Perioperative complications of anterior procedures on the spine

We reviewed the operative and hospital records of 447 patients in order to determine the rates of perioperative complications associated with an anterior procedure on the thoracic, thoracolumbar, or lumbar spine. The anterior procedures were performed to treat spinal deformity or for débridement or decompression of the spinal canal. The diagnostic groups that we studied included idiopathic scoliosis in adolescents or young adults (100 patients), scoliosis in mature adults (sixty-three patients), kyphosis (sixty-one patients), neuromuscular scoliosis (sixty patients), fracture (forty-seven patients), a revision procedure (thirty-nine patients), congenital scoliosis (thirty-six patients), tumor (nineteen patients), vertebral osteomyelitis or discitis (eight patients), and miscellaneous (fourteen patients). Complications occurred in 140 (31 per cent) of the 447 patients and were classified as major or minor. Forty-seven patients (11 per cent) had at least one major complication and 109 (24 per cent) had at least one minor complication. Two patients died, both from pulmonary complications after the operation. The most common type of major complication was pulmonary; the most common type of minor complication was genito-urinary. The adolescent or young adult patients who had idiopathic scoliosis had the lowest rate of complications, and the patients who had neuromuscular scoliosis had the highest. An age of more than sixty years at the time of the operation was associated with a higher risk of complications. The duration of the procedures involving a thoracic approach was shorter than that of those involving a thoracolumbar or lumbar approach; however, the rate of complications was not significantly different among the three approaches. Vertebrectomies took longer to perform and were associated with a greater estimated blood loss than discectomies; however, there was no significant difference in the rate of complications between the two types of procedures. The patients who had a fracture or a tumor lost more blood than those from the other diagnostic groups. Blood loss increased as the duration of the operation increased for all procedures. Combined anterior and posterior procedures performed during the same anesthesia session were associated with a higher rate of major complications than were procedures that were staged. A logistical regression analysis showed that the variables that increased the risk of a major complication were an estimated blood loss of more than 520 milliliters and an anterior and posterior procedure performed sequentially under the same anesthesia session. This analysis also demonstrated that the diagnosis of idiopathic scoliosis in adolescents or young adults was associated with a reduced risk of major complications. Compared with other major operations, an anterior procedure on the thoracic, thoracolumbar, or lumbar spine performed for the indications mentioned in this study is relatively safe.     

Circulating factors as markers and mediators of endothelial cell dysfunction in preeclampsia

3 different types of complex spinal trauma are defined: Type I means a multilevel contiguous or non contiguous unstable injury, type II is described as a spinal injury with concomitant thoracic or abdominal lesion, type III stands for the coincidence of spinal injury and polytrauma. Overlapping of different types occurs. Type I: The incidence amounts according a german multicenter study to about 2.5%. Multilevel injuries need to be stabilized for a long distance from posterior. With a thorough analysis the segments to be fused are determined. Type II: The leading thoracic injury is a lung contusion which occurs in up to 50% of the cases. A CT scan of the thorax during the first diagnostic screening is recommended. Early reduction and stabilization from posterior should be aimed at. During the first two weeks anterior procedures are contraindicated. Abdominal injuries are to be found in 3-4% of all spinal injuries. All organs could be affected. A typical constallation is the "seat-belt syndrome" with lesions of the upper abdominal organs and a flexiondistraction injury of the upper lumbar spine. The main problem is to make the diagnosis of both components initially. Most of the patients may be treated in one operation by first taking care of the abdominal injury and than stabilizing the spine. The prognosis of this combination is favorable. Type III: In 17-18% of all polytraumatized patients lesions of the spine are to be diagnosed. From these only one third need surgical care. From 680 patients with operatively treated fractures of the thoracolumbar junction 6.2% were polytraumatized according to the multicenter study mentioned above. The risk of missing a spinal injury in polytrauma totals approximately 20%. Surgical stabilization should be performed in the primary phase (day-1-surgery). Additional injuries, potentially time consuming operations with a high blood loss sometimes necessitate a different approach. Non stabilized spinal injuries apparently do not have the same negative effect on the whole organism as long bone fractures. In the early phase of treatment on the C-spine only anterior procedures and on the thoracolumbar spine only posterior techniques should be applied.     

