Special Issue:
Challenges and Opportunities in Spine Surgery
Abstract
Background: Due to risks of reinjury and osteoarthritis, the timing of return to sports after surgery is important. Although there are numerous studies on the return to sports (RTS) criteria in athletes who have undergone knee surgery, there are no studies on the return to dance (RTD) criteria after knee surgery in dancers. In this retrospective clinical study, we investigated the rates of osteoarthritis and reinjury after arthroscopic knee surgery and the criteria for RTD.
Materials and Methods: In a professional dance group consisting of 84 members (mean age: 29.8 ± 9.2 range: 18 to 49 years), during an 11 year period (between January 2009 and January 2020), 14 dancers (mean age 29.1±5.7 (20-38) years) sustained knee injuries (3 meniscus tears, 4 Anterior Cruciate Ligament (ACL) tears, 1 Posterior Cruciate Ligament (PCL), 1 patellar dislocation, 1 infrapatellar bursitis, 2 Hoffa’s fat pad syndromes, 2 symptomatic medial plicas) that required arthroscopic surgery. The RTD times after surgery, follow up lenghts, clinical and functional tests used for deciding on RTD were recorded.
Result: The postoperative follow up period was 56.7± 23 (26-108) months. The rate of reinjury was 7.14% after knee surgery. All dancers who underwent knee surgery were evaluated for osteoarthritis according to the Kellgren Lawrence classification, and the ostearthridites were classified as G:0 in 7 patients, G:1 in 3 patients, and G:2 in 4 patients on final knee radiographs.
Conclusion : In dancers who have undergone arthroscopic surgery, the return to dance criteria should assess painless repeated turnout after meniscus repair, and also safe landing and postural contol after ACL reconstruction or PCL reconstruction.
Christopher L. Antonacci, MD, MS, MPH
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648
M. Darryl Antonacci, MD
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648
William P. Bassett, MD
Eastern Maine Medical Center at Northern Light Health, 489 State Street, Webber West, Suite 340, Bangor, ME 04401
Laury A. Cuddihy, MD
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648
Allison R. Haas, RNFA
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648
Janet L. Cerrone, PA-C
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648
Dominique S. Haoson
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648
Randal R. Betz, MD
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648
Abstract
Anterior vertebral body tethering (VBT) in growing children has been reported as an alternative to fusion for thoracic idiopathic scoliosis. Anterior scoliosis correction (ASC) is our multi-year, multi-generational advancement upon VBT and is a “de-tethering,” not tethering, procedure. ASC incorporates cords/screws similarly to VBT but is a technique that allows for large derotation, curve correction, and restoration of kyphosis using anterior longitudinal ligament complex release (ligament, annular capsule, and disc). It has been used to treat adolescents with minimal or no growth remaining. In this retrospective IRB-approved analysis, we report outcomes of an early cohort of skeletally maturing/mature (Sanders ≥ 5) patients undergoing ASC.
Methods: Inclusion criteria: patients with AIS, at least one operative curve 35-70°, Sanders ≥ 5, age ≤ 21 years, minimum 2-year follow-up or failure before. Forty-nine patients with 82 treated curves with surgery from January 2015 to December 2017 met the criteria and were reviewed. Mean follow-up was 30.3 months range 24 to 50 months. Average age at surgery was 15.2 years.
Results: The average coronal correction was 65.5% for thoracic curves and 66.7% for lumbar curves. 71.4% of patients with thoracic curves received at least 1 thoracic disc release. Kyphosis (T5-T12) calculated 3D corrected from average 2° pre to 34° post-op. Clinical success (final curve ≤ 30°) was achieved in 45/49 (92%) patients and in 78/82 curves (95%). One unanticipated revision was recommended but not performed.
Conclusion: The 2-4 year results of ASC in maturing and mature patients with AIS demonstrated average curve correction of 65.5% in thoracic and 66.7% in lumbar curves. Clinical success with residual curves ≤ 30° was achieved in 47/49 (96%) of all thoracic curves and 31/33 (94%) of all lumbar curves. Average 3D thoracic kyphosis corrected from 2° pre to 34° post.
Double Screw-Line Technique of Anterior Scoliosis Correction with Thoracic Disc Releases for Thoracic Curves > 65 Degrees: Surgical Techniques and Outcomes
M. Darryl Antonacci, MD
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA
Anthony Yung, MMSc
Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
Ashleigh Kozicz, MPH/PA-C
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA
Janet Cerrone, PA-C
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA
Christopher L. Antonacci, MD
Dept. of Orthopaedic Surgery, UConn Health, Farmington, CT, USA
Yashvi Verma
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA
Madeline Sweeney, APN
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA
Laury A. Cuddihy, MD
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA
Randal R. Betz, MD
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA
Abstract
Anterior Scoliosis Correction (ASC) is the proprietary technique of the authors and is an anterior spinal “de-tethering” technique using multiple flexible rod-cords and multiple screw constructs. It is performed through a modified anterior fusion approach that is a muscle-sparing mini-thoracotomy. ASC is the multi-year (since 2013), multi-generational modification of the original anterior vertebral body tethering procedure but includes preservation of the segmental arteries and incorporates multilevel releasing techniques of the contracted anterior longitudinal ligament and annular disc complex. Because of this, ASC, unlike vertebral body tethering, has been shown to derotate the hypokyphotic scoliotic spine effectively towards a more normal thoracic kyphosis and is not restricted to small curves or pediatric patients with growth remaining as is vertebral body tethering.
We retrospectively reviewed all 309 ASC procedures performed between September 2017 and August 2020, and 26 patients met the inclusion criteria (adolescent idiopathic scoliosis and at least a thoracic operative curve with severe coronal curve angles between 66° and 90°, double screw and rod-cord construct, and minimum 2-year follow-up).
The results of ASC on severe curves showed an average curve correction of 78.4% in thoracic and 71.2% in lumbar curves in the instrumented curves. Anterior longitudinal ligament and annular disc complex releases were performed on all patients having thoracic curves to help obtain adequate correction. An average of 4.1 discs per patient were released, all in the thoracic region. Clinical success with residual curves ≤ 35° was 96% (25/26 curves) in all patients and 92.3% in patients with curves ≤ 30° (24/26 curves). Three-dimensional (3D) thoracic kyphosis corrected an average of 39° from preoperative hypokyphosis of -4° to 35° postoperatively. There were no revisions performed in this group of patients.
In conclusion, Anterior Scoliosis Correction has potential expanded indications and increased ability to correct severe curves (> 65°) in patients with adolescent idiopathic scoliosis as compared to vertebral body tethering.
Guilherme Zanini Rocha Aluízio Augusto Arantes Junior
Neurosurgeon, Professor at the Department of Surgery, Faculty of Medicine, UFMG – Minas Gerais, Brazil
Maurício Queiroz Cardoso
Orthopedist, Fellow of the Spine Surgery Service at Madre Teresa Hospital in Belo Horizonte, Minas Gerais, Brazil
Diogo Nogueira Ribeiro
Orthopedics and traumatology resident at Madre Teresa Hospital in Belo Horizonte, Minas Gerais, Brazil
Abstract
This article aims to describe the development of a head support for prone spinal surgery, which allows the patient’s head to be positioned in neutral alignment with the body and enables monitoring of the position of the eyes, mouth, nose, and orotracheal tube, thus avoiding damage due to poor positioning during surgery. A literature review was conducted focusing on complications resulting from head positioning in different supports to develop an option that would reduce the risks of injury. It was developed a support that protects the patient’s head and allows easy visualization of the face during surgery, with sufficient space for the anesthesia team to manage the orotracheal tube if necessary. Since its creation, no serious complications have been observed in the use of this support.
Tejas Karnati
Department of Neurological Surgery, University of California, Davis
Dylan Goodrich
Department of Neurological Surgery, University of California, Davis
Kee D. Kim
Department of Neurological Surgery, University of California, Davis
Abstract
Techniques and technology for spinal surgery have evolved together throughout the past few decades. There has been a growing popularity of image-guided surgery that has now progressed to robotic-assisted surgery with many FDA approved image-guided surgical robot systems now widely available such as Medtronic’s Mazor X Stealth™ Edition robotic guidance system or Globus Medical’s ExcelsiusGPS® Robotic Navigation Platform. As this trend continues, it is important to understand the basis for these technologies and examine the benefits and trajectories to improve safety and effectiveness going forward. In this review we examine the history, currently available technology, and the multiple benefits that have been studied regarding image-guided navigation and robotics in spine surgery.
Melissa Yunting Tang
Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
Gwendolyn Sowa
Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
Joon Y Lee
Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
Nam Vo
Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
James Kang
Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard University, Boston, MA, USA.
Abstract
Intervertebral disc degeneration is a pervasive condition contributing to chronic back pain, affecting up to a third of the population, with risk further increasing with age. It is a significant driver of disability for millions of Americans and others worldwide. The standard of care today is reliant on symptomatic treatment rather than addressing the root cause of disease. Surgical interventions alter the structural integrity and biomechanics of the spine, often leading to loss of function and motion, and post-operative complications. This is the basis for innovation in novel biologic treatments, including gene therapy, which aims to reestablish the optimal balance between matrix catabolism and anabolism within pathologically degenerating disc cells. This review will cover the significant advances that have led to identification of target therapeutic genes combined with regulated expression of the therapeutic transgene and successful systems for gene delivery into cells. Recent advances in viral and non-viral vectors for gene transfer, silencing of genes by RNA interference, editing of genes by clustered regularly interspaced short palindromic repeats, and modifying mammalian target of rapamycin signaling pathwayS offer promising treatment avenues. Clinical translation of these approaches, however, will require further investigation of the pathological basis of disc degeneration in addition to systematic safety measures for the adoption of gene therapy.
Simon Diaz
Department of Neurosurgery, University Hospital of Lausanne, Switzerland; Spine Surgery department, Lausanne University Hospital, Switzerland
Giulia Cossu
Department of Neurosurgery, University Hospital of Lausanne, Switzerland; Spine Surgery department, Lausanne University Hospital, Switzerland
Mihailo Obrenovic
Department of Internal Medicine, Cantonal Hospital of Fribourg, Switzerland
Juan Barges-Coll
Spine Surgery Department, Lausanne University Hospital, Switzerland
Abstract
Background: Spinal cord tumors represent 2-4% of all CNS tumors. Ependymomas are the most frequent lesions of the spinal cord1. Gross total resection remains the gold standard2.
Method: We describe the mini-invasive surgical technique using a fixed tubular retractor performed for the resection of an ependymoma of the filum terminale, along with its advantages and limits.
Conclusion: This mini-invasive technique has shown to be safe and effective for the resection of filum terminale ependymoma, with a good impact on postoperative pain and less risks of CSF leak, which is probably secondary to a limited dead space.
M. Darryl Antonacci, MD
Work Performed at the Institute for Spine and Scoliosis, Lawrenceville, NJ
Anthony Yung, MD
Work Performed at the Institute for Spine and Scoliosis, Lawrenceville, NJ
Christopher L. Antonacci, MD, MPH
Work Performed at the Institute for Spine and Scoliosis, Lawrenceville, NJ
Laury A. Cuddihy, MD
Work Performed at the Institute for Spine and Scoliosis, Lawrenceville, NJ
Randal R. Betz, MD
Work Performed at the Institute for Spine and Scoliosis, Lawrenceville, NJ
Abstract
Adolescent idiopathic scoliosis (AIS) can continue to progress after skeletal maturity. Once the progression is severe, posterior spinal fusion (PSF) is the gold standard for surgical treatment. While effective in achieving curve correction, PSF is associated with many problems, including loss of spinal flexibility, uncorrected sagittal deformity, and adjacent segment disease. We present a case of a 50-year-old woman with a documented 38º thoracic curve as a late teen who experienced curve progression after skeletal maturity to >70 ° and underwent Anterior Scoliosis Correction (ASC), a motion-preserving scoliosis correction surgery. Her progressive curve improved from 71º Lenke 1A main thoracic curve to 28°, with a 59% correction being maintained within 5° (33°) at 7 years. She also obtained a 50% correction of her compensatory lumbar curve and correction of hypokyphosis from 2.4° to 23° at 7 years. Along with improvement of her thoracic kyphosis, her lumbar lordosis decreased to a normal range of 60° from 70°, giving her better overall alignment. This case report suggests that motion preserving surgical treatment may be considered for some select adult patients with progressive scoliosis.
Jaclyn DeRieux, MD
Santa Barbara Cottage Hospital, Department of General Surgery, 400 West Pueblo St Santa Barbara, CA 93015
Dina Obed, MD
Santa Barbara Cottage Hospital, Department of General Surgery, 400 West Pueblo St Santa Barbara, CA 93015
Kevin Casey, MD, FACS
Santa Barbara Cottage Hospital, Department of General Surgery, 400 West Pueblo St Santa Barbara, CA 93015
Abstract
Nutcracker Syndrome is a rare condition secondary to either compression of the left renal vein in its normal anatomic position by the superior mesenteric artery and aorta, or rarely, when the left renal vein is in a retroaortic position, compressed between the aorta and the spine. Left renal vein compression varies widely in presentation and severity, ranging from asymptomatic imaging findings, to chronic pelvic or flank pain. While left renal vein transposition remains the most common management modality, there is growing acceptance for other surgical interventions as well as endovascular treatments–particularly stenting. However, there remains a scarcity of evidence for these less invasive techniques. We conduct a review of the recent literature and discuss the diagnosis and current management strategies for nutcracker syndrome. We also revisit a unique case of nutcracker syndrome in a female patient with a history of chronic pelvic pain and venous congestion wherein transposition of the left renal vein resulted in complete resolution of her symptoms.
Pedro Luz Alves
MD
Estela Alves De Oliveira, David Del Curto, Renato Hiroshi Salvioni Ueta & Eduardo Barros Puertas
Abstract
Introduction: Acromegalic arthropathy is a cause of morbidity and functional disability, affecting large peripheral joint, especially the spine. Affected patients can suffer from lumbar and sciatic pain, with or without radiculopathy. Due to the severe arthrosis, stenosis with ossification of the ligamentum flavum can often occur.
Patient history: This study presents a 57-year-old patient with acromegalic arthropathy resulting from a growth hormone secreting pituitary macroadenoma. He was previously submitted to transsphenoidal surgery and present a history of L4-L5 decompression due to disc herniation and bilateral knee arthroplasty. The condition evolved to an acute left lumbar sciatic pain and the patient was refractory to clinical and physical therapy treatment. Surgical procedure: Decompression and discectomy were performed through an interlaminar endoscopic approach. Cutting and diamond burs and Keirrinson-type forceps were used for decompression. Diamond burs were used in the calcified yellow ligament and in the intervertebral disc to remove the protruding disc.Imaging exams: Preoperative exams showed calcified disc herniation and stenosis, with ossification of the posterior longitudinal ligament. Postoperative exams showed good decompression, removal of the calcified disc herniation and ossification of the posterior longitudinal ligament.Patient follow-up: Immediate resolution of sciatica pain and neurological deficit, with a negative nerve stretching test. At one-year follow-up, the patient had no return of radicular symptoms.Conclusion: Endoscopic surgery can be a reliable treatment option in approaching patients with severe stenosis of the spinal canal associated with calcified disc hernias and ossification of the ligamentum flavum, even when submitted to previous surgeries. This approach also presents benefits of a minimally invasive surgery.