Incidence of Iatrogenic Lumbar Spinal Instability after Laminectomy, Discectomy or Facetectomy

OBJECTIVE: This thesis aim to report the incidence of iatrogenic spinal instability that occurs after laminectomy, discectomy or facetectomy in Lumbar spine surgery. METHODS: This is a prospective study of 50 cases of degenerative lumbar spondylosis complaining of various symptoms of claudication, sciatica and back pain which were surgically managed by laminectomy according to the level of stenosis in the period between October 2018 and October 2020 in the neurosurgery department at Cairo university hospitals. Mesial facetectomy was added according to the degree of stenosis if needed. Some patients needed discectomy if sciatica was an eminent symptom. RESULTS: Out of 50 patients included: 9 patients (18%) developed postoperative instability. The number of levels operated on and the degree of mesial facetectomy were found to be variables that may affect postoperative stability. CONCLUSION: Iatrogenic instability may result from large laminectomy and extensive facetectomy for lumbar stenosis in patients who do not have obvious pre-existing instability. Key words: Iatrogenic spinal instability - Laminectomy - conventional open discectomy - Mesial facetectomy.

Differences in Outcomes Between Anterior and Posterior Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis

Background: The glenohumeral joint is one of the most frequently dislocated joints in the body, particularly in young, active adults. Purpose: To conduct a systematic review and meta-analysis to evaluate and compare outcomes between anterior versus posterior shoulder instability. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed using the PubMed, Cochrane Library, and MEDLINE databases (from inception to September 2019) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they were published in the English language, contained outcomes after anterior or posterior shoulder instability, had at least 1 year of follow-up, and included arthroscopic soft tissue labral repair of either anterior or posterior instability. Outcomes including return-to-sport (RTS) rate, postoperative instability rate, and pre- and postoperative American Shoulder and Elbow Surgeons (ASES) scores were recorded and analyzed. Results: Overall, 39 studies were included (2077 patients; 1716 male patients and 361 female patients). Patients with anterior instability had a mean age of 23.45 ± 5.40 years (range, 11-72 years), while patients with posterior instability had a mean age of 23.08 ± 8.41 years (range, 13-61 years). The percentage of male patients with anterior instability was significantly higher than that of female patients (odds ratio [OR], 1.36; 95% CI, 1.04-1.77; P = .021). Compared with patients with posterior instability, those with anterior instability were significantly more likely to RTS (OR, 2.31; 95% CI, 1.76-3.04; P < .001), and they were significantly more likely to have postoperative instability (OR, 1.53; 95% CI, 1.07-2.23; P = .018). Patients with anterior instability also had significantly higher ASES scores than those with posterior instability (difference in means, 6.74; 95% CI, 4.71-8.77; P < .001). There were no significant differences found in postoperative complications between the anterior group (11 complications; 1.8%) and the posterior group (3 complications; 1.6%) (OR, 1.12; 95% CI, 0.29-6.30; P = .999). Conclusion: Patients with anterior shoulder instability had higher RTS rates but were more likely to have postoperative instability compared with posterior instability patients. Overall, male patients were significantly more likely to have anterior shoulder instability, while female patients were significantly more likely to have posterior shoulder instability.

The effects of age and gender on the quality of life after anterior cruciate ligament reconstruction

Introduction. The aim of the study was to determine whether there is was statistically significant difference in patients of different age and gender regarding quality of life and causes of postoperative knee instability after anterior cruciate ligament reconstruction. Material and Methods. The study included 776 subjects, aged 15 to 59 (average age 27 years), who we divided into groups by age and gender. All volunteered to complete the Knee injury and Osteoarthritis Outcome Score questionnaire. We examined the postoperative instability using clinical tests in order to determine its causes and incidence among the groups of patients. Results and Discussion. The average values related to pain during sports activities were the highest in the youngest group of patients, up to 18 years of age (81 points). Postoperative instability was reported by 27 patients (3.5%), more frequently by males. Among the causes of instability, the most common was a new sports injury, in 11 cases (40%), and inappropriate tunnel positioning in 7 (26%). The highest incidence of postoperative instability was found in the youngest group of patients, under the age of 18 years, (5%), and no such cases were found in patients aged over 41 years. Conclusion. There was no statistically significant correlation between the quality of life of younger and older patients after anterior cruciate ligament reconstruction, but there were differences in individual segments of the questionnaire. Postoperative instability was not common, but it was more common in males and in the youngest examinees. Inappropriate tunnel positioning and new sport injuries were the most common reasons for dissatisfaction after the primary surgery.

