disc space to be evacuated. An autologous bone graft was placed on both sides of the space. T10-S1 pedicle screws were placed. An L1 pedicle osteotomy was performed and joined using two rods. Results: The patient's back and leg pain disappeared after the surgery. The plain X-rays showed that the sagittal balance was restored. In this case, it is impossible to see the disc space because the nerve root blocks its view. Conclusions: The classic approach in such cases is to perform a fusion by either a transperitoneal or retroperitoneal approach or by performing a posterior intertransverse fusion. However, it is very challenging to execute an anterior L5-S1 fusion on a patient with pelvic retroversion. When the spinopelvic junction is included in the fusion, one common problem observed is pseudarthrosis. The surgical technique defined in this article makes it possible to drill the bone tissue through the disc space and the upper surface of the sacrum, accessing the pedicle bone. Then, a discectomy is performed at the disc space, a bone graft is placed, and a posterior lumbar interbody fusion is performed.
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A novel surgical technique aiding the reduction of lumbar spondylolisthesis using the Jazz™ Band p. 167
Robin Gordon, Jonathan MacDonald, Nagy Darwish
DOI:10.4103/jcvjs.JCVJS_65_18  PMID:30443135
Posterior reduction and fusion of spondylolisthesis has a number of recognized and accepted procedural difficulties dependent on its severity. The Jazz™ Band is a novel system designed primarily for posterior fixation of the spine; however, its uses can be applied to a breadth of spinal conditions. Its benefits include that one size will fit all spinal levels; the connector is designed for multiple union rod diameters and reduced comorbidity when compared with other surgical methods. We present a case of a 26-year-old female with an L5/S1 spondylolisthesis slip angle of 117.4°. A 25° improvement in the spondylolisthesis slip angle was achieved with the use of the Jazz™ Band. The Jazz™ Band demonstrates excellent short-term results, and in order to determine the clinical outcomes and efficacy of the Jazz™ Band system, long-term results and analysis should be performed.
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Comparison of the outcomes of cage-stand-alone with cage-with-plate fixation in one level and two levels for treating cervical disk diseases p. 170
Mohammadreza Etemadifar, Ali Andalib, Hossein Shafiee, Milad Kabiri Samani
DOI:10.4103/jcvjs.JCVJS_74_18  PMID:30443136
Introduction: Anterior cervical discectomy and fusion (ACDF) surgery is an accepted method for many spinal cord abnormalities. The purpose of this study was to evaluate the outcomes of treating patients with spinal cord lesions at one level or two levels through ACDF with cage-stand-alone (ACDF-CA) and ACDF with cage-with-plate fixation (ACDF-CP) surgery and comparing these results with each other. Methods: In this prospective, cross-sectional, descriptive study, eighty patients undergoing ACDF surgery were enrolled according to the inclusion and exclusion criteria. Demographic data, before and after surgery findings, and clinical symptoms were investigated. Data were collected by means of visual analog scale (VAS) and Neck Disability Index (NDI) questionnaires. The adverse effects and surgical outcomes were evaluated based on Odom's criteria and patients' satisfaction. The collected data of the groups were then compared and assessed. Results: There was no significant difference between the groups in regards of gender, age, duration of surgery to visit, surgical level, preoperative and postoperative VAS and cervical range of motion, preoperative NDI, results based on Odom's criteria, and satisfaction of patients (P > 0.05). The VAS, NDI, and range of motion scores were significantly reduced in the four groups after the operation compared to the preoperative stage. Postoperative NDI scores in the ACDF-CA group at one level were significantly lower than other groups (P < 0.05). Conclusion: Both of the methods revealed acceptable outcomes in comparison to the preoperative stage, and despite some minor differences, there are generally no significant differences in outcomes and complications.
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Lateral suboccipital retrosigmoid retrocondylar approach for foramen magnum meningiomas p. 175
Jose Carlos Lynch, Mariangela Barbi Gonçalves, Celestino Esteves Pereira, Leonardo Welling
DOI:10.4103/jcvjs.JCVJS_38_18  PMID:30443137
Objective: The objective of the study was to describe our approach and the surgical technique and analyze its safety and the outcome for foramen magnum meningiomas (FMMs). Methods: From 1986 to 2016, 15 FMM patients were operated on using the lateral suboccipital retrocondylar approach. Results: In this series, there were 12 (80%) female and 3 (20%) male patients. The patients ranged in age from 33 to 63 years. There was no operative dead, but two patients died during the follow-up period, which varied from 1 to 24 years (mean, 10.2 years). Twelve patients (80%) achieved Glasgow Outcome Scale 4 or 5. Gross total resection was achieved in 13 (86.6.7%) patients. Conclusions: The majority of FMM can be safely removed using the lateral suboccipital retrocondylar approach without condylar resection, associated to meticulous microsurgical technique.
