The usefulness and safety of the simultaneous parallel anterior and posterior combined lumbar spine surgery using intraoperative 3D fluoroscopy-based navigation (SPAPS)

Background The combined anterior-posterior surgery in the lateral decubitus position generally needs the intraoperative repositioning. However, prolonged surgical time and increased medical costs due to intraoperative repositioning have been problematic. In recent years, there have been reports of combined anterior-posterior procedure with a single position performing anterior and posterior fixation consecutively where the patient remains in the lateral decubitus position (single surgeon method-SS method). We had further advanced this method, and have adopted the Simultaneous Parallel Anterior and Posterior combined lumbar spine Surgery using intraoperative 3D fluoroscopy-based navigation (SPAPS method), where anterior and posterior procedure are performed independently by two spine surgeons. Methods 66 cases that underwent SPAPS method (n=37) and SS method (n=29) from 2015 to 2019 at single institution were concluded in this study. The pre- and post-operative changes in the following were compared retrospectively between the two groups: surgical factors and clinical evaluations including JOA back pain evaluation questionnaire (JOABPEQ), visual analogue scale (VAS) on lower back pain, buttock/lower limb pain, and buttock/lower limb numbness, and Roland-Morris disability questionnaire (RDQ). Results The SPAPS method was able to significantly reduce the surgical time (p=0.0025) compared to the SS method, and allowed a reduction of approximately 24.4 minutes per segment. The estimated blood loss were similar in both groups, and with regards to post-operative outcomes, both groups improved equally well. The rates of screw deviation and fusion were also similar. Conclusions In the case of performing the combined anterior-posterior surgery under a single position, the anterior and posterior procedure can be performed independently and simultaneously by two spine surgeons by utilizing the 3D fluoroscopy-based navigation. The surgical time can be significantly reduced by approximately 24.4 minutes per segment comparing to the SS method

Dominant Vertebral Artery Injury during Posterior Atlantoaxial Transarticular Screw Fixation in a Juvenile Rheumatoid Arthritis Patient with Atlantoaxial Subluxation

Many authors have reported on iatrogenic vertebral artery (VA) injury, but, to our knowledge, this is the first report of a dominant VA injury with compensatory blood flow from the hypoplastic VA. A 23-year-old woman with juvenile rheumatoid arthritis and atlantoaxial subluxation sustained injury to her dominant VA after occipitocervical fusion using transarticular screws. This did not result in lethal consequences due to compensation from her hypoplastic contralateral VA. Postoperative angiography, however, illustrated occlusion of the dominant left side, while the hypoplastic VA of the right side was enlarged. The patient experienced vertigo and loss of consciousness several times during rehabilitation. At the 4-year follow-up exam, bony fusion was observed, with no neurological deficits or correction loss. She had had no episodes of unconsciousness and no recurrence of any symptoms over the previous 3 years

Novel magnetic resonance imaging evaluation for valgus instability of the knee caused by medial collateral ligament injury

Instability of the knee after the medial collateral ligament (MCL) injury is usually assessed with the manual valgus stress test, even though, in recent years, it has become possible to apply magnetic resonance imaging (MRI) to the assessment of the damage of the ligament. The valgus instability of 24 patients (12 isolated injuries and 12 multiple ligament injuries) who suffered MCL injury between 1993 and 1998 was evaluated with the Hughston and Eilers classification, which involves radiographic assessment under manual valgus stress to the injured knees. We developed a novel system for classifying the degree of injury to the MCL by calculating the percentage of injured area based on MRI and investigated the relationship between this novel MRI classification and the magnitude of valgus instability by the Hughston and Eilers classification. There was a significant correlation between the 2 classifications (p=0.0006). On the other hand, the results using other MRI based classification systems, such as the Mink and Deutsch classificaiton and the Petermann classification, were not correlated with the findings by the Hughston and Eilers classification in these cases (p0.05). Since MRI is capable of assessing the injured ligament in clinical practice, this novel classification system would be useful for evaluating the stability of the knee and choosing an appropriate treatment following MCL injury.</p

Surgical results of sacral perineural (Tarlov) cysts.

The purpose of this study was to investigate the surgical outcomes and to determine indicators of the necessity of surgical intervention. Twelve consecutive patients harboring symptomatic sacral perineural cysts were treated between 1995 and 2003. All patients were assessed for neurological deficits and pain by neurological examination. Magnetic resonance of imaging, computerized tomography, and myelography were performed to detect signs of delayed filling of the cysts. We performed a release of the valve and imbrication of the sacral cysts with laminectomies in 8 cases or recapping laminectomies in 4 cases. After surgery, symptoms improved in 10 (83%) of 12 patients, with an average follow-up of 27 months. Ten patients had sacral perineural cysts with signs of positive filling defect. Two (17%) of 12 patients experienced no significant improvement. In one of these patients, the filling defect was negative. In conclusion, a positive filling defect may become an indicator of good treatment outcomes.</p

