Search

Objective: Microsurgical decompression for patients with symptomatic lumbar spinal stenosis (LSS) has demonstrated long-term improvement concerning pain and function. Nonetheless, a considerable proportion of these patients do not experience satisfactory alleviation of symptoms. Previous studies have not found a direct influence of single sagittal parameters on patient outcomes. However, recent research indicates that a composite of parameters, presented in specific sagittal profile types (SPTs) that were defined by Roussouly and colleagues, may affect these outcomes. This study aims to investigate the impact of SPT on long-term outcomes of patients with LSS following microsurgical decompression., Methods: This study is a prospective clinical observation. Patients with symptomatic LSS, who underwent microsurgical treatment and had long-term follow-up data for at least 36 months, were included. Patients with spinal deformity, fractures, or significant instability were excluded. Outcomes were measured using the numeric rating scale for pain, 36-Item Short Form Health Survey for quality of life, walking distance, Oswestry Disability Index, Roland-Morris Disability Questionnaire, and Odom's criteria. SPT was determined in blinded fashion by using preoperative long standing radiographs., Results: The initial population of this observational study consisted of 128 patients, with long-term results available for 87 individuals, including 24 patients with SPT1, 20 with SPT2, 27 with SPT3, and 16 with SPT4. The average age was 70 years, with a slight male majority (56.3%) and a mean BMI of 27.9 kg/m2. After a median follow-up of 48 months, all groups showed significant improvement in walking distance, leg pain, and disability. Overall, 75% reported satisfaction with the surgery. However, patients with SPT1, which is characterized by low sacral slope and specific spinal curvatures, experienced significantly less improvement in back pain (p = 0.018) and related disability (p = 0.030), and lower satisfaction compared to other SPT groups (p = 0.008)., Conclusions: The sagittal spinal type is influencing the long-term outcome of patients suffering from symptomatic LSS. Patients with a combination of a flat sacral slope and a low overall lumbar lordosis with a high lordosis in the lower lumbar spine (i.e., spinal SPT1) showed worse outcome concerning back pain and had decreased satisfaction with surgery than comparable subjects from other SPT groups. Consequently, the authors recommend the assessment of sagittal spinal types in patients diagnosed with symptomatic spinal stenosis prior to decompression surgery. Inclusion of SPT in the preoperative consultation process can provide valuable insights, potentially guiding practitioners to more tailored patient counseling.

Objective: Surgical management of thoracic ossification of the posterior longitudinal ligament (OPLL) remains challenging because of the anatomical complexity of the thoracic spine and the fragility of the thoracic spinal cord. Several surgical approaches have been described, but it remains unclear which of these is the most effective. The present study describes the microsurgical removal of OPLL in the middle thoracic level via the transthoracic anterolateral approach without spinal fusion, including the surgical outcome and operative tips., Methods: Between 2002 and 2017, a total of 8 patients with thoracic myelopathy due to OPLL were surgically treated via the transthoracic anterolateral approach without spinal fusion. The surgical techniques are described in detail. Clinical outcome, surgical complications, and the pre- and postoperative thoracic kyphotic angle were assessed., Results: The mean patient age at the time of surgery was 55 years (range 47-77 years). There were 5 women and 3 men. The surgically treated levels were within T3-9. The clinical symptoms and Japanese Orthopaedic Association (JOA) score improved postoperatively in 7 cases, but did not change in 1 case. The mean JOA score increased from 6.4 preoperatively to 7.5 postoperatively (recovery rate 26%). Intraoperative CSF leakage occurred in 4 cases, and was successfully treated with fibrin glue sealing and spinal drainage. The mean follow-up period was 82.6 months (range 15.3-169 months). None of the patients had deterioration of the thoracic kyphotic angle., Conclusions: Anterior decompression is the logical and ideal procedure to treat thoracic myelopathy caused by OPLL on the concave side of the spinal cord; however, this procedure is technically demanding. Microsurgery via the transthoracic anterolateral approach enables direct visualization of the thoracic ventral ossified lesion. The use of microscopic procedures might negate the need for bone grafting or spinal instrumentation.

OBJECTIVE Surgical decompression is extremely effective in relieving pain and symptoms due to lumbar spinal stenosis (LSS). Decompression with interlaminar stabilization (D+ILS) is as effective as decompression with posterolateral fusion for stenosis, as shown in a major US FDA pivotal trial. This study reports a multicenter, randomized controlled trial in which D+ILS was compared with decompression alone (DA) for treatment of moderate to severe LSS. METHODS Under approved institutional ethics review, 230 patients (1:1 ratio) randomized to either DA or D+ILS (coflex, Paradigm Spine) were treated at 7 sites in Germany. Patients had moderate to severe LSS at 1 or 2 adjacent segments from L-3 to L-5. Outcomes were evaluated up to 2 years postoperatively, including Oswestry Disability Index (ODI) scores, the presence of secondary surgery or lumbar injections, neurological status, and the presence of device- or procedure-related severe adverse events. The composite clinical success (CCS) was defined as combining all 4 of these outcomes, a success definition validated in a US FDA pivotal trial. Additional secondary end points included visual analog scale (VAS) scores, Zürich Claudication Questionnaire (ZCQ) scores, narcotic usage, walking tolerance, and radiographs. RESULTS The overall follow-up rate was 91% at 2 years. There were no significant differences in patient-reported outcomes at 24 months (p > 0.05). The CCS was superior for the D+ILS arm (p = 0.017). The risk of secondary intervention was 1.75 times higher among patients in the DA group than among those in the D+ILS group (p = 0.055). The DA arm had 228% more lumbar injections (4.5% for D+ILS vs 14.8% for DA; p = 0.0065) than the D+ILS one. Patients who underwent DA had a numerically higher rate of narcotic use at every time point postsurgically (16.7% for D+ILS vs 23% for DA at 24 months). Walking Distance Test results were statistically significantly different from baseline; the D+ILS group had > 2 times the improvement of the DA. The patients who underwent D+ILS had > 5 times the improvement from baseline compared with only 2 times the improvement from baseline for the DA group. Foraminal height and disc height were largely maintained in patients who underwent D+ILS, whereas patients treated with DA showed a significant decrease at 24 months postoperatively (p < 0.001). CONCLUSIONS This study showed no significant difference in the individual patient-reported outcomes (e.g., ODI, VAS, ZCQ) between the treatments when viewed in isolation. The CCS (survivorship, ODI success, absence of neurological deterioration or device- or procedure-related severe adverse events) is statistically superior for ILS. Microsurgical D+ILS increases walking distance, decreases compensatory pain management, and maintains radiographic foraminal height, extending the durability and sustainability of a decompression procedure. Clinical trial registration no.: NCT01316211 (clinicaltrials.gov).

OBJECTIVE Microsurgical decompression (MD) in patients with lumbar spinal stenosis (LSS) shows good clinical results. Nevertheless, 30%-40% of patients do not have a significant benefit after surgery-probably due to different anatomical preconditions. The sagittal profile types (SPTs 1-4) defined by Roussouly based on different spinopelvic parameters have been shown to influence spinal degeneration and surgical results. The aim of this study was to investigate the influence of the SPT on the clinical outcome in patients with LSS who were treated with MD. METHODS The authors retrospectively investigated 100 patients with LSS who received MD. The patients were subdivided into 4 groups depending on their SPT, which was determined from preoperative lateral spinal radiographs. The authors analyzed pre- and postoperative outcome scales, including the visual analog scale (VAS), walking distance, Oswestry Disability Index, Roland-Morris Disability Questionnaire, Odom's criteria, and the 36-Item Short Form Health Survey score. RESULTS Patients with SPT 1 showed a significantly worse clinical outcome concerning their postoperative back pain (VAS back-SPT 1 = 5.4 ± 2.8; VAS back-SPT 2 = 2.6 ± 1.9; VAS back-SPT 3 = 2.9 ± 2.6; VAS back-SPT 4 = 1.5 ± 2.5) and back pain-related disability. Only 43% were satisfied with their surgical results, compared with 70%-80% in the other groups. CONCLUSIONS A small pelvic incidence with reduced compensation mechanisms, a distinct lordosis in the lower lumbar spine with a high load on dorsal structures, and a long thoracolumbar kyphosis with a high axial load might lead to worse back pain after MD. Therefore, the indication for MD should be provided carefully, fusion can be considered, and other possible reasons for back pain should be thoroughly evaluated and treated.

Of the posterior third ventricular tumors, a papillary tumor of the pineal gland is a rare entity that originates from specialized ependymoma of the subcommissural organ. In this video narration, we present a case of a 33-year-old male with headaches and recent cognitive decline due to a posterior third ventricular lesion. The patient underwent a posterior interhemispheric approach, and a gross-total decompression was achieved with no signs of recurrence in a 2-year follow-up period. With this case we highlight the microsurgical technique employed for decompressing tumors of the posterior third ventricular region with preservation of eloquent structures and draining veins. The video can be found here: https://youtu.be/o0WbyOqmtX0 .