Prospects in video-assisted spinal surgery

Advances in spinal surgery for both posterior procedures on herniated discs and anterior procedures involving the vertebral body have been greatly affected by developments in video-assisted techniques. Many of the procedures mentioned here are still in the development stage, others have proven their efficacy. Discoscopy, achieved by introducing the endoscope via a posterolateral route into the intervertebral disc, can be used for diagnosis and treatment of the disc and the end plates. Other techniques exploring the spinal canal are also being developed. With miniaturization, these techniques will undoubtedly be predominant in the near future. The anterior route is facilitated at the thoracic level by the pleural cavity. Current indications for anterior endoscopic spinal surgery are limited to cord compression syndromes, but perspectives for trauma or tumor surgery as well as reconstruction surgery for malformations in children are quite promising. On the lumbar level, surgery involving the lombo-sacral disc is the main indication for transperitoneal endoscopy. The risks (sepsis, occlusion, gas emboli) cannot be overlooked, but few complications have been observed to date. The retroperitoneal route can be used to approach the anterolateral aspect of the spine, particularly useful for the upper lumbar bodies. A third possibility is the extraperitoneal anterior route for video-assisted procedures from L2-L3 to L5-S1. Although video-assisted procedures have not yet been shown to improve long-term outcome after spinal surgery, the immediate post-operative period is greatly simplified, a point which may be of particular importance depending on the patient's general status.     

Video-assisted thoracoscopic surgery to the upper thoracic spine

BACKGROUND: The standard open technique for exposure of the upper thoracic spine, T1-T4, usually requires a difficult thoracotomy. From November 1, 1995 to June 30, 1997, eight patients underwent video-assisted thoracoscopic spinal surgery in our institute to treat their upper thoracic spinal lesions endoscopically. METHODS: A new approach, the so-called "extended manipulating channel method," was used in this series that allows the combined use of video-assisted thoracoscopy and conventional spinal instruments to enter the chest cavity freely for the procedures. Patients' ages ranged from 44 to 89 years (average, 60 years). Definitive diagnoses included two pyogenic spondylitis and six spinal metastases. Five patients presented initially with myelopathy. RESULTS: There were no deaths or neurologic injuries associated with this technique. The mean surgical time was 3.1 h. The mean duration of chest tube retention was 3.3 days. The mean total blood loss was 1,038 ml, and two patients had a blood loss of more than 2,000 ml owing to bleeding from epidural veins or raw osseous surfaces. Complications included one superficial wound infection and one subcutaneous emphysema that resolved spontaneously. In this series, there was no need of conversion to open thoracotomy for the patients. CONCLUSIONS: The thoracoscopy-assisted spinal technique using the extended manipulating channels, usually 2.5-3.5 cm, allows variable instrument angulations for manipulation. The mean surgical time (3.1 h) was considered no longer than for an open technique for the equivalent anterior procedure. Such an approach can achieve less procedure-related trauma and has proved to be a good alternative to other treatment modalities.     

Anterior and antero-lateral surgery of the lower cervical spine (25 years after H. Verbiest). 2: Indications, results, complications)

The present course on the anterior and antero-lateral surgical approach of the lower cervical spine was organized for the neurosurgery trainees by the French Speaking Neurosurgical Society, and was held during the winter meeting in December 1995. The aim of this course was to recall the basic technical principles of the microsurgical anterior cervical approach, and to discuss the main indications of this surgical treatment. Many theoretical points were strengthened by the author's personal experience and comments. In Part I, the technical bases of the different anterior or antero-lateral approaches were presented (1996, 42 : 105-122). In the present Part II, the main indications of the anterior surgical approach to the cervical disk or the vertebral body are detailed, and the requirement of a bone graft and/or an osteosynthesis are discussed with their consequences on the final results. Secondly, variants of the surgical technics in use in case of cervical spinal instability are commented. Then various approaches to the cervical spinal tumors and to the vertebral artery are detailed and commented. Lastly, general and specific complications of the anterior cervical approach are listed with their rate of occurrence, and their prevention and management are discussed.     

