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ABSTRACT: The authors present a new method of minimally invasive surgical management of lumbar burst fractures through the posterior approach. The method includes minimally invasive corpectomy and interbody fusion, both of which are performed through a keyhole approach, and percutaneous pedicle screw fixation of the fracture. The technique of the posterior keyhole corpectomy presented in this report is a novel and original concept of the first author (AM). The percutaneous pedicle screw stabilization is performed with the use of a percutaneous instrumentation system (Sextant; Medtronic, Inc., Minneapolis, MN). The Sextant system has been dedicated and used in nontrauma degenerative cases; the novel aspect of this system is its application in spine fractures. Indications for the method include Denis classification subtype B or Magerl subtype A.3.1 burst fractures. Both subtypes represent fractures with failure and retropulsion of the upper part of the vertebral body.
The clinical experience of this study includes four cases of burst fractures with significant retropulsion and occlusion of the spinal canal. Long-term results were assessed at a minimum follow-up period of 1 year (maximum, 3.5 yr). The follow-up assessments included: 1) the quality of decompression and reconstruction of the spinal canal (computed tomographic and magnetic resonance imaging scanning); 2) the stability of the operated segment (dynamic x-rays); 3) the quality of interbody fusion (computed tomographic scanning and dynamic x-rays); and 4) correction of the fracture kyphosis and its postoperative loss (measurements of Cobb angles for the assessment of sagittal plane deformity). The minimum armamentarium requirements for this method include a typical micro lumbar discectomy retractor set; a surgical microscope; two-plane intraoperative fluoroscopy; and a system for percutaneous pedicle screw stabilization (Sextant). "Posterior keyhole corpectomy" indicates corpectomy of the posterior upper half of the vertebral body or removal of the retropulsed bone fragment via two keyhole skin incisions on both sides of the spinous process (each skin incision measures 2 to 3 cm long). Exposure of the retropulsed fragment (the posterior upper part of the vertebral body) is achieved by medial or complete facetectomy along with complete or medial resection of the pedicle. This has to be performed bilaterally. Percutaneous stabilization requires four additional stab skin incisions.
We observed no surgery-related complications (neurological, hardware, dural tears, or deep or superficial wound infections); there was perfect decompression and clearance of the spinal canal (confirmed by computed tomographic and magnetic resonance imaging scanning); and there was solid stability at the affected segments (confirmed by dynamic x-rays). Healed fusion was noted in all patients but one. The latter patient had no clinical symptoms of spinal instability. Kyphotic deformity was corrected and reversed into lordosis in three patients. Loss of deformity correction was noted in all patients; however, all patients retained lordotic alignment of the affected segment.
The advantages of this method include sparing the posterior elements (lamina, spinous process, supraspinous and interspinous ligaments, and paravertebral muscles), safety of the decompression provided by the use of a surgical microscope, and perfect illumination of the operating field. The drawbacks of the method include limitation to certain types of burst fractures, the method is surgically demanding, and the method requires development of a special retractor system to eliminate the cumbersome alternate insertion and the reinsertions of the typical microdiscectomy retractor set.
Neurosurgery 05/2007; 60(4 Suppl 2):232-41; discussion 241-2. · 2.79 Impact Factor
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ABSTRACT: The authors present the diagnostic methods and basic surgical procedures used in treatment of spinal neoplasms. Both metastatic and primary spinal tumours lead to instability and loss of the protective function. Spinal cord can be damaged by compression or increased mobility of the vertebral column. Pain is reported as common symptom. Investigations include: plain X-ray films, myelography, radioisotope bone scan, CT, MRI and needle biopsy. The goal of surgery is to improve the quality of life with preservation of neurological function, reduction of pain and assured spinal stability. Indications for surgery are related with patient's general condition, grade of neoplasmatic disease, neurological symptoms and spinal involvement. Curative surgery include total removal of the tumour with affected vertebral body, followed by spinal stabilization. Palliative surgery as partial tumour removal, partial removal of the vertebral body or laminectomy are performed for spinal decompression. In the majority of cases surgery is combined with radiotheraphy, chemiotheraphy and treatment of pain.
Main goal of surgery in the treatment of spinal metastatic lesions are: tumor removal (cytoreduction), protection of the spinal cord and spinal stabilization. The choice of surgical treatment depends on spinal involvement and neurological status.
Ortopedia, traumatologia, rehabilitacja 08/2003; 5(4):530-3.
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ABSTRACT: Developmental abnormalities or inflammatory disorders provoke deformations and instability of the craniocervical junction. The most dangerous results of these lesions are: sudden brainstem compression or cervical myelopathy. The authors propose the guidelines for surgical management of non-traumatic deformities caused by: a) rheumatoid arthritis of the spine, b) congenital anatomic changes of the occipit and odontoid. Main goals of surgical treatment are decompression and stabilization. The choice of surgical approach and method depends on pathology. It is very important to estimate individual anatomic changes and mobility--possibility of reduction. The authors discuss surgical methods actually used for fusion and decompression of the occipitocervical junction.
Neurologia i neurochirurgia polska 36(2):349-61; discussion 361-2. · 0.43 Impact Factor
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ABSTRACT: The authors present their experience in the minimally invasive posterior keyhole lumbar corpectomy with transpedicular stabilization. This technique involves the removal of the posterior part of the affected vertebral body with the pedicle screw fixation through four 2-3 cm long skin incisions on the back. Two cephalad skin incisions provide an approach for corpectomy and instrumentation of the upper pedicles of the construct. Two caudal skin incisions provide an approach for instrumentation of the lower pedicles of the construct. The minimum armamentarium requirement includes classic micro lumbar discectomy retractor set and intraoperative fluoroscopy. According to the authors' best knowledge this is the first minimally invasive posterior keyhole lumbar corpectomy ever reported in the literature (2002). This is also the first minimally invasive transpedicular fixation ever performed in Poland (2002). This technique was presented during EANS Congress (Lisbon, September 2003). Some reports have recently appeared in the literature on percutaneous pedicle screw fixation of the lumbar spine in non traumatic cases. A special instrumentarium system (Sextant by Medtronic) has been developed and used in this type of minimally invasive stabilization. Although this system has not been dedicated for spine fractures it is feasible in trauma cases. We have one case of L2 burst fracture fixed percutaneously with Sextant.
Neurologia i neurochirurgia polska 38(6):511-6; discussion 517. · 0.43 Impact Factor