Radiation exposure to the hand

Study Design: Prospective study. Purpose: During fluoroscopically guided spinal procedure, the hands of spinal surgeons are placed close to the field of radiation and may be exposed to ionizing radiation. This study directly measured the radiation exposure to the hand of a spinal interventionalist during fluoroscopically guided procedures. Overview of Literature: Fluoroscopically guided spinal procedures have been reported to be a cause for concern due to the radiation exposure to which their operators are exposed. Methods: This prospective study evaluated the radiation exposure of the hand of one spinal interventionalist during 52 consecutive fluoroscopic spinal procedures over a 3-month period. The interventionalist wore three real-time dosimeters secured to the right forearm, under the lead apron over the chest, and outside the lead apron over the chest. Additionally, one radiophotoluminescence glass dosimeter was placed under the lead apron over the left chest and one ring radiophotoluminescence glass dosimeter was worn on the right thumb. The duration of exposure and radiation dose were measured for each procedure. Results: The average radiation exposure dose per procedure was 14.9 µSv, 125.6 µSv, and 200.1 µSv, inside the lead apron over the chest, outside the lead apron over the chest, and on the right forearm, respectively. Over the 3-month period, the protected radiophotoluminescence glass dosimeter over the left chest recorded less than the minimum reportable dose, whereas the radiophotoluminescence glass ring dosimeter recorded 368 mSv for the thumb. Conclusions: Our findings indicated that the cumulative radiation dose measured at the dominant hand may exceed the annual dose limit specified by the International Commission on Radiological Protection. Spinal interventionalists should take special care to limit the duration of fluoroscopy and radiation exposure

Treatment of Thoracolumbar Spinal Fracture Accompanied by Diffuse Idiopathic Skeletal Hyperostosis Using Transdiscal Screws for Diffuse Idiopathic Skeletal Hyperostosis: Preliminary Results

Study Design This retrospective case series enrolled 13 patients who underwent posterior fixation with both transdiscal screws for diffuse idiopathic skeletal hyperostosis (TSDs) and pedicle screws (PSs) to treat spinal injury accompanied by diffuse idiopathic skeletal hyperostosis (DISH). Purpose To describe the usefulness, feasibility, and biomechanics of TSD. Overview of Literature Vertebral bodies accompanied by DISH generally have lower bone mineral density than normal vertebral bodies because of the stress shielding effect. This phenomenon tends to makes screw fixation challenging. To our knowledge, solutions for this issue have not previously been reported. Methods Patients were assessed using the data on surgical time, estimated intraoperative blood loss, mean number of stabilized intervertebral segments, number of screws used, perioperative complications, union rate, and the three-level EuroQol five-dimensional questionnaire (EQ5D-3L) score at the final follow-up. The Hounsfield unit (HU) values of the screw trajectory area, and the actual intraoperative screw insertion torque of TSDs and PSs were also analyzed and compared. Results The surgical time and estimated intraoperative blood loss were 165.9±45.5 minutes and 71.0±53.4 mL, respectively. The mean number of stabilized intervertebral segments was 4.6±1.0. The number of screws used was 4.9±1.3 for TSDs and 3.0±1.4 for PSs. One death occurred after surgery. The union rate and EQ5D-3L scores were 100% and 0.608±0.128, respectively. The HU value and actual intraoperative screw insertion torque of TSDs were significantly better than those of PSs (p<0.001, p=0.033). Conclusions We were able to achieve stable surgical outcomes using the combination of TSDs and PSs. The HU value and actual intraoperative screw insertion torque were significantly higher for TSDs than for PSs. Based on these results, when treating thoracolumbar spinal fractures accompanied by DISH in elderly populations, the TSD could be a stronger anchor than the PS

Radiation Exposure to the Hand of a Spinal Interventionalist during Fluoroscopically Guided Procedures

Study DesignProspective study.PurposeDuring fluoroscopically guided spinal procedure, the hands of spinal surgeons are placed close to the field of radiation and may be exposed to ionizing radiation. This study directly measured the radiation exposure to the hand of a spinal interventionalist during fluoroscopically guided procedures.Overview of LiteratureFluoroscopically guided spinal procedures have been reported to be a cause for concern due to the radiation exposure to which their operators are exposed.MethodsThis prospective study evaluated the radiation exposure of the hand of one spinal interventionalist during 52 consecutive fluoroscopic spinal procedures over a 3-month period. The interventionalist wore three real-time dosimeters secured to the right forearm, under the lead apron over the chest, and outside the lead apron over the chest. Additionally, one radiophotoluminescence glass dosimeter was placed under the lead apron over the left chest and one ring radiophotoluminescence glass dosimeter was worn on the right thumb. The duration of exposure and radiation dose were measured for each procedure.ResultsThe average radiation exposure dose per procedure was 14.9 µSv, 125.6 µSv, and 200.1 µSv, inside the lead apron over the chest, outside the lead apron over the chest, and on the right forearm, respectively. Over the 3-month period, the protected radiophotoluminescence glass dosimeter over the left chest recorded less than the minimum reportable dose, whereas the radiophotoluminescence glass ring dosimeter recorded 368 mSv for the thumb.ConclusionsOur findings indicated that the cumulative radiation dose measured at the dominant hand may exceed the annual dose limit specified by the International Commission on Radiological Protection. Spinal interventionalists should take special care to limit the duration of fluoroscopy and radiation exposure