Buckling of the Ligamentum Flavum as a Rare Complication of Anterior Cervical Corpectomy and Fusion: A Case Report

Introduction and Importance Neurological deterioration due to buckling of the ligamentum flavum (LF) is an uncommon complication after anterior cervical corpectomy or discectomy with fusion. Case Presentation In this report, we present the case of a 66-year-old male who underwent anterior cervical partial corpectomy of C5 and discectomy of prolapsed C5-C6 with fusion. Postsurgery, the patient displayed signs of neurological deterioration. Upon immediate cervical magnetic resonance imaging (MRI), posterior canal stenosis and severe compression with cord signal due to LF buckling were detected. A posterior laminectomy procedure and canal decompression at the C5-C6 level with bone fusion were performed. Clinical Discussion Patient presented with walking difficulty, then walking disability, followed by bilateral upper and lower limb paresthesia with burning sensation. Examination showed ⅘ muscle strength in both handgrips. Further investigation showed brisk deep tendon reflexes, positive Hoffman sign unilaterally, equivocal Babinski sign, and progressive quadriparesis. Magnetic resonance imaging showed mild and diffuse building of some cervical discs, with spinal cord progression. We performed an anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF); a titanium mesh with plates and screws was used for fusion, with removal of a calcified and herniated subligamentous disc. Postoperatively, upper and lower limb strength deteriorated; immediate cervical and thoracic MRI showed LF buckling, which caused canal stenosis and severe compression. Urgent posterior laminectomy and canal decompression with bone fusion was scheduled on the same day. The patient underwent physiotherapy and regained upper and lower limb strength and his ability to walk. Conclusion This indicates the possibility of neurological deterioration as a result of LF buckling, which may be a result of LF thickening accompanied by hyperextension in the cervical region. In this regard, immediate imaging following signs of neurological complications after anterior cervical corpectomy or discectomy warrants early detection, which results in a better prognosis.

Microsurgical Resection of Dorsal Pontine Cavernous Malformation: The Telovelar Approach Augmented by the Tonsillouvular Fissure Exposure: 2-Dimensional Operative Video

Surgical approaches to lesions of the fourth ventricle (FV) have been modified over the years to reduce the complications associated with splitting the inferior cerebellar vermis (ICV) and disrupting the brainstem and critical surrounding structures.1-4 Two common approaches to lesions of this region include the transvermian approach (TVA) and telovelar approach (TeVA).2 The TVA was initially considered the conventional route of access to lesions of the FV1 but has been associated with significant risks, including possible gait ataxia and dysarthria.3 The TeVA is advantageous, as it involves dissection along natural clefts and division of non-neural tissue and provides good exposure of the superolateral recess with modest exposure of the rostral FV. The TeVA approach can be augmented by opening the tonsilouvular fissures (TUFs). This added dissection allows greater lateral and superior exposure with less need for retraction. In this operative video, we demonstrate a case in which we augmented the TeVA with a TUF dissection to access a dorsal pontine cavernous malformation. We performed a midline suboccipital craniotomy with a C1 posterior laminectomy. TUF dissection was followed by division of the tela choroidea (TC), which allowed for more lateral exposure of the FV and excellent visualization of the cavernous malformation without the need to traverse neural tissue. TeVA augmented by TUF dissection provided adequate access to the dorsal pons for complete resection of the cavernous malformation. The patient consented to the procedure as shown in this operative video and gave informed written consent for use of her images in publication. Anatomic images provided by courtesy of © The Rhoton Collection. http://rhoton.ineurodb.org/. Video © Mayo Foundation for Medical Education and Research, 2021. Used with permission.

