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BACKGROUND: Neurogenic claudication secondary to degenerative lumbar stenosis is typically managed with nonsurgical options, such as epidural corticosteroid injections. As a standard and effective treatment for lumbar stenosis, clinicians must be aware of the corticosteroids choice when injecting in the epidural space. CASE REPORT: A 62-year-old man presenting with sciatic pain is treated with multiple neuroforaminal, facet, and caudal corticoid injections over the course of several months without any symptomatic resolution. A magnetic resonance imaging of his lumbar spine revealed focal bilateral central stenosis at the L4-L5 level. A computed tomography revealed hyperdense lesions at that level. The patient was referred for a surgical option. He underwent complete minimally invasive resection of the bilateral lesion with instrumented and interbody fusion. The final pathology report identified the mass as a calcified granuloma. CONCLUSIONS: Following repetitive methylprednisolone acetate injections, one must be aware of all the potential complications arising from particulate corticosteroids. KEY WORDS: Spinal stenosis, epidural injections, granulomas, corticosteroids

The incidence of multiple primary malignancies (MPM) has increased in recent decades. Our aim was to evaluate incidence, clinical features, and survival in cases of spinal metastases from MPM in which one of the malignancies is lung cancer.We retrospectively reviewed an institutional database of lung cancer patients with spinal metastasis and extracted all cases of MPM.Among 275 patients who had spinal metastasis with lung cancer as one of the diagnoses, 21 (7.6%) patients with MPM were identified. Mean patient age was 68.5 years (95% confidence interval [CI], 65.3-71.7). The most common cancers diagnosed in addition to lung cancer were breast cancer (5 patients, 24%), upper aerodigestive tract cancer (4 patients, 19%), and prostate cancer (4 patients, 19%). Eighteen (86%) patients walked independently, and 3 (14%) patients walked with help. Seventeen (80.9%) patients had a good Karnofsky performance scale score. The median survivals from the date of first cancer diagnosis, last cancer diagnosis, and spinal metastasis diagnosis were 109.8 months (95% CI, 23.5-196.1), 17.8 months (95% CI, 5.8-29.8), and 10.3 months (95% CI, 5.4-15.2), respectively. Actual rates of survival at 6 months, 12 months, and 24 months from the date of spinal metastasis diagnosis were 81%, 42.9%, and 23.8%, respectively.The present study is the first series to our knowledge to show that survival of patients with spinal metastasis and MPM involving lung cancer is not clearly inferior to that of patients with spinal metastasis and lung cancer alone.

One of the main concerns of anterior lumbar spine approaches are vascular complications. The aim of our study is to provide technical details about a flap technique using the anterior longitudinal ligament (ALL) when approaching the lumbar spine via an anterior corridor. This can help decrease complications by protecting the adjacent vascular structures. We also include a retrospective cohort review.This is a retrospective bicentric study: 189 patients with a mean age of 44.2 years underwent anterior lumbar spine surgery using the ALL flap technique. Patients were diagnosed with degenerative pathologies. We treated 239 lumbar levels primarily at the L4-5 and L5-S1: 88 single-level anterior lumbar interbody fusions, 9 two-level ALIFs, 51 total disk replacements (TDR), and 41 hybrid constructs (i.e., ALIF L5S1 and TDR L4L5). Anterior approaches were performed by two senior spine surgeons. The ALL flap technique was utilized in all of these cases, by carefully dissecting the ALL, with the flap suspended using sutures. As such, this ALL flap provided a "safe corridor" to avoid any potential vascular laceration.The operative and early surgical complication rate was 3.2%. There was no arterial injury. There were only 2 minor venous lacerations (1.05%). No blood transfusion was required. Neither lacerations happened during disk space preparation.Here, we provide technical details about a simple and reproducible technique using the ALL as a flap, which may help spine surgeons minimize vascular injuries during ALIF or even TDR surgeries.

Objective Spinal metastases occur primarily in the thoracic spine (50%–60%), less commonly in the lumbar (30%–35%), and, infrequently, in the cervical spine (10%–15%). There has been only 1 study with a limited population comparing the postoperative outcome among cervical, thoracic, and lumbar spine metastasis. The aim of this study is to identify whether the region of surgically treated spinal metastasis affects postoperative outcomes. Methods A retrospective study of patients with spinal metastasis was performed. The collected data were as follows: age, gender, smoking history, tumor histology, revised Tokuhashi score, preoperative and postoperative American Spinal Injury Association score, region of spinal metastasis, ambulatory status, surgical approach, surgery time, blood loss, complications, length of hospital stay, postoperative pain relief, postoperative adjuvant therapy, and survival. Data were analyzed to identify the factors affecting the survival and postoperative functional outcome. Results We studied 191 patients with spinal metastasis including 47 cervical spine metastases, 96 thoracic spine metastases, and 48 lumbar spine metastases, with a mean age of 60.91 ± 9.72 years. The overall median survival was 7 months (95% confidence interval, 2.9–20.63 months). Univariate analysis showed that region of the spine involved with metastasis did not significantly affect the survival and postoperative motor function improvement. Multivariate analysis showed that revised Tokuhashi score, postoperative radiotherapy, and postoperative chemotherapy were independent factors affecting survival. The rate of 30-day complications among patients with different regions of spine metastasis did not reach significance. Conclusions The postoperative outcomes of patients undergoing surgery for metastases are not affected by the region of the spine.