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Modified high cervical approach for C3-4 anterior pathology in difficult neck patients p. 182
Shyam Sundar Krishnan, Pulak Nigam, Adarsh Manuel, Madabushi Chakravarthy Vasudevan
DOI:10.4103/jcvjs.JCVJS_75_18  PMID:30443138
Introduction: The anterior approach to cervical pathologies is a time-tested versatile approach. It is, however, associated with a number of pharyngo-tracheo-laryngeal complications (PTL complications) such as dysphonia, dysphagia, and aspiration, more commonly in high cervical C3-4 inclusive pathologies and even more so in patients with “difficult neck.” The modified high cervical approach was devised and employed to address these issues at our institution. Materials and Methods: Patients who underwent surgery for anterior cervical C3-4 inclusive pathologies between January 2015 and April 2018 were included in the study. Parameters for considering difficult neck were defined. Patient subgroup with difficult neck underwent surgery through a modified high cervical approach, whereas others underwent surgery through a standard approach. The incidence of pharyngo-tracheo-laryngeal complications in both subgroups of this patient set was compared among itself as well with a similar patient set with the same two subgroups, both of which underwent surgery through standard approach alone from May 2010 to December 2014 – before the introduction of modified high cervical approach. Results: A total of 280 patients underwent surgery for C3-4 level pathology between May 2010 and April 2018. There were 197 males and 93 females in this population. Mean age was 45.8 ± 6.3 years. Incidence of pharyngo-tracheo-laryngeal complications was 20.3% in patients who underwent surgery before the employment of modified high cervical approach – 32.4% of difficult neck and 16.6% of others developed features of pharyngo-tracheo-laryngeal complications. After employment of modified high cervical approach, 16.67% of difficult neck and 16.2% of other patients developed features of pharyngo-tracheo-laryngeal complications. Conclusion: The modified high cervical technique is a good surgical option to prevent pharyngo-tracheo-laryngeal complications in cases of anterior C3-4 pathology when operating of patients with difficult neck.
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Percutaneous endoscopic ventral facetectomy: An innovative substitute of open decompression surgery for lateral recess stenosis surgical treatment? p. 188
Stylianos Kapetanakis, Nikolaos Gkantsinikoudis, Jannis V Papathanasiou, Georgios Charitoudis, Tryfon Thomaidis
DOI:10.4103/jcvjs.JCVJS_76_18  PMID:30443139
Background: Percutaneous transforaminal endoscopic surgery (PTES) constitutes an innovative method principally recruited for the treatment of lumbar disc herniation. Indication spectrum of PTES is constantly widened in current years. Hence, PTES has been proposed to represent a satisfactory alternative for the treatment of lateral recess stenosis (LRS), being defined as percutaneous endoscopic ventral facetectomy (PEVF) in these cases. The aim of this original study is to determine, for the first time in the literature, the outcomes of PEVF, especially in otherwise healthy nonelderly patients with LRS, alongside with special focus in health-related quality of life (HRQoL) assessment. Materials and Methods: Eighty-five otherwise healthy individuals from 58 to 64 years were diagnosed with LRS, being subjected to successful PEVF. Patients were prospectively evaluated in 6 weeks, in 3, 6, and 12 months, and in 2 years postoperatively. Visual analog scales (VASs) were separately utilized for leg and low back pain evaluation (VAS-LP and VAS-BP, respectively), whereas Short Form-36 (SF-36) questionnaire was sequentially implemented for HRQoL assessment. Results: All indexes of SF-36 as well as VAS-LP featured maximal amelioration in 6 weeks postoperatively, with subsequent further enhancement until 3 months and successor stabilization until 2 years. In contrast, VAS-BP presented minimal quantitative amelioration in 6 weeks, featuring no additional alterations. Values of all indexes in all follow-up intervals were demonstrated to be statistically significant in comparison with preoperative values (P < 0.05). No remarkable differentiation was observed between distinct parameters of SF-36. Conclusions: PEVF implementation in nonelderly patients with LRS was displayed to be safe and effective, providing alongside considerable improvement in HRQoL 2 years postoperatively.