Short-term and long-term failures of anterior polymethylmethacrylate construct with esophageal perforation

Three patients with a history of anterior spinal surgery treated with a polymethylmethacrylate construct had extrusion of their constructs. In two instances, there were life-threatening esophageal fistulas, mediastinitis, and sepsis 3 months to 10 years after the original surgery. Surgical treatment required removal of the construct, treatment of the esophageal injury, and use of new spinal stabilization. Based on their experience and a review of the literature, the authors strongly recommend against the use of polymethylmethacrylate alone in anterior procedures involving the cervical spine except to treat malignancies in patients with a short life expectancy.     

Video-assisted thoracoscopic surgery versus open thoracotomy for anterior thoracic spinal fusion. A comparative radiographic, biomechanical, and histologic analysis in a sheep model

STUDY DESIGN: In this in vivo investigation, a sheep model was used to compare the efficacy of a video-assisted thoracoscopic approach and a traditional thoracotomy in promoting a successful interbody spinal arthrodesis. OBJECTIVES: To compare the incidence of successful anterior spinal arthrodesis among three stabilization techniques-iliac crest, Bagby and Kuslich device, and Z-plate--performed using a video-assisted thoracoscopic approach and conventional open thoracotomy approaches. SUMMARY OF BACKGROUND DATA: A clinical outcome study on open versus endoscopic spinal fusion is not yet available. Moreover, no basic scientific investigations have been conducted to determine whether the success of an endoscopic arthrodesis is comparable to that of a conventional open procedure. METHODS: Fourteen Western Crossbred sheep underwent three identical destabilization procedures at T5-T6, T7-T8, and T9-T10, in which the anterior and middle osteoligamentous columns of the spine were resected, followed by three randomized reconstruction procedures using iliac autograft alone, and Z-plate stabilization with iliac autograft. In seven sheep, the entire destabilization-reconstruction procedure was performed using a video-assisted thoracoscopic surgical approach. In the remaining seven, the procedure was performed by conventional open thoracotomy. RESULTS: Histomorphometric and biomechanical evaluation demonstrated that the video-assisted thoracoscopic approach and open thoracotomy arthrodesis had comparable bone formation and biomechanical properties (P > 0.05). However, the Z-plate fusions, as a group, demonstrated increased flexion-extension stiffness properties and trabecular bone formation compared with the autograft and Bagby and Kuslich device fusions (P < 0.05). CONCLUSIONS: Thoracic interbody spinal fusions performed by thoracoscopy have demonstrated histologic, biomechanical, and radiographic equivalence to those performed by a thoracotomy approach. However, in the endoscopy group, intraoperative complications causing longer operative times, higher estimated blood loss, and increased animal morbidity indicated a substantial learning curve associated with the adoption of this surgical technique.     

Refined crystal structure and mutagenesis of human granulocyte-macrophage colony-stimulating factor

We reviewed the clinical and technical outcomes of 25 patients with neuromuscular scoliosis, who were treated by Luque instrumentation and posterior spinal fusion from the upper thoracic spine to L5 between 1981 and 1988. A mean curve correction of 46% was obtained operatively with a mean 8 degrees loss of correction during the follow-up period that ranged from 1.9 to 9.4 years (mean, 5.5). Pelvic obliquity was improved 50% from a mean of 16.1 degrees to a mean of 8.1 degrees in 24 patients for whom data were available. At final follow-up, the mean pelvic obliquity increased to 11.4 degrees with only two patients increasing > 8 degrees. The cause for major postoperative increase in pelvic obliquity was continued anterior spinal growth with torsion of the fusion mass and was not related to changes limited to the L5-S1 motion segment. Posterior fusion and instrumentation from the upper thoracic spine to L5 without anterior fusion provides adequate correction and control of spinal deformity for many patients with cerebral palsy. Those patients with significant growth remaining, or with severe deformities, may benefit by preliminary anterior release and fusion or inclusion of the pelvis and sacrum.     

Different patterns of endothelial cell activation in renal and pulmonary vascular disease in scleroderma

This study analyzed the postoperative results of surgical treatment for thoracic and cervicothoracic myelopathy caused by ossification of the posterior longitudinal ligaments (OPLL) or ossification of the yellow ligaments (OYL) in 22 patients using magnetic resonance imaging (MRI), myelography and computed tomography (CT). Anterior procedures were performed in 11 patients for OPLL, while posterior approaches were adopted for the management of 11 patients for both OYL and OPLL combined with OYL lesions. Clinical symptoms were improved using both anterior and posterior techniques. MRI and myelo-CT studies, which show the direction of cord compression, the form and extent of the lesion, and the degree of thoracic kyphosis, are very useful when the surgical procedure for OPLL and OYL in the thoracic and cervico-thoracic spine is selected.     

