Axial neck pain can frequently be a vexing clinical problem for practitioners. Cervical spine surgery is generally regarded as less successful for axial neck pain than arm complaints. Although only few case series exist in the literature, there is evidence to suggest that upper cervical radiculopathy could be an important, treatable source of axial neck pain. Unlike patients with axial neck pain, patients with radiculopathy usually present with unilateral pain, particularly in the trapezial, parascapular, mid clavicular, or even in the form of suboccipital headaches. Similar to other regions of the cervical spine, initial imaging often consists of plain radiographs of the cervical spine, with the use of magnetic resonance imaging (MRI) or computed tomography (CT) if further evaluation of the pathology is warranted. Selective injections and electromyography can be used in conjunction with the imaging studies to aid with proper diagnosis. The surgical management of upper cervical radiculopathy is reserved for patients who fail to improve with non-operative modalities. Anterior cervical discectomy and fusion (ACDF) remain the most commonly performed and most reliable procedure for the treatment of cervical radiculopathy. Wide decompression of disc material from uncinate to uncinate is performed with or without a foraminotomy on the symptomatic side to address anterior compressive pathology. Artificial disc replacement (ADR) has been recently introduced in hopes of maintaining motion at the pathologic levels. Young patients (<40 years old) with minimal facet joint arthrosis are best indicated for this surgery. Posterior cervical foraminotomy avoids many approach related complications associated with anterior surgery and is the preferred approach when anterior surgery is contraindicated. Very few studies with small sample sizes (likely due to underdiagnosis) make it difficult to perform a comparative analysis of the different types of procedures. Ultimately, an accurate diagnosis is likely the most important predictor of a positive surgical outcome.
This is a review paper on the topic of genetic background of degenerative disc diseases in the lumbar spine. Lumbar disc diseases (LDDs), such as lumbar disc degeneration and lumbar disc herniation, are the main cause of low back pain. There are a lot of studies that tried to identify the causes of LDDs. The causes have been categorized into environmental factors and genetic factors. Recent studies revealed that LDDs are mainly caused by genetic factors. Numerous studies have been carried out using the genetic approach for LDDs. The history of these studies is divided into three periods: (1) era of epidemiological research using familial background and twins, (2) era of genomic research using DNA polymorphisms to identify susceptible genes for LDDs, and (3) era of functional research to determine how the genes cause LDDs. This review article was undertaken to present the history of genetic approach to LDDs and to discuss the current issues and future perspectives.
Introduction: Pulmonary embolism (PE) is a risk of mortality following spine surgery. Many studies have demonstrated that deep venous thrombosis (DVT) may affect and actually advance to PE, but few studies have shown how venous thromboembolism (VTE), including PE and DVT, affect blood markers after spine surgery. In this study, we examined changes in blood markers with PE or DVT after low-risk spine surgery, namely cervical laminoplasty or lumbar laminectomy.
Methods: Seventy-two spine surgery patients were studied. A 16-row multidetector computed tomography was performed before and 3 d after the surgery. Patients with a history of cerebral vascular accident or arterial thrombotic episode or pre-surgical asymptomatic PE or DVT were excluded. Plasma levels of soluble fibrin monomer complex, D-dimer, plasminogen activator inhibitor type-1 (PAI-1), and white blood cell and platelet counts were measured preoperatively and postoperatively at days 1, 3, and 7.
Results: No patient developed symptomatic post-surgical VTE. Six patients with asymptomatic PE and six with asymptomatic DVT were detected post-surgery, including one patient with both. D-dimer postoperatively at days 3 and 7 was significantly higher in the post-op PE group than in the no-PE group. PAI-1 preoperatively was significantly higher in the DVT and VTE groups than in the no-DVT and no-VTE groups.
Conclusions: Elevated D-dimer at postoperative days 3 and 7 is a predictive factor for the early diagnosis of PE after spine surgery. Moreover, elevated PAI-1 preoperatively is a predictive factor for the early diagnosis of DVT and VTE. Consequently, PE may occur through a pathway other than DVT.
Introduction: During upper cervical anterior fusion involving C2, the branches of the superior laryngeal and hypoglossal nerves traversing the operative field are at risk for injury, mainly from excessive retraction and/or incidental ligation. These injuries would cause postoperative dysphagia and/or dysphonia that are often transient but might sometimes persist for several months. The aim of this study was to describe our modified approach for upper cervical anterior fusion and to examine the surgical outcomes and postoperative complications in a small case series.
Methods: Four patients underwent upper cervical anterior fusion at our institution. Detaching the omohyoid and sternohyoid muscles from the hyoid bone increased the mobility of the hyoid bone and enabled visualization of the thyrohyoid membrane. This maneuver facilitated access to C2 without excessive retraction to the larynx and the hypoglossal nerve traversing above the hyoid bone. Moreover, this maneuver enabled easy identification and dissection of the internal branch of the superior laryngeal nerve piercing the thyrohyoid membrane.