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Transforaminal lumbar interbody fusion with expandable cages: Radiological and clinical results of banana-shaped and straight implants p. 196
Tjark Tassemeier, Marcel Haversath, Marcus Jäger
DOI:10.4103/jcvjs.JCVJS_56_18  PMID:30443140
Purpose: Expandable titanium transforaminal lumbar interbody fusion (TLIF) devices are a relatively new group of implants allowing restoration of lumbar lordosis (LL) and thus improvement of sagittal alignment. The purpose of our study is to compare clinical and radiological results of two different expandable TLIF devices. Materials and Methods: In a retrospective study, patients who underwent TLIF surgery with a banana-shaped or straight TLIF cage in our spine center were analyzed. Primary outcome was change of disc height (DH), segmental lordosis angle (SLA), and lumbar lordotic angle (LLA). Moreover, basic patients parameters and cage subsidence were evaluated. Results: Sixty-one patients were studied (33 banana-shaped and 28 straight cages). DH changed in the banana group from 4.8 mm (standard deviation SD 2.5) to 10.4 (SD 2.4) and in the straight cage group from 6.2 mm (SD 2.5) to 9.6 mm (SD 1.7). The difference was statistically significant (P = 0.03). In addition, SLA correction was higher in the banana group with 5.8° (SD 5.0)–3.7° (SD 3.6), but not significant. LLA improved in the straight group with 5.2 (SD 6.4) compared to 3.7° (SD 5.8) in the banana group. We found subsidence in four patients (6.6%) in the banana-shaped group and nine cases (14.8%) in the other group. Conclusions: Expandable titanium implants show similar improvements in restoring segmental and global lordosis. Banana-shaped expandable cages offer higher potency restoring the intervertebral DH and show less rates of subsidence compared to straight expandable cages.
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CASE REPORTS Top

Giant cell glioblastoma with spinal and spinal leptomeningeal metastasis in a child: A rare presentation of a rare tumor p. 202
Rituparna Biswas, Subhash Gupta, KP Haresh, Anirban Halder, GK Rath
DOI:10.4103/jcvjs.JCVJS_39_18  PMID:30443141
Giant cell glioblastoma (GCG) is a rare subtype of classic glioblastoma multiforme with favorable prognosis and little is known about its metastatic potential. We hereby present a unique case of GCG in a 7-year-old child who developed spinal and spinal leptomeningeal metastasis during adjuvant therapy. She succumbed to it in spite of salvage therapy.
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Giant cell tumor with pathological fracture of C2 with C1-C2 instability: A rare case with review of literature p. 205
Abhijeet B Kadam, Ashok K Rathod, Anoop C Dhamangaonkar
DOI:10.4103/jcvjs.JCVJS_31_18  PMID:30443142
Giant cell tumor (GCT) or osteoclastoma is a benign, locally aggressive tumor with a tendency to recur. Involvement of the axial skeleton is very rare and majority of them are seen in the sacrum. The authors report a rare case of a 19-year-old female who presented with a C2 dens GCT with a pathological fracture and atlantoaxial dislocation. The patient was operated in two stages: first stage, with posterior instrumentation and stabilization followed by the second stage, tumor resection by anterior transoral approach. The residual tumor cavity was packed with autologous corticocancellous bone grafts. At a 5-year follow-up, computed tomography scan showed a C1-C2 fusion mass. There was no radiological or clinical evidence of tumor recurrence with the patient having good functional outcome without any neurological deficit.
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Rare manifestation of common disease with an unique method of minimally invasive spine stabilization: Cervical 2–3 facet lesion p. 209
Parichay J Perikal, Umesh Srikantha, Aniruddha T Jagannath, Kiran Khanapure, Ravi Gopal Varma, AS Hegde
DOI:10.4103/jcvjs.JCVJS_69_18  PMID:30443143
Cervical granulomatous infections of the posterior elements are very rare, it is often difficult to diagnose due to rarity and variable presentation of symptoms. Any cervical surgical procedure carries a certain morbid risk to the patient. We present a case of cervical 2–3 facet joint lesion which was managed by a minimally invasive technique with a favorable outcome.
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Basilar impression in osteogenesis imperfecta treated with staged halo traction and posterior decompression with short-segment fusion p. 212
Mutlu Cobanoglu, Jennifer M Bauer, Jeffrey W Campbell, Suken A Shah
DOI:10.4103/jcvjs.JCVJS_63_18  PMID:30443144
Basilar impression is a cranial base abnormality associated with osteogenesis imperfecta (OI) with serious neurologic implications but controversial treatment options. Combined anterior and posterior decompression with long-segment posterior fusion is often recommended. We report a patient with OI (Sillence type III) with basilar impression treated with halo traction followed by posterior surgery. The patient was a 12-year-old female with a presentation of hiccups and change in upper extremity function. Diagnostic imaging revealed syringomyelia, compensated hydrocephalus, basilar impression, and Chiari type I malformation. The patient was treated with halo traction followed by posterior decompression fusion from the occipital bone to C2. Bone fusion and improved syrinx were evident on images during the 5 years of follow-up. Five years after surgery, syrinx recurred and the fourth ventricular catheter was revised. The treatment with halo traction followed by posterior-only surgery of basilar impression associated with OI resulted in a good postoperative outcome.
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LETTER TO EDITOR Top

Nonunited secondary ossification centers of the spinous processes of vertebrae at multiple levels presenting as aberrant articulations in an adult p. 216
Reddy Ravikanth, Rijesh Pottangadi
DOI:10.4103/jcvjs.JCVJS_23_18  PMID:30443145
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