Background Various surgical techniques have been described to address intraforaminal/extraforaminal lumbar lesions. They vary from the classic posterior open approaches to minimally invasive techniques with tubular retractors and even endoscopy. These lesions have been approached from either an ipsilateral or a contralateral approach. Only a few reports have described a contralateral minimally invasive tubular approach to address these lesions. However, none of them have been able to address calcified pathologies. Method We used a contralateral tubular approach to remove the calcified disc herniations in 2 patients presenting with radiculopathy secondary to a calcified intraforaminal L5-S1 disc herniation. Results Early clinical and radiological outcomes were positive. No perioperative complications occurred. Conclusions To our knowledge, this is the first report of the expanded use of fixed tubular retractors to address calcified lumbar intraforaminal disc herniations. This approach allows a satisfactory access and view of the contralateral foramen and offending lesion. It permits a wide decompression while preserving the facet joint and thus prevents iatrogenic instability. It can also avoid the iliac crest, which does not allow an ipsilateral extraforaminal approach at the L5-S1 level. This approach is a safe and effective way to treat this specific pathology.

To compare different survival prognosis scores among patients operated on for spinal metastasis from lung cancer.A single-center retrospective review of patients with lung cancer and spinal metastases who underwent spinal surgery at our institution from January 2008 to October 2020 was conducted. We calculated the prognostic value of the following scoring systems: revised Tokuhashi, revised Bauer, Skeletal Oncology Research Group classic, and New England Spinal Metastatic Score. For each scoring system, discrimination was assessed by computing the area under the curve.The study included 94 patients operated on for spinal metastasis from lung cancer. Mean patient age was 62 years (range, 32-79 years); 51% of patients were male. The 1-year survival rate was 18%, and the median survival time was 4 months. The 6- and 12-month area under the curve was 60% and 76%, respectively, for revised Tokuhashi, 55% and 58% for revised Bauer, 58% and 63% for Skeletal Oncology Research Group classic, and 61% and 69% for New England Spinal Metastatic Score.The revised Tokuhashi score seemed to be the most accurate scoring system for assessing survival prognosis in patients operated on for spinal metastasis from lung cancer. Newer scores including biological parameters did not add further precision among this specific population.

BACKGROUND Hajdu-Cheney syndrome (HCS) is a rare connective tissue disorder characterized by severe bone demineralization. In the spine, it is associated with the early onset of severe osteoporosis and can cause spondylolisthesis. Spinal instrumentation in the setting of severe osteoporosis is challenging because of poor resistance of vertebrae to biomechanical stress. OBSERVATIONS A 59-year-old woman with known idiopathic HCS presented with a grade 4 L5-S1 spondylolisthesis and right L5 pedicle fracture associated with a left L5 pars fracture, causing a progressive L5 radiculopathy that was worse on the left side than the right side and bilateral foot drop. The authors performed decompressive lumbar surgery, which included a complete L5 laminectomy and resection of the left L5 pedicle. This was followed by multilevel lumbosacral instrumentation using cement-augmented fenestrated pedicle screws as well as transdiscal sacral screws and bilateral alar-iliac fixation. Postoperatively, the radicular pain resolved, and the left foot drop partially recovered. LESSONS Stabilization of high-grade spondylolisthesis in the setting of bone demineralization disorders is challenging. The use of different instrumentation techniques is important because it increases biomechanical stability of the overall instrumentation construct.

Vertebral hemangiomas are benign, highly vascular spinal lesions that are extremely rare in the pediatric population. We report a pediatric case of symptomatic vertebral hemangioma treated with total en bloc spondylectomy. Our objective is to demonstrate that en bloc spondylectomy is feasible and addresses some pitfalls of traditional total tumor resection. Our patient presented with bilateral lower limb and perineal paresthesia, paraparesis, as well as urinary retention. Locally aggressive vertebral hemangioma was the presumed diagnosis following imaging. The patient received partial angioembolization to reduce the vascularization of the lesion then underwent total en bloc spondylectomy of T8 under intraoperative neuromonitoring. The intervention was well tolerated. Postoperative course was marked by clinical improvement and only transient, treatable complications. On 1-year follow-up, the patient is neurologically intact, and imaging reveals adequate position of hardware, good alignment, and no tumor recurrence. Total en bloc spondylectomy is a feasible procedure in pediatric patients. It reduces local recurrence through reduction of tumor cell contamination and residual tumor and thus may avoid postoperative radiotherapy in select cases. It may also enhance functional neurological recovery by allowing circumferential decompression and increased spinal cord blood flow.