Prognostic factors in anterior decompression for metastatic cord compression. An analysis of results

During the 10-year period 1981-1990, 59 patients suffering from spinal cord or cauda equina compression underwent anterior spinal decompression and in most cases spinal restabilization with methylmethacrylate cement and/or instrumentation. Follow-up in 55 patients showed that 75% were improved neurologically by the procedure, one-third of these showing complete recovery from the spinal cord compression. The results in younger female patients suffering from metastatic breast cancer were considerably better than those of older men with prostatic metastases. Other genitourinary system tumors also had a relatively poorer prognosis. There was a significantly better result for metastatic lesions of the thoracic or thoracolumbar spine than for lesions in the lumbar spine causing cauda equina paralysis.     

A biomechanical comparison of open and thoracoscopic anterior spinal release in a goat model

STUDY DESIGN: A biomechanical assessment of anterior release and discectomy in the thoracic spine was performed on an animal model using thoracoscopic and open thoracotomy techniques. OBJECTIVES: To compare the relative efficacy of these two techniques of release in achieving increased spinal mobility. BACKGROUND DATA: The clinical use of video-assisted thoracoscopy in the correction of spinal deformity is increasing. The effectiveness of thoracoscopic anterior spinal release with discectomy has not been evaluated biomechanically. METHODS: Anterior release with discectomy was performed on six midthoracic motion segments in five mature goats. The thoracoscopic technique was used for three levels on one side, and an open thoracotomy was used for the alternating three levels of the contralateral side. The duration of surgery for disc excision and the amount of blood loss for each technique were recorded. The intact cranial and caudal motion segments served as controls. The motion segments were individually subjected to nondestructive biomechanical testing. Torsional, sagittal, and coronal bending torques were applied, and the resulting angular displacement was measured. RESULTS: The duration of surgery to remove a disc thoracoscopically decreased as experience was gained by the surgeon. The amount of intraoperative blood loss was comparable using the two methods. There was significantly increased flexibility in the released segments with both techniques, compared with the flexibility in the intact levels for all three loading directions. There was no difference in the motion obtained after release between the two techniques. CONCLUSION: Open and thoracoscopic anterior release and discectomy have been demonstrated, through biomechanical in vitro testing, to increase the flexibility of the spine to a similar extent.     

Counterflow centrifugal elutriation: present and future

Only single cases with rheumatoid arthritis of the thoracic spine with vertebral subluxation have been reported to date. In a review of 100 patients with severe rheumatoid arthritis who had undergone occipitocervical fusion, arthritis of the upper thoracic spine with subluxation was discovered on conventional radiographs in four patients. Two additional patients were found elsewhere. Magnetic resonance imaging (MRI) was performed in three of the patients, confirming the diagnosis of subluxation of the upper thoracic vertebrae. In addition, MRI revealed encroachment on the anterior subarachnoid space and compression of the spinal cord.     

Practical guidelines for the management of closed spinal cord injuries

The principles underlying the necessity of operative management in handling closed spinal cord trauma, its indications and types of operative interventions are comprehensively discussed. Under separate headings are described the peculiarities of the approach to injuries involving cervical, thoracic and lumbal segments of the vertebral column, with a summarization of currently used methods and procedures, contributing to the more complete functional recovery of the spine, preservation and creation of optimal conditions for regaining the functions of the spinal cord affected which in turn, renders easier the performing of daily living activities, precludes the development of a variety of complications in the body as a whole, and first and foremost, allows for early initiation of rehabilitation measures.     

Spine and spinal cord war injuries during the war in Croatia

OBJECTIVE: The present report summarizes the experience of an evacuation hospital in southern Croatia in treating 96 patients with spine and spinal cord war injuries. METHODS: A retrospective review was done for 96 wounded persons (86 soldiers, 10 civilians) with spinal cord injuries from August 1991 through December 1995. The ages ranged from 15 to 59 years (mean, 28.3 years for soldiers, 38.5 years for civilians). Diagnostic procedures were plain radiography, computed tomography, and computed tomographic myelography. However, in most cases a more conservative surgical approach was used. RESULTS: The highest rates of admittance were recorded in 1992 (N = 38) and 1993 (N = 47). The lumbar spine was injured in 55% of the patients, the cervical and thoracic spines in 17.7%. All injuries were caused by projectiles from automatic rifles and sniper fire (51%) and from fragments of explosive devices (49%). Blast injury of the spinal cord was found in 10 patients. The most frequent complications caused by the fragments were wound infection, urinary tract infection, decubitus, and pneumonia. Four patients (4.2%) died in the hospital, and 43.0% of patients survived but were severely handicapped. CONCLUSION: Careful clinical examination combined with modern diagnostic imaging and use of broad-spectrum antibiotics reduced the need for surgical intervention in patients with spinal cord injuries.     

An autopsy case of an extensive epidural spinal abscess demonstrating necrotizing poliomyelopathy

A 59-year-old man with a history of diabetes mellitus (NIDDM) presented with fever, back pain and weakness in the left lower limb. Three weeks later he suddenly developed flaccid paraklegia, a sensory deficit below the abdomen and sphincter dysfunction. MR images of the spinal cord showed an extensive anterior spinal epidural abscess extending from the seventh cervical to the twelfth thoracic spine and osteomyelitis in the lower thoracic spines. He died of pulmonary infection one year after the disease onset. Postmortem examination revealed a large empyema in the lung. On neuropathological examination, small multiple hemorrhagic or ischemic lesions were found in the basal ganglia and the pons. The spinal cord was markedly atrophic in the lumbar cord. However, there was neither compression deformity in the cord nor occlusion in the anterior spinal artery. Throughout the thoracic cord, rarefaction and focal cavity formation was selectively present in the gray matter, particularly the posterior horns. In the white matter, vacuolar changes were seen peripherally as well as Wallerian degeneration in the lateral and anterior corticospiral tracts and in the fascicles gracilis bilaterally. The mechanisms inducing the cord damage in cases of epidural spinal abscess have been speculated to be either direct compression by the abscess or the secondary circulatory disturbance in the cord due to compression. In our case, the cord showed necrotizing poliomyelopathy, which was similar to that of ischemic myelopathy found in the cases of cardiac arrest or dissecting aneurysm of the aorta. Autopsy study of spinal cord lesion associated with epidural abscess has been limited in number and our case should contribute to the understanding of the pathomechanism of such myelopathy.     

Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine

STUDY DESIGN: A retrospective clinical study of patients with vertebral osteomyelitis of the lumbar spine necessitating surgical treatment. All patients underwent sequential (same-day) or simultaneous anterior decompression and posterior stabilization of the involved vertebrae. OBJECTIVE: To evaluate the efficacy and clinical out-come of sequential or simultaneous anterior and posterior surgical approaches in the management of vertebral osteomyelitis of the lumbar spine. SUMMARY OF BACKGROUND DATA: Anterior approach alone and staged anterior decompression and posterior stabilization have been advocated as the surgical treatment methods of choice for patients with vertebral osteomyelitis of the lumbar spine. The drawbacks of the latter management plan are the necessity to use external support or the delayed patient mobilization and the need for additional anesthesia and surgical trauma. Sequential (same-day) anterior and posterior approaches are used regularly in the surgical management of scoliosis and other spinal deformities. It would appear advantageous to also use the same strategy (i.e., combined same-day double approaches) in the management of vertebral osteomyelitis of the lumbar spine. METHODS: Ten consecutive patients who had a diagnosis of vertebral osteomyelitis of the lumbar spine underwent combined (same-day) anterior and posterior approaches either in a sequential or simultaneous manner. Indications for surgery included neurologic deficit, abscess formation, instability with localized kyphosis formation, and failure of nonoperative treatment. Patients were evaluated clinically and radiographically after surgery. RESULTS: All 10 patients had uneventful surgery. Only one patient required a second surgical procedure because of expulsion of the anterior bone graft and pull-out of instrumentation. All patients were mobilized within the 2 days immediately after surgery. At the mean follow-up examination 30 months after surgery, all patients had regained their motor function and prior ambulatory status. CONCLUSIONS: Patients with lumbar osteomyelitis necessitating surgery can undergo combined, same-day surgery either in a sequential or simultaneous manner. This is a safe and efficient way to control the infection and stabilize the affected segments, allowing for early mobilization of these sick elderly patients.     

Spontaneous thoracic spinal cord herniation. A case report

STUDY DESIGN: This is a case report. OBJECTIVE: To focus attention on spontaneous spinal cord herniation as a rare cause of myelopathy that can be diagnosed preoperatively and can be corrected surgically. SUMMARY OF BACKGROUND DATA: A 34-year-old woman presented with spastic paraparesis. Magnetic resonance imaging scan of the thoracic spine revealed anterior displacement and tethering of the cord at T6-T7 and a dorsal intradural arachnoid cyst. Excision of the cyst was performed without improvement in symptomatology. During reoperation the thoracic spinal cord hernia was discovered and was reduced intradurally. METHODS: The authors describe the clinical, radiographic, and surgical findings of this patient and review the findings from other reported cases. They discuss the proposed theories for the pathophysiology of the cord herniation and the surgical management. RESULTS: The patient had idiopathic thoracic spinal cord herniation as there was no history of previous spine surgery or injury. The authors believe that the cord herniated through a congenital dural defect, which resulted in the development of a pseudoarachnoid cyst dorsally to the hernia. The patient improved after intradural reduction of the hernia and closure of the dural defect. CONCLUSION: Idiopathic spinal cord herniation should be recognized as a cause of progressive myelopathy that can be managed successfully with microsurgical techniques.     

Spinal problems in mucopolysaccharidosis I (Hurler syndrome)

Bone-marrow transplantation has increased the survival of patients with mucopolysaccharidosis-I. We describe the spinal problems and their management in 12 patients with this disorder who have been followed up for a mean of 4.5 years since transplantation. High lumbar kyphosis was seen in ten patients which was associated with thoracic scoliosis in one. Isolated thoracic scoliosis was seen in another. One patient did not have any significant problems in the thoracic or lumbar spine but had odontoid hypoplasia, which was also seen in three other children. Four of the eight patients in whom MRI of the cervical spine had been performed had abnormal soft tissue around the tip of the odontoid. Neurological problems were seen in two patients. In one it was caused by cord compression in the lower dorsal spine 9.5 years after posterior spinal fusion for progressive kyphosis, and in the other by angular kyphosis with thecal indentation in the high thoracic spine associated with symptoms of spinal claudication.     

A case of idiopathic spinal cord herniation

The authors experienced a case of idiopathic spinal cord herniation with duplicated dura mater. A 63-year-old woman presented right dominant slowly progressive spastic paraplegia and dissociated sensory disturbance. Magnetic resonance imaging (MRI) demonstrated an enlarged dorsal arachnoid space associated with an apparently focally narrowed thoracic cord. The cord was kinked towards the anterior and closely applied to vertebral body at the level of Th3-4. Computed tomographic myelography (CTM) revealed homogeneous filling at dorsal arachnoid space immediately after injection and no defects. At operation multilocular arachnoid cyst and duplicated dura mater was respectively observed dorsally, and ventrally. From defected area of the inner layer, a ventral part of the spinal cord was incarcerated between the two dural layers. After rejection of arachnoid cyst and inner layer was performed, the patient recovered neurologically. Idiopathic spinal cord herniation is a rare disease that shows slowly progressive myelopathy at middle age. The herniations were observed at ventral thoracic cord in all reported cases. The mechanism of this disease is still uncertain. But at least three successive factors seem to be necessary for formation of herniation, 1) abnormal structure of the dura mater such as defect, diverticulum and duplication; 2) adhesion between the cord and the destructive dura mater, and 3) continuous cerebrospinal fluid (CSF) pressure pushing the cord outward from subdural space. In the thoracic spine, mobility is limited compared with the cervical and lumbar spine, and because of physiological curvature the cord situates rather ventrally. For these reasons the incidence of adhesion might be higher at ventral thoracic spine. Although neuroradiological imagings especially MRI and CTM were useful, operative findings were necessary for definitive diagnosis in many reported cases. Considering the effectiveness of surgical treatment, study of the ventral side of the cord should be important to avoid misdiagnosis.