Prediction of the risk of C5 palsy after posterior laminectomy and fusion with cervical myelopathy using a support vector machine: an analysis of 184 consecutive patients

Background This study aimed to predict C5 palsy (C5P) after posterior laminectomy and fusion (PLF) with cervical myelopathy (CM) from routinely available variables using a support vector machine (SVM) method. Methods We conducted a retrospective investigation based on 184 consecutive patients with CM after PLF, and data were collected from March 2013 to December 2019. Clinical and imaging variables were obtained and imported into univariable and multivariable logistic regression analyses to identify risk factors for C5P. According to published reports and clinical experience, a series of variables was selected to develop an SVM machine learning model to predict C5P. The accuracy (ACC), area under the receiver operating characteristic curve (AUC), and confusion matrices were used to evaluate the performance of the prediction model. Results Among the 184 consecutive patients, C5P occurred in 26 patients (14.13%). Multivariate analyses demonstrated the following 4 independent factors associated with C5P: abnormal electromyogram (odds ratio [OR] = 7.861), JOA recovery rate (OR = 1.412), modified Pavlov ratio (OR = 0.009), and presence of C4–C5 foraminal stenosis (OR = 15.492). The SVM model achieved an area under the receiver operating characteristic curve (AUC) of 0.923 and an ACC of 0.918. Additionally, the confusion matrix showed the classification results of the discriminant analysis. Conclusions The designed SVM model presented satisfactory performance in predicting C5P from routinely available variables. However, future external validation is needed.

One-stage posterior laminectomy with instrumented fusion and foraminotomy for cervical ossification of posterior longitudinal ligament with radiculopathy pain

Objective To explore the clinical efficacy of posterior LFF for cervical OPLL with radicular pain of upper limbs Methods Between January 2014 and January 2018, 48 OPLL patients with radicular pain symptoms of upper limbs who underwent a one-stage posterior laminectomy and instrumented fusion with/without foraminotomy were reviewed retrospectively and divided into two groups: LF group (laminectomy with instrumented fusion without foraminotomy) and LFF group (laminectomy with instrumented fusion and foraminotomy). Clinical data were assessed and compared between the two groups. The radicular pain of upper limbs and neck was measured using the visual analog scale (VAS). The neurological function was evaluated with the American Spinal Injury Association (ASIA) scale. Changes of sagittal alignment were investigated by postoperative plain x-ray or computed tomography (CT). Moreover, the decompression of the spinal cord was evaluated based on postoperative MRI. Results All the 48 patients were followed up for 24–42 months with an average follow-up time of 31.1±5.3 months. A total of 56 cervical intervertebral foramens were enlarged in 48 patients, including 40 cases (83.3%) with 1 intervertebral foramen enlargement and 8 cases (16.7%) with 2 intervertebral foramen enlargements. There were no significant differences in intraoperative blood loss, postoperative drainage amount, Japanese Orthopaedic Association (JOA) scores, JOA recovery rates, VAS scores for neck pain, and ASIA grade between two groups. The mean operative time was shorter in the LF group compared with the LFF group. The VAS score for arm pain was significantly lower while the surgical duration was longer in group B. No statistical difference was observed between the two groups in terms of C2–C7 SVA, cervical lordosis, focal angulation at the foraminotomy segment, and local spinal cord angle. Compared with the LF group, there was no segmental kyphosis or instability where the additional posterior foraminotomy was performed in the LFF group. Conclusions One-stage posterior LFF can achieve satisfied clinical efficacy in improving neurological function and relieving the radicular pain of the upper limbs for OPLL patients with radiculopathy symptoms.

Prediction of the Risk of C5 Palsy After Posterior Laminectomy and Fusion With Cervical Myelopathy Using Support Vector Machine: an Analysis of 184 Consecutive Patients

Background: This study aimed to predict the C5 palsy (C5P) after posterior laminectomy and fusion (PLF) with cervical myelopathy (CM) from routinely available variables by using support vector machine (SVM) method.Methods: We conducted a retrospective investigation based on 184 consecutive patients with CM after PLF, and data was collected from March 2013 to December 2019. Clinical and imaging variables were obtained and imported into univariable and multivariable logistics regression analysis to identify risk factors for C5P. According to published reports and clinical experience, a series of variables was selected to develop an SVM machine learning model to predict C5P. The accuracy (ACC), area under the receiver operating characteristic curve (AUC) and confusion matrices were used to evaluate the performance of the prediction model.Results: Among the total 184 consecutive patients, C5P occurred in 26 patients (14.13%). Multivariate analyses demonstrated the following 4 independent factors associated with C5P: electromyogram abnormal (odds ratio [OR] = 7.861), JOA recovery rate (OR = 1.412), modified Pavlov ratio (OR = 0.009), and presence of foraminal stenosis C4-C5 (OR = 15.492). The SVM model achieved an area under receiver operating characteristic curve (AUC) of 0.923 and ACC of 0.918. Meanwhile, the confusion matrix shown the classification results of the discriminant analysis. Conclusions: The designed SVM model presented a satisfied performance in predicting C5P from routinely available variables. However, future external validation is needed.

One-stage posterior laminectomy with instrumented fusion and foraminotomy for cervical ossification of posterior longitudinal ligament with radiculopathy pain

ObjectiveTo explore the clinical efficacy of posterior LFF for cervical OPLL with radicular pain of upper limbs.MethodsBetween January 2014 and January 2018, 48 OPLL patients with radicular pain symptoms of upper limbs who underwent a one-stage posterior laminectomy and instrumented fusion with/without foraminotomy were reviewed retrospectively and divided into two groups: LF Group (laminectomy with instrumented fusion without foraminotomy) and LFF Group (laminectomy with instrumented fusion and foraminotomy). ໿Clinical data were assessed and compared between the two groups. The radicular pain of upper limbs and neck was measured using the visual analog scale (VAS). The neurological function was evaluated with the American Spinal Injury Association (ASIA) scale. Achievement of fusion and changes of sagittal alignment were investigated by postoperative plain x-ray or computed tomography (CT). Moreover, the decompression of spinal cord was evaluated based on postoperative MRI.ResultsAll the 48 patients were followed up for 24-42months with an average follow-up time of 31.1 ± 5.3 months. A total of 56 cervical intervertebral foramens were enlarged in 48 patients, including 40 case (83.3%) with 1 intervertebral foramens enlargement and 8 cases (16.7%) with 2 intervertebral foramen enlargements. There were no significant differences in intraoperative blood loss, ໿postoperative drainage amount, Japanese Orthopaedic Association (JOA) scores, JOA recovery rates, VAS scores for neck pain and ASIA grade between two groups. The mean operative time was shorter in the LF group compared with the LFF group. The ໿VAS score for arm pain was significantly lower while the surgical duration was longer in group B. No statistical difference was observed between the two group in terms of C2–C7 SVA, cervical lordosis, ໿focal angulation at the foraminotomy segment and local spinal cord angle. Compared with the LF group, there was no segmental kyphosis or instability where the additional posterior foraminotomy was performed in the LFF group.ConclusionsOne-stage posterior LFF can achieve satisfied clinical efficacy in improving neurological function and relieving the radicular pain of the upper limbs for OPLL patients with radiculopathy symptoms.

Perioperative Complications of Surgery for Degenerative Cervical Myelopathy: A Comparison Between 3 Procedures

Study Design: Retrospective comparative study. Objectives: To compare the perioperative complications of propensity score-matched cohorts of patients with degenerative cervical myelopathy (DCM), who were treated with anterior cervical discectomy and fusion (ACDF), posterior laminectomy with fusion, or laminoplasty. Methods: The Humana PearlDiver Patient Record Database was queried using the International Classification of Diseases (ICD-9 and ICD-10) and the Current Procedural Terminology (CPT) codes. Propensity score-matched analysis was done using multiple Chi-squared tests with Bonferroni correction of the significance level. Results: Cohorts of 11,790 patients who had ACDF, 2,257 patients who had posterior laminectomy with fusion, and 477 patients who had laminoplasty, were identified. After propensity score matching, all the 3 groups included 464 patients. The incidence of dysphagia increased significantly following ACDF compared to laminoplasty, P < 0.001, and in laminectomy with fusion compared to laminoplasty, P < 0.001. The incidence of new-onset cervicalgia was higher in ACDF compared to laminoplasty, P = 0.005, and in laminectomy with fusion compared to laminoplasty, P = 0.004. The incidence of limb paralysis increased significantly in laminectomy with fusion compared to ACDF, P = 0.002. The revision rate at 1 year increased significantly in laminectomy with fusion compared to laminoplasty, P < 0.001, and in ACDF compared to laminoplasty, P < 0.001. Conclusions: The incidence of dysphagia following laminectomy with fusion was not different compared to ACDF. Postoperative new-onset cervicalgia and revisions were least common in laminoplasty. The highest rate of postoperative limb paralysis was noticed in laminectomy with fusion.

Atypical fungal thoracic vertebral osteomylitis resembling metastatic tumor and literature review of fungal vertebral osteomylitis

Case DescriptionFungal vertebral osteomylitis is a rare disease that difficult to diagnosis and cure. Because the early specific clinical manifestations of this disease are few and atypical, it is often missed or misdiagnosed, resulting in treatment delay and aggravation of the disease.ObjectiveTo report a rare case of cryptococcal osteomyelitis that resembles metastatic tumor happened in an immunecompromised patient with a history of mantle cell lymphoma and to review cases reported in literature.Study DesignBased on imaging studies, metastatic tumor was highly suspected. For a further examination and therapy, the patient was referred to our spine clinic. After admission to our clinical, chest and abdominal CT were checked to evaluate the disease status.TreatmentsAfter general anesthesia, posterior thoracic pedicle screw fixation (T2.3.5.6) were performed, followed by posterior laminectomy and decompression of T4 vertebral body. The right facet joint of T3/4, costal transverse joint, right pedicle and transverse process of T4 vertebra were fully removed and curetted. After careful hemostasis, posterolateral bone grafting was performed. The nail-rod connection is fixed.OutcomesThe postoperative intercostal neuralgia and chest pain were significantly relieved, without complications. The postoperative pathological results were suppurative inflammation with focal granuloma formation, dead bone formation and fungal (cryptococcal) infection. ConclusionsWhen complicated with vertebral fungal spondylitis, no obvious abnormality and fever can be found. When pain or nerve dysfunction caused by spinal cord compression or nerve root compression occurs, surgical treatment can effectively relieve clinical symptoms.

Clinical outcomes of posterior laminectomy and pedicle screw fixation for upper cervical intraspinal tumors: a case series

Objective This study was performed to introduce posterior laminectomy and pedicle screw fixation for the treatment of upper cervical spinal cord tumors and investigate the curative effects. Methods Eighteen patients (11 men, 7 women) who underwent surgical treatment of an upper cervical intraspinal tumor from January 2008 to June 2013 were reviewed. Clinical parameters including age, sex, affected spinal levels, lesion location, duration and type of symptoms, and pathological features were retrospectively investigated. Results The mean operation time was 181.9 ± 25.5 minutes (range, 135–240 minutes), and the mean blood loss volume was 1038.9 ± 284.2 mL (range, 750–1530 mL). The Frankel grade, Japanese Orthopaedic Association score, and Karnofsky performance status score were significantly better postoperatively than preoperatively. The radiographic examination revealed good bone graft fusion. Two patients developed tumor recurrence, while four patients developed intraoperative or postoperative complications. Conclusions Management of upper cervical intraspinal tumors by posterior laminectomy and pedicle screw fixation can relieve compression of the cervical cord and nerve root, thoroughly remove the tumor lesion, reconstruct the stability of the upper cervical spine, and improve patients’ quality of life.