Study Design: A retrospective, matched cohort study of a prospective database.Purpose: To evaluate the efficacy and safety of the Cervision system (Spinologics, Montreal, Canada), a new shoulder traction device that improves the fluoroscopic visualization of the lower cervical spine using caudal traction of the shoulders out of the radiographic field.Overview of Literature: Operating at a wrong level is a common error that may be committed by nearly 50% of surgeons during their career. Intraoperative fluoroscopy of the cervical vertebrae is an extremely important step in cervical spine surgery. Optimal lateral cervical radiography of the C1–T1 vertebrae is not always possible due to overlap of the shoulders.Methods: In this study, a group of patients (n=33, device group) underwent surgery with the new device used to apply caudal traction to both shoulders, and another group of patients (n=33, matched control group) had surgery with the tape traction. Data about the lowest vertebra visible on lateral fluoroscopic view, installation time, skin irritation under the traction area, and postoperative brachial palsy were recorded, and these parameters were analyzed using the t-test.Results: The mean numbers of visible cervical vertebra were 6.3±0.41 in the device group and 5.6±0.32 in the matched control group (p t-test). The mean installation times were 83.9±5.15 minutes in the device group and 73.7±6.32 minutes in the matched control group (p

Study Design: Retrospective case series. Objective: Posterior surgery for thoracic disc herniation was associated with increased morbidity and mortality and new minimally invasive approaches have been recommended for soft disc herniation but not for calcified central disc. The objective of this study is to describe a posterolateral microscopic transpedicular approach for central thoracic disc herniation. Methods: This is a single center retrospective review of all the cases of giant thoracic calcified disc herniation as defined by Hott et al. Presence of myelopathy, percentage of canal compromise, T2 hypersignal, ASIA score, and ambulatory status were recorded. This posterolateral technique using a tubular retractor was thoroughly described. Results: Eight patients were operated upon with a mean follow-up of 16 months. Mean canal compromise was 61%. Mean operative time was 228 minutes and mean operative bleeding was 250 mL. There were no cases of dural tear or neurologic degradation. Conclusion: This is the first report of posterior minimally invasive transpedicular approach for giant calcified disc herniation. There were neither cases of neurological deterioration nor increased rate of dural tears. This technique is thus safe and could be recommended for treatment of this rare disease.

Background Osteoblastomas are locally aggressive bone tumors typically affecting the posterior elements of the vertebral column. The treatment of choice is total surgical resection, traditionally through an open laminectomy, often with facetectomy and fusion when the lesion is in the foramen. Objective To seek an alternative to open surgery, allowing quick and full functional recovery, to meet the youth and athlete population's specific surgical goals. In this population especially, open surgery can be associated with significant impairment and morbidity. Methods We report a pediatric case of posterior L5 osteoblastoma completely removed using a facet-sparing and fusion-avoiding contralateral foraminal minimally invasive approach using a tubular retractor system. A 12-yr-old male competitive tennis player presented with progressive right L5 lumbosciatica. Computed tomography scan and magnetic resonance imaging revealed a lesion of the right L5 pedicle, facet, and vertebral body with significant foraminal soft-tissue extension. Being unfit for percutaneous radiofrequency ablation, the patient underwent a minimally invasive biopsy and resection using an 18-mm-wide METRx nonexpandable tubular retractor (Medtronic) through a contralateral approach, sparing the facet and avoiding fusion surgery. Results Postoperative imaging showed residual tumor. The patient was reoperated in a similar fashion with complete tumor removal. His symptoms resolved completely postoperatively. He resumed tennis within 4 mo and remains symptom- and tumor-free at 12-mo follow-up. Conclusion Minimally invasive contralateral facet-sparing resection of a pediatric lumbar osteoblastoma is an alternative to standard technique and is associated with significant advantages for young athletes, such as quick and full functional recovery, along with avoidance of fusion when the facet joint is involved.

Vertebroplasty is a minimally invasive treatment option for osteolytic spinal lesions. It provides pain relief and stability with established good results. In this paper, we describe a new CT guided percutaneous vertebroplasty technique using a direct lateral approach between the carotid sheath and the vertebral artery, that can be safely performed under conscious sedation in an outpatient setting. We report the case of a patient presenting a lytic lesion of C2 treated using the CT guided percutaneous vertebroplasty under conscious sedation. Local anesthesia using approximately 10 mL of lidocaine 1% was delivered in the skin, soft tissues and to the periosteum of C2. With the patient in dorsal decubitus on the CT table, a bone biopsy needle was introduced laterally, through the parotid and between the carotid artery and vertebral artery. The entry point on C2 was right under the lateral mass of C1 and anterolaterally to the vertebral vascular foramen. The procedure was well tolerated by the patient. No neurological changes were noted per-operatively. No immediate or short-term complications were noted. Patient was observed on a stretcher for 2 hours with nursing supervision before being discharged home. Patient reported satisfactory pain control at 6-month follow-up. CT guided percutaneous vertebroplasty under conscious sedation can be safely performed in an outpatient setting.

BACKGROUND Atlantoaxial sublaminar wiring has many known complications related to hardware failure, but intracranial hemorrhage is a rare complication. OBSERVATIONS A 61-year-old female patient with prior atlantoaxial sublaminar wiring for odontoid fracture nonunion experienced decreased level of consciousness due to a subarachnoid and subdural hemorrhage of the posterior fossa with intraventricular extension and hydrocephalus. Rupture of the sublaminar wire with intramedullary protrusion was the cause of the hemorrhage. The patient was treated with ventriculostomy for hydrocephalus and occipital cervical fusion for spinal instability, along with removal of the broken wire and drainage of a hematoma. LESSONS This uncommon cause of intracranial hemorrhage highlights an additional risk of atlantoaxial sublaminar wiring compared with other atlantoaxial fusion techniques. In addition, this case suggests cervical instrumentation failure as a differential diagnosis of subarachnoid and subdural hemorrhage of the posterior fossa when a history of prior instrumentation is known.