Results: Three patients underwent C2-3 fusion and one patient underwent C2-5 fusion followed by instrumentation. In all patients, wide, adequate exposure of C2 and proper instrumentation was achieved, and both the internal branch of the superior laryngeal nerve and the hypoglossal nerve were identified and preserved. No patient experienced remarkable postoperative dysphagia, dyspnea, and dysphonia. Solid union was achieved in all patients.
Conclusions: The technique of detaching the infrahyoid muscles from the hyoid bone during upper cervical anterior fusion involving C2 reduced the traction force to the larynx and the hypoglossal nerve, enabled easy identification of the internal branch of the superior laryngeal nerve, and prevented postoperative complications, such as dysphagia.
Introduction: To identify the temporal comparison of biochemical markers for early detection of surgical site infection (SSI) following instrumented spinal fusion that are not affected by operative factors.
Methods: We reviewed data on C-reactive protein level and total white blood cell count and differential count before instrumented spinal fusion and at 1, 4, and 7 days postoperatively. The 141 patients in our sample were divided into an SSI group (patients who developed deep SSI) and a non-SSI group. We investigated the peak or nadir value day and identified those not affected by operative circumstances (operating time, intraoperative blood loss, and number of fusion segments) in the non-SSI group. If there was a significant difference between the peak or nadir value day and the next survey day, we considered the temporal comparison between these unaffected markers as an indicator of SSI and examined the usefulness of these indicators by calculating sensitivity and specificity. Furthermore, we investigated the usefulness of the combination of these markers (if even each one marker was recognized, we considered it positive).
Results: Four biochemical markers of SSI were selected: neutrophil percentage at postoperative day 4 more than day 1 (sensitivity 36%, specificity 95%), neutrophil count at postoperative day 4 more than day 1 (sensitivity 46%, specificity 93%), lymphocyte percentage at postoperative day 4 less than day 1 (sensitivity 36%, specificity 90%), and lymphocyte count at postoperative day 4 less than day 1 (sensitivity 36%, specificity 90%). The combination of these markers showed sensitivity 100%, specificity 80%, respectively.
Conclusions: Four markers are reliable indicators for early detection of SSI following spinal instrumented fusion because they are not affected by operative factor. The combination of each indicator had both high sensitivity and specificity. Therefore, it is reliable and much useful for early detection of SSI.
Introduction: To assess the bone fusion rates and clinical results of two surgical methods (pedicle screw claw-hook fixation and pedicle screw hook fixation) of lumbar spondylolysis repair.
Methods: A multicenter database of surgical patients with lumbar spondylolysis was reviewed. All patients < 20 years old with a minimum of 6 months of follow-up and computed tomography images were included. Operation time and blood loss amount were investigated. Visual analogue scale (VAS; 0-10) scores for lower back pain were evaluated to assess clinical results.
Results: A total of 17 patients met the inclusion criteria. Pedicle screw hook fixation was performed in five patients (the hook group), and pedicle screw claw-hook fixation was performed in 13 patients (the claw-hook group). One patient was included in both groups because each method was performed at different lumbar levels (L4 and L5). The bone fusion rates at 3, 6, and 9 months after surgery were significantly higher in the claw-hook group than those in the hook group. Operation time and blood loss amount were not significantly different between the groups. VAS scores improved in the claw-hook group but not in the hook group because of a small number of patients.
Conclusions: Pedicle screw claw-hook fixation was more effective than pedicle screw hook fixation in terms of bone fusion rates.
Introduction: To comprehensively investigate the anatomy of the neuromuscular, visceral, vascular, and urinary tissues and their general influence on lateral lumbar interbody fusion (LLIF) surgery in the presence or absence of spinal deformity.
Methods: We retrospectively reviewed 100 consecutive surgery cases for lumbar degenerative disease of patients aged on average 70.5 years and of which 67 were women. A sagittal vertical axis deviation of more than 50 mm was defined as adult spinal deformity (ASD: 50 patients). The degenerative disease of the other patients was defined as lumbar spinal stenosis (LSS: 50 patients). We analyzed the relative anatomical position of the psoas major muscle, lumbar plexus, femoral nerves, inferior vena cava, abdominal aorta and its bifurcation, ureter, testicular or ovarian artery, kidney and transverse abdominal muscle in patients with ASD or with LSS, using preoperative magnetic resonance imaging (MRI).
Results: For patients with ASD, the L4-5 intervertebral disk was closer to the lumbar nerve plexus than it was in those with LSS (p < 0.0001), and a rising psoas sign at the L4-5 disk was significantly more frequent in patients with ASD than in those with LSS (p < 0.05). The aortic bifurcation frequently appeared at the level of L4-5 in patients with either degenerative disease, so the common iliac artery may pass near the disk. The inferior vena cava passed closer to the center of the L4-5 disk in patients with ASD than it did in those with LSS (p < 0.05). The transverse abdominal muscle at L2-3, L3-4, and L4-5 was closer to and less than 3 mm from the kidneys in many more patients with ASD than was the case for patients with LSS (p = 0.3, p < 0.05, p = 0.29, respectively).
Conclusions: We recommend careful preoperative MRI to determine the location of organs to help to avoid intraoperative complications during LLIF surgery, especially for patients with ASD.
Introduction: Osteoporosis and sarcopenia are said to be similar disorders. However, few reports have described the effects of anti-osteoporosis drugs on muscle mass in clinical practice.
Methods: We selected 150 postmenopausal women with osteoporosis treated by minodronate (osteoporosis medication [OM] group) and 50 postmenopausal women without osteoporosis who did not receive treatment (no osteoporosis [NO] group). The OM group was further divided into two treatment subgroups: a combination of monthly minodronate and daily activated vitamin D vs. monthly minodronate alone. We measured lumbar spine and femoral neck bone mineral density (BMD) with dual-energy X-ray absorptiometry and muscle mass of the upper limbs, lower limbs, and trunk with bioelectrical impedance analysis at baseline and after 6 months.
Results: The OM and NO groups contained 130 and 37 patients, respectively (mean age: 73.9 ± 8.3 and 74.1 ± 10.0 years, respectively). In the OM group, lumbar spine BMD significantly increased after 6 months, while lower limb muscle mass significantly decreased. In the NO group, lumbar spine BMD and lower limb muscle mass did not significantly change after 6 months. In the OM group, BMD of the lumbar spine significantly increased but the lower limb muscle mass significantly decreased after 6 months relative to the NO group. In the combination therapy subgroup of the OM group muscle mass decreased significantly less than in the minodronate-alone subgroup.
Conclusions: In postmenopausal women with osteoporosis, minodronate can increase BMD but cannot increase muscle mass. However, simultaneous use of activated vitamin D can suppress muscle mass decrease. The combination of activated vitamin D and minodronate may be useful for treating osteoporosis in postmenopausal women.
Introduction: Double-door laminoplasty (DDL) of the cervical spine (Kurokawa's method) was developed as one of posterior decompression surgical methods in the late 1970s and after then has been modified by adding various procedures such as the posterior muscle handling and the use of artificial spacers.
There are three principles of DDL: First, to decompress the cervical spinal cord by central splitting of the spinous processes and laminae, preserving those lengths as much as possible and widening the spinal canal space symmetrically. Second, to maintain the widened spinal canal space steadily by fixing spacers made of hydroxyapatite the contour is almost the same as the widened space. Third, to re-suture the semispinalis muscles to the C2 spinous process to restore the strength of the posterior cervical muscles.
Technical note: The important technical points in performing osteotomy are as follows: At each vertebra, osteotomy is performed from the caudal side and gradually proceeds to the cranial side because there is a space between the lamina and the dura mater at the caudal side and the osteotomy can be safely made. The surgeon must pay attention to the changes in color of the osteotomy site from red of cancellous bone, to white of the inner cortex, and finally to yellow of the yellow ligament and extradural fat tissue. Attention must be paid to the changes in sound and tactile sensation delivered from the air-drill when completing osteotomy of the inner cortex of lamina. By moving an air-drill slowly, tactile sensation can be more sensitive. During osteotomy, the process must be checked frequently by touching the inner cortex of the lamina with a probe.
Conclusion: At present, DDL is a useful surgical method for cervical myelopathy at multiple level lesions.
Introduction: Pyogenic arthritis in the spinal facet joint is rare, although the wide availability of magnetic resonance imaging (MRI) has increased the detection rate. Pyogenic arthritis of a lumbar facet joint is often combined with abscesses in the paraspinal muscles and epidural space. However, there is no report of pyogenic arthritis of a lumbar facet joint causing a retroperitoneal abscess. We report on a patient with pyogenic lumbar facet arthritis, which caused a huge retroperitoneal abscess.
Case Report: The patient was a 67-year-old woman with a 3-week history of fever and pain in her lower back, left lower abdomen, and left thigh. Blood tests revealed high levels of inflammatory markers. Computed tomography (CT) showed a huge retroperitoneal abscess, and MRI of the lumbosacral spine showed an abscess at the left L5/S facet joint, that had invaded into the paraspinal muscles, epidural space, and retroperitoneal space. We diagnosed pyogenic arthritis of a lumbar facet joint combined with abscesses in the paraspinal muscles, epidural space, and retroperitoneal space. CT-guided percutaneous drainage of the retroperitoneal abscess was performed, and the patient was treated with antibiotics. The bacterial strain cultured was Streptococcus pneumoniae. The patient recovered after 10 weeks of antibiotic treatment combined with additional CT-guided percutaneous drainage.
Conclusions: Pyogenic arthritis of a lumbar facet joint can cause a retroperitoneal abscess through the vertebral foramen as well as the more common abscesses in the paravertebral muscles and epidural space, and the finding of MRI is characteristic. The clinician should suspect of pyogenic arthritis of a lumbar facet joint in a patient presenting with retroperitoneal abscesses that are not secondary to diseases of kidney or gastrointestinal tract.