Risk factors for instability after reverse shoulder arthroplasty

Background This study aims to identify risk factors related to postoperative instability after reverse shoulder arthroplasty and evaluate the modalities and results of treatments in a large series of patients, with medium to long-term follow-up. Methods Retrospective multicenter series of 1035 consecutive Grammont type reverse shoulder arthroplasties implanted between 1992 and 2010. 19.9% had a reverse shoulder arthroplasty with bony lateralization on the glenoid side. Patients were reviewed and radiographed with minimum five years’ follow-up. Results At a mean follow-up of eight years, the overall rate of postoperative instability was 3.0%. Instability was more frequent in case of reverse shoulder arthroplasty for revision surgery, in younger patients, in case of scapular notching, and tuberosity resorption. Lateralized reverse shoulder arthroplasties were associated with a lower instability rate. A reoperation to restore stability was needed in 70% of cases. The improvement in Constant Score was lower in patients with unstable reverse shoulder arthroplasties when compared to stable reverse shoulder arthroplasties. Conclusions Younger patients are at higher risk for instability after Grammont type reverse shoulder arthroplasty implantation. Conversely, lateralized reverse shoulder arthroplasties resulted protective. When conservative treatment had failed, shoulder stability can be obtained with reoperation or prosthetic revision (needed in 70% of the cases), but to the price of lower functional results.

Interposition Arthroplasty for Posttraumatic Ulnohumeral Arthritis

Posttraumatic elbow arthritis presents a difficult problem in young patients. Total elbow arthroplasty may not be suited to the functional demands placed on the prosthesis in younger, more active individuals. Interposition arthroplasty is a useful nonprosthetic alternative in these patients. Various biologic materials have been employed as an interpositional graft, with Achilles tendon allograft being the preferred material. Successful outcomes have been reported in 26% to 94% cases, with the best results in patients with posttraumatic arthritis with stiffness and no underlying instability. Poor prognostic factors associated with this procedure include malalignment and pre- and postoperative instability. Use of a hinged-distraction device to allow immediate postoperative range of motion while protecting the graft may further improve results. In those patients where postoperative instability occurs or where results deteriorate with time, stability and pain relief can be salvaged by conversion to a semiconstrained total elbow arthroplasty.

Clinical and X- Ray Stability Evaluation in Arthroscopic Bankart Repair

Objectives: Crank test and the radiological Sulcus sign are described as reliable parameters of shoulder instability. Our objective is to establish by these methods, the clinical and x- ray stability outcome in patients with arthroscopic Bankart repair. Methods: We studied 30 patients, 21 males and 9 female, average age 31 years (17-45), with ISIS average of 3.5 (2-5), all the cases presented Bankart lesion. All patients were treated on by the same team, all the surgeries were did by the same arthroscopic technique. Average follow up 21 months (6 - 36). The radiological and clinic assessment was done by the same surgeon to the 3, 6, 12 and 24 months postoperatively. Results: We found In 25 patients a negative result of clinical - x ray evaluation, 4 patients had crank test positive,1 patient presented both, Crank test and positive Sulcus sign. Discussion: These clinical and radiological tests are a practical tool that reproduced the gleno humeral postsurgical instability; In addition, it was found that the positive cases of instability coincide with a 6 points preoperative ISIS evaluation. Conclusion: We can infer that both, Crank test as Sulcus sign are reliable parameters for evaluate postoperative instability. We know that the success of the surgical outcome is the preoperative screening of the patient.

The use of inside-outside screws for occipitocervical fusion in pediatric patients

Object The authors describe the use of inside-outside occipital screws in 21 children with occipitocervical instability requiring occipitocervical fusion. Methods The ages of the patients were from 2 to 15 years, and patients presented with a variety of causes of occipitocervical instability, including congenital disorders, posttraumatic instability, idiopathic degeneration, and postoperative instability. Surgeries frequently included foramen magnum decompression, duraplasty, and laminectomy, but all patients required occipitocervical instrumentation and arthrodesis. Postoperative orthosis included the use of either a cervical collar or halo device. In all but one case, patients were followed postoperatively for at least 12 months. Results The mean age of patients was 9.93 years. Inside-outside screws were used in all reported cases. Rib autograft was used in all patients. In addition, demineralized bone matrix was used in 2 cases, and bone morphogenetic protein was used in 2 patients. Two patients required halo placement, and the other 19 were placed in cervical collars. The average time postoperative orthotics were used was 2.82 months. Arthrodesis was determined radiographically and was noted in all patients. No operative complications were noted; however, postoperative complications included 1 wound infection, 2 cases of hardware loosening, and the need for tracheostomy in 2 patients. Conclusions Inside-outside screws were found to be a useful component of occipitocervical instrumentation in pediatric patients ranging from 2 to 15 years of age. Arthrodesis was demonstrated in all cases.

Management of complex giant spinal arachnoid cysts presenting with myelopathy

A giant spinal arachnoid cyst is an unusual cause of progressive epidural compressive syndrome. The authors describe 4 cases of a “complex” subtype of this lesion and discuss aspects of surgical management. The patients presented with progressive spastic paraparesis and were found to harbor extensive spinal extradural arachnoid cysts with multiple septations and significant paraspinal extensions. Extensive laminotomy and excision of the cyst along with its extensions were performed in all cases. Compared with previously indexed cases of surgically managed extensive spinal extradural arachnoid cysts, the cases reported here are unique because of their complex nature. Curative treatment consists of radical excision inclusive of the paraspinal extensions as well as closure of a dural defect, if found. A laminotomy or laminoplasty should be performed to avoid postoperative instability related to the extensive exposure. Extended follow-up and instrumentation may be required in select cases.