Osteoid osteomas are benign primary bone tumors that typically arise in posterior vertebrae of the spine. For patients with severe pain or those poorly controlled with non-steroidal anti-inflammatory drugs, surgical management is the mainstay of treatment. The recommended surgical treatment option is complete open excision, although minimally invasive CT-guided percutaneous excision and CT-guided radiofrequency ablation have been reported. Open resection can result in prolonged hospital stays, activity restrictions, and possible spinal destabilization. We sought to utilize a lateral minimally invasive approach. We highlight the importance of aggressive surgical resection and the utility of using fluoroscopy and O-arm guidance to optimize the extent of resection. We report a pediatric case of a 12-year-old male who presented with an S3 osteoid osteoma. The patient underwent a minimally invasive resection with complete resection and confirmation of the histopathologic diagnosis. Postoperative imaging showed complete resection of the tumor. The patient went home five hours after surgery with return to daily activities; his symptoms resolved completely. However, the patient had symptomatic recurrence and underwent a second more aggressive minimally invasive resection using O-arm guidance. At the current three-month follow-up, the patient is symptom- and tumor-free. The minimally invasive resection of a pediatric sacral osteoid osteoma is a valid alternative to standard open resection and is associated with a decreased blood loss, decreased length of stay in the hospital, and decreased time to full functional recovery. The pitfalls are learning curve and risk of incomplete resection that can be counterbalanced with an intraoperative O-arm to guide resection and confirm complete excision.

Background The silastic tube technique, in which a chest tube is placed into the vertebral body defect and impregnated with polymethyl methacrylate, showed good results in patients with lumbar and thoracic neoplastic diseases. There has been only 1 study about the effectiveness and safety of this technique in patients with cervical metastases. We aimed to report our experience in using this technique to reconstruct the spine after corpectomy for cervical metastasis. Methods All patients with cervical spinal metastasis who underwent surgical treatment using a chest tube impregnated with polymethyl methacrylate in conjunction with anterior cervical plate stabilization were retrospectively recruited. Demographics, tumor histology, revised Tokuhashi score, preoperative and postoperative American Spinal Injury Association score, preoperative and postoperative ambulatory status, perioperative complications, and survival time were collected. Results This study included 16 patients. The most common primary tumor site was the lung (6 patients; 37.5%). The mean (SD) survival time was 408 (795) days (range, 1–2797 days), and the median survival time was 72 days (95% confidence interval 28–116 days). Four patients (25%) died within 30 postoperative days. There was no surgical site infection or instrument failure after the surgery. Five patients (31.2%) lived >180 days, and 3 patients (18.8%) lived >360 days. One patient (6.2%) was still alive at the end of the study. Conclusions The silastic tube technique in conjunction with anterior cervical plate stabilization might be safe, effective, and cost-effective for patients with cervical spine metastasis.

Cavernous angiomas are congenital vascular malformations that affect the central nervous system. Reports implicated radiation therapy as a triggering factor for the formation of cavernomas but not in relation with head and neck radiation therapy. Radiation-induced cavernomas (RIC) should be considered in the differential diagnosis of focal neurological symptoms in any patient who has received previous cranial-spinal or head and neck radiotherapy.

STUDY DESIGN Retrospective cohort study. PURPOSE The objective of this study was to compare three widely used interbody fusion approaches in regard to their ability to correct sagittal balance, including pelvic parameters. OVERVIEW OF LITERATURE Restoration of sagittal balance in lumbar spine surgery is associated with better postoperative outcomes. Various interbody fusion techniques can help to correct sagittal balance, with no clear consensus on which technique offers the best correction. METHODS The charts and imaging of patients who have undergone surgery through either open transforaminal lumbar interbody fusion (TLIF), minimally invasive TLIF (MIS TLIF), or oblique lumbar interbody fusion (OLIF) were retrospectively reviewed. The following sagittal balance parameters were measured pre- and postoperatively: segmental lordosis, lumbar lordosis, disk height, pelvic tilt, and pelvic incidence. Data on postoperative complications were gathered. RESULTS Only OLIF managed to significantly improve segmental lordosis (4.4°, p

Study Design: Retrospective cohort study.Purpose: This study aimed to evaluate the outcomes of patients who had T4 Pancoast tumors invading the spine and underwent en bloc resection and spinal stabilization through a single-stage posterior approach.Overview of Literature: Surgical resection for Pancoast tumors affecting the spine has been successfully performed in two stages involving spinal reconstruction and tumor resection. However, reports have rarely presented the results of en bloc resection combined with spinal stabilization for T4 Pancoast tumors invading the spine through a single-stage posterior approach.Methods: Patients who had T4N0M0 Pancoast tumors invading the spine and underwent a single-stage posterior approach were retrospectively recruited. The following data were obtained and examined: demographics, tumor histology, preoperative and postoperative therapy, complications, spinal reconstruction technique, tumor resection extent, survival time, and disease recurrence.Results: Eighteen patients were included. The mean population age was 61±17 years, and the most common pathological type was adenocarcinoma (61.1%). Complete resection (R0) was obtained in 15 patients (83.3%), positive surgical margins (R1) were found in three patients (16.7%), and the 90-day mortality rate was 0%. Postoperative major complications were detected in 12 patients (66.7%), who required reoperation. The mean survival time was 67±24 months, but the median survival time was not reached. Among the patients, 10 (55.6%) are still alive at the end of the study. The 2- and 5-year actual survival rates were 59% (95% confidence interval [CI], 35.7%–82.3%) and 52.5% (95% CI, 28.4%–76.6%), respectively.Conclusions: En bloc resection and spinal stabilization through a single-stage posterior approach might be effective for T4 Pancoast tumors invading the spine.

Study design Retrospective analysis. Objective To define C2–C3 vertebral disc angle (VDA) in patients with and without cervical spondylotic myelopathy. Summary of background data C2–C3 VDA is a new radiological index of cervical spine alignment. Recent studies have suggested that high postoperative values are associated with greater mechanical complications in patients with cervical spondylotic myelopathy. However, normative values for patients without myelopathy has yet to be defined. Methods Patients with and without cervical myelopathy between 2017 and 2019 were included. Inclusion criteria were patients above 18 years of age with antero-posterior (AP) and lateral (LAT) cervical X-rays. In the non-myelopathic group, patients were excluded if they had neurological symptoms or deficits, presence of cervical axial pain, previous spinal surgery, or diagnosis of either spondylolisthesis or scoliosis. In the myelopathic group, patients were excluded if they had previous spinal surgery. Radiological indices evaluated include: C2–C3 disc angle, C2–C7 Cobb angle, C7 sagittal vertical axis, T1 slope. Results In total, 99 patients without myelopathy and 22 patients with myelopathy were identified and analyzed. In patients without myelopathy, the mean for C2–C3 VDA was 25.9 ± 7.9. For patients with myelopathy, preoperative values were 24.4 ± 10.0 and 27.1 ± 7.9 postoperatively. No statistically significant differences were found between patients with and without myelopathy. C2–C3 disc angle was not correlated with age (R = −0.173). Conclusion This study did not find statistically significant differences in C2–C3 VDA values between patients with and without cervical myelopathy. This study provides normative data for C2–C3 vertebral disc angle in patients with and without cervical spondylotic myelopathy. Furthermore, C2–C3 vertebral disc angle may be independent from age.

Fungal spondylodiscitis is rare (0.5%–1.6% of spondylodiscitis) and mainly caused by Candida albicans. Surgical intervention in spondylodiscitis patients is indicated for compression of neural elements, spinal instability, severe kyphosis, failure of conservative management and intractable pain. However, there is no evidence-based optimal surgical approach for spondylodiscitis. There have been only case reports of surgical treatment for Candida spondylodiscitis. We evaluated the preliminary results of the efficacy and safety of one-stage debridement via oblique lateral corridor with interbody fusion (OLIF) using stand-alone cement reconstruction after debridement for the treatment of Candida spondylodiscitis in patients with major co-morbidities. Five patients (4 males, 1 female, mean age: 64.2 years) suffering from Candida albicans lumbar spondylodiscitis who underwent this procedure were studied. Their predominant symptoms were unremitting back and leg pain and all had pre and postoperative anti-fungal therapy under microbiologist supervision. The operative time ranged from 137 minutes to 260 minutes (mean: 213.4 minutes). The mean blood loss was 160 mL (range: 100–200 mL). There were no perioperative complications. At follow-up all showed major improvement in pain and ambulatory status. CT scan showed radiological stability for all patients at 6–12 months. Our preliminary results showed stand-alone anterior debridement and spinal re-construction with cement through mini-open OLIF approach might be a safe and effective option for patients with spinal fungal infection and major comorbidities.

STUDY DESIGN This was a retrospective study. OBJECTIVE Evaluate the prognosis and surgical outcomes of patients with spinal metastasis from lung cancer undergoing surgical treatment. SUMMARY OF BACKGROUND DATA The spine is the most common site of metastatic lesions in patients with lung cancer. There have been a few studies, all small cohorts studying prognosis and surgical outcomes and the results were discordant. MATERIALS AND METHODS A retrospective study on a prospectively collected database was conducted. Data collected were the following: age, tobacco use, tumor histology, American Spinal Injury Association score, revised Tokuhashi score, ambulatory status, perioperative complications, postoperative adjuvant treatment, and survival time. Univariate and multivariate analyses were performed to identify the prognostic factors of survival. RESULTS The authors studied 87 patients with a mean age of 61.3±1.9 years. Median survival was 4.1±0.8 months. Twenty-eight patients (32.2%) lived >6 months and 14 patients (16.1%) lived >12 months. The medical complication rate was 13.8% and the surgical complication rate was 5.7%. The 30-day mortality rate was 4.6%. Univariate analysis showed tobacco use, revised Tokuhashi score, preoperative and postoperative American Spinal Injury Association score, postoperative walking ability, postoperative radiotherapy, and postoperative chemotherapy were prognostic factors. There was no significant difference in survival between adenoma lung cancers, nonadenoma lung cancers, and small cell lung cancers (P=0.51). Multivariate analysis revealed tobacco use, revised Tokuhashi score, postoperative walking ability, postoperative radiotherapy, and postoperative chemotherapy affected the survival. CONCLUSIONS This is the largest reported study of patients with spinal metastasis from lung cancer undergoing spinal surgery. It is the first study showing that tobacco use has a negative impact on survival. Spinal surgery improves the quality of life and offers nonambulatory patients a high chance of regaining walking ability with an acceptable risk of complications.

Background: Spontaneous spinal epidural hematoma (SSEH) is a rare condition that is typically associated with hypertension, the use of antithrombotic or sympathomimetic drugs. Here, we report a case of SSEH attributed to the use of amphetamines. Case Description: A 27-year-old amphetamine user presented with the sudden onset of paraplegia (Frankel A) following amphetamine use. An MRI revealed C7–T2 spinal cord compression due to an epidural hematoma. Following a negative angiogram, the SSEH was removed, and the patient markedly recovered. Notably, by exclusion, the etiology for the SSEH was attributed to the use of amphetamines. Conclusion: Here, we demonstrate the case of a 27-year-old male who presented paraplegic due to an acute C7– T2 SSEH secondary to amphetamine abuse.

Objectives: With the current trend of aging of the population, neurosurgeons will be more and more confronted to surgical decision-making involving the elderly. Faced with this increasing demand and frailty of aged patients, a better understanding on the post-operative outcome of this growing population is warranted. The objective of the present study is to assess the post-operative outcome in regard of complications of elderly patients undergoing a craniotomy. Patients and methods: The files of consecutive patients aged 80 years old and more who underwent a craniotomy at a single institution were retrospectively reviewed. Data on demographics, surgical indication, length of surgery, operative blood loss, urgency of surgery, comorbidities using the Elixhauser comorbidity index and post-operative complications were gathered. We performed a multivariate analysis in search of risk factors for post-operative complications. Results: A total of 53 patients were included in the study. The mean age of all patients was 84 years old with the main indication for surgery being subdural hematoma. The overall complication rate was 62%, with 34% of patients suffering from a major complication and 47% from a minor complication. The mean Elixhauser comorbidity index, operative time and operative blood loss were similar to those reported in adult craniotomy series. None of the studied variables were statistically associated with the occurrence of complications in the multivariate analysis. Conclusion: Patients 80 years-old and more were found to harbour a high complication rate following craniotomy when compared to literature. Our study suggests increasing age itself remains an important risk factor for postoperative complications. Keywords: Comorbidity, Complication, Craniotomy, Elderly, Outcome

Study Design Retrospective case series. Purpose To evaluate the clinical and radiological efficacy of anterolateral kyphoplasty for cervical spinal metastasis. Overview of Literature Although the spine is the third most common site of tumor metastasis, the cervical spine is the least commonly affected (incidence, 10%–15%). Surgical decompression is highly challenging because of the proximity of neural and vascular elements. Kyphoplasty for cervical spine metastasis has been described in small case reports with promising results. Methods Retrospective analysis of a prospective collected single-center spine metastasis database was done for cervical kyphoplasty cases. Data pertaining to age, sex, primary tumor diagnosis, modified Tokuhashi score, Spinal Instability Neoplastic Score (SINS), preoperative Visual Analog Scale (VAS) score, and analgesic medication were extracted. Postoperative data included VAS score at postoperative day 1, duration of hospitalization, self-reported functional outcome, and VAS score at the last follow-up. Results Eleven patients (mean age, 62.5 years) with cervical spine metastases were treated with 15-level kyphoplasty. Mean Tokuhashi score was 8.1, and mean SINS was 7.85. Mean preoperative pain score was 7.1, and 82% of patients used opioid analgesics. Mean total bleeding volume was 100 mL. Mean complication-free length of stay was 2.6 days with a decrease in postoperative pain (VAS score=2.8, p

Nonunion at the lumbosacral junction is a classic complication of long construct and deformity corrections. Iliac fixations have been extensively studied in the literature and have demonstrated superior biomechanical proprieties and lower complication rates. S2 alar iliac screws address the drawbacks of classical iliac screws but demonstrate similar biomechanical advantage. The main aim of this paper was to describe the S1 alar iliac (S1AI) screw fixation technique while evaluating our early results. S1AI screw fixation technique has the advantage of being able to achieve pelvic fixation without dissection to the S2 pedicle entry and is therefore a viable option for salvage of a failed S1 promontory screw.

Surgical site infection (SSI) in spinal metastasis surgery represents the most common postoperative surgical complication with high morbidity and mortality.This study aims to evaluate the incidence of SSI in spinal metastasis surgery and its risk factors.This is a retrospective analysis of a prospectively collected data.Preoperative, operative, and postoperative data were collected together with the modified Tokuhashi score and Frankel score at all time checkpoints. Surgical site infection was divided into superficial and deep SSI, as well as early (90 days) and late SSI. Multiple logistic regression analysis was performed to identify independent risk factors, with p.05 as significance threshold.A total of 297 patients were included, with an incidence of SSI of 5.1% (superficial SSI: 3.4%; deep SSI: 1.7 %). Cervicothoracic surgery was associated with the highest incidence of SSI, whereas cervical surgery had the lowest incidence. Smoking, higher number of spinal metastasis, elevated body mass index (BMI), and higher ASA (American Society of Anesthesiologist) score were the preoperative factors associated with increased risk of SSI. Increased intraoperative blood loss and increased number of fixed vertebra increased the SSI incidence. SSI increased hospital stay by a mean of 12 days. When all these variables are analyzed in a multiple regression model, only surgical time≥4 hours and ASA≥3 were found to be independent risk factors for the occurrence of SSI.This paper represents the largest series of spinal metastasis with a mean incidence of SSI of 5.1%. Smoking, higher BMI, higher number of spinal metastasis, higher ASA score, higher number of fused vertebra, intraoperative bleeding≥2000 mL, and neurologic deterioration are risk factors for SSI occurrence. Only ASA≥3 and operative duration≥4 hours are independent risk factors for this complication occurrence. Finally, SSI occurrence is associated with increased hospital stay, increased 30-day mortality rate, and decreased survival rates.

BACKGROUND Treatment of thoracic spinal dural arteriovenous fistulas (DAVFs) by microsurgery has recently been approached using minimally invasive spine surgery (MISS). The advantages of such an approach are offset by difficult maneuverability within the tubular retractor and by the creation of "tunnel vision" with reduced luminosity to a remote surgical target. OBJECTIVE To demonstrate how the pitfalls of MISS can be addressed by applying 3-D endoscopy to the minimally invasive approach of spinal DAVFs. METHODS We present 2 cases of symptomatic thoracic DAVFs that were not amenable to endovascular treatment. The DAVFs were excluded solely via a minimally invasive approach using a 3-D endoscope. RESULTS Two patients underwent exclusion of a DAVF following laminotomy, one through a midline 5-cm incision and the other through a paramedian 3-cm incision using minimally invasive nonexpandable tubular retractors. The dura opening, intradural exploration, fistula exclusion, and closure were performed solely under endoscopic 3-D magnification. No incidents were recorded and the postoperative course was marked by clinical improvement. Postoperative imaging confirmed the exclusion of the DAVFs. Anatomical details are exposed using intraoperative videos. CONCLUSION When approaching DAVFs via MISS, replacing the microscope with the endoscope remedies the limitations related to the "tunnel vision" created by the tubular retractor, but at the expense of losing binocular vision. We show that the 3-D endoscope resolves this latter limitation and provides an interesting option for the exclusion of spinal DAVFs.

Resume Type d’etude Etude retrospective monocentrique. Objectif Evaluer la faisabilite et les complications potentielles de l’arthrodese lombaire par voie anterolaterale retroperitoneale (OLIF) au niveau L5–S1. Contexte L’abord anterolateral retroperitoneal (OLIF) a ete decrit initialement en 2012 pour permettre de realiser une fusion inter-somatique, tout en limitant la iatrogenie de l’acces a la colonne anterieure. La plupart des equipes qui utilisent cette technique recommandent des approches alternatives pour le niveau L5–S1, en raison de l’anatomie vasculaire qui expose a des difficultes et des complications potentielles. Methodes Nous rapportons une serie retrospective de patients operes d’une arthrodese anterolaterale retroperitoneale au niveau L5–S1 de 2013 a 2015. Nous decrivons egalement une modification a la technique prealablement decrite, qui consiste a identifier et ligaturer la veine iliolombaire pour faciliter et securiser la mobilisation des vaisseaux iliaques. Resultats Six patients (3 hommes et 3 femmes, âge moyen de 62 ans) ont ete operes entre 2013 et 2015. Aucune complication vasculaire ou neurologique n’est survenue. Quatre complications ont ete rapportees : une migration precoce de cage reoperee, une faiblesse transitoire du muscle psoas, une hospitalisation prolongee pour douleur lombaire resolutive et une transfusion sanguine chez un patient en rapport avec l’abord posterieur complementaire. Conclusions L’abord anterolateral retroperitoneal est realisable au niveau L5–S1 avec peu de difficulte et de complication vasculaire, en identifiant et controlant la veine iliolombaire.

STUDY DESIGN Monocentric prospective study. PURPOSE To assess the safety and effectiveness of the posterior approach for resection of advanced Pancoast tumors. OVERVIEW OF LITERATURE In patients with advanced Pancoast tumors invading the spine, most surgical teams consider the combined approach to be necessary for "en-bloc" resection to control visceral, vascular, and neurological structures. We report our preliminary experience with a single-stage posterior approach. METHODS We included all patients who underwent posterior en-bloc resection of advanced Pancoast tumors invading the spine in our institution between January 2014 and May 2015. All patients had locally advanced tumors without N2 nodes or distant metastases. All patients, except 1, benefited from induction treatment consisting of a combination of concomitant chemotherapy (cisplatin-VP16) and radiation. RESULTS Five patients were included in this study. There were 2 men and 3 women with a mean age of 55 years (range, 46-61 years). The tumor involved 2 adjacent levels in 1 patient, 3 levels in 1 patient, and 4 levels in 3 patients. There were no intraoperative complications. The mean operative time was 9 hours (range, 8-12 hours), and the mean estimated blood loss was 3.2 L (range, 1.5-7 L). No patient had a worsened neurological condition at discharge. Four complications occurred in 4 patients. Three complications required reoperation and none was lethal. The mean follow-up was 15.5 months (range, 9-24 months). Four patients harbored microscopically negative margins (R0 resection) and remained disease free. One patient harbored a microscopically positive margin (R1 resection) and exhibited local recurrence at 8 months following radiation treatment. CONCLUSIONS The posterior approach was a valuable option that avoided the need for a second-stage operation. Induction chemoradiation is highly suitable for limiting the risk of local recurrence.

Anterior sacral meningoceles (ASMs) are rare defects in the sacrum with thecal sac herniations and symptoms that commonly include constipation, dysmenorrhea, and urinary disturbances. An ASM causing hydronephrosis and acute renal failure from compression of the lower portion of the urinary tract is a rare clinical entity. Only one other case has been reported. The authors present the case of a 37-year-old man admitted for obstructive renal failure and hydronephrosis due to a giant ASM that measured 25 × 12 × 18 cm and compressed the ureters and bladder. The ASM was successfully treated via an anterior transabdominal approach in which the authors used a novel technique for watertight closure of the meningocele pedicle with an endoscopic cutting stapler. The authors review the literature and discuss the surgical options for the treatment of ASMs, specifically the management of ASMs in the context of obstructive renal failure and hydronephrosis.

Background: Jefferson fractures are burst fractures involving both the anterior and posterior arches of C1. They typically result from axial compression or hyperextension injuries. Most are stable, and neurological deficits are rare. They are often successfully treated with external immobilization, but require surgery (e.g., fusion/ stabilization). Case Description: An 89-year-old male presented with a left-sided hemiplegia following a trivial fall. The cervical computed tomography scan revealed a left-sided displaced comminuted C1 fracture involving the arch and lateral mass. The MR revealed posterior cord compression and focal myelomalacia. Six months following an emergent C1–C3 decompression with occiput to C4 instrumented fusion, the patient was neurologically intact and pain-free. Conclusion: An 89-year-old male presented with a left-sided hemiplegia due to a Type 3/4 C1 Jefferson fracture. Following posterior C1–C3 surgical decompression with C0–C4 instrumented fusion, the patient sustained a complete bilateral motor recovery.

Resume L’epanchement de Morel-Lavallee est une lesion traumatique rare ou des forces de cisaillement provoquent un decollement entre les tissus sous-cutanes et le fascia sous-jacent. Cette lesion a ete rarement rapportee, expliquant que le diagnostic est souvent meconnu. Alors que le traitement peut etre conservateur ou minimalement invasif a un stade precoce, une prise en charge invasive est requise en cas de retard diagnostique. Par ailleurs, les lesions non traitees peuvent entrainer des douleurs, des surinfections ou des tumefactions sous-cutanees evolutives pouvant etre confondues avec des tumeurs des parties molles. Nous rapportons les donnees cliniques et radiologiques d’un patient de 45 ans presentant un volumineux epanchement de Morel-Lavallee lombaire diagnostique tardivement. Nous avons egalement realise une revue de la litterature pour resumer les principaux criteres diagnostiques et les modalites de prise en charge.

Objectives The surgical management of dumbbell tumors of the lumbar spine remains controversial, because of their large volume and complex location, involving both the spinal canal and the retro peritoneum. While sporadically reported, our study aims to confirm the value of minimally invasive posterior access for the complete resection of large lumbar dumbbell tumors. Patients and Methods In this prospective study, we included all consecutive patients who underwent the resection of a voluminous dumbbell tumor at the lumbar spine through a minimally invasive approach, between March 2015 and August 2017. There were 4 men and 4 women, with a mean age at diagnosis of 40.6 years (range 29–58 years). The resection was performed through a trans muscular tubular retractor by the same surgical team. Operative parameters and initial postoperative course were systematically reported. Clinical and radiological monitoring was scheduled at 3 months, 1 year and 2 years. Results The mean operative time was 144 min (range 58–300 minutes) and the mean estimated blood loss was 250 ml (range 100–500 ml). Gross total resection was achieved in all patients. No major complication was reported. The mean length of hospital stay was 3.1 days (range 2 to 6 days). Histological analysis confirmed the diagnosis of grade 1 schwannoma in all patients. The mean follow up period was 14.9 months (range 6 to 26 months), and 5 patients completed at least 1-year follow-up. At 6 months the Macnab was excellent in 6 patients, good in one patient and fair in one patient because of residual neuropathic pain requiring the maintenance of a long-term treatment. No tumor recurrence was noted to date. Conclusion Lumbar dumbbell tumors can be safely and completely resected using a single-stage minimally invasive procedure, in a trained team.

International audience; Background: Due to their important size and complex localization, the management of thoracic dumbbell tumors is challenging, frequently requiring the need for an anterior approach. Our study aims to first report the feasibility and safety of a single-stage posterior minimally invasive procedure in achieving complete resection of voluminous thoracic dumbbell tumors.Methods: We retrospectively reviewed the medical records of five consecutive patients, who underwent the minimally invasive resection of a type III thoracic dumbbell tumor in our institution between March 2007 and March 2012. There were two men and three women, with a mean age at diagnosis of 57 years (range 41-68 years). After the placement of a non-expandable tubular retractor under fluoroscopic control, a costotransversectomy was achieved. By moving the retractor in all directions, the tumor was largely exposed and resected with the cavitron ultrasonic surgical aspirator. Clinical and radiological monitoring was performed before discharge, at 6 months, 1 year and 2 years.Results: No major intraoperative complication was reported. Gross total resection was achieved in four patients. The mean operative time was 219 mins (range 75-540 mins) and the mean estimated blood loss was 230 ml (range 50-500 ml). No postoperative complication was reported. The mean length of hospital stay was 3.6 days (range 2-6 days) and all patients were discharged home. Histological analysis confirmed the diagnosis of grade 1 schwannoma in four patients and revealed a hemangiopericytoma in one patient. No tumor recurrence was noted with a mean follow up period of 46 months (range 32-54 months).Conclusion: Thoracic dumbbell tumors can be safely and completely resected using a single-stage minimally invasive procedure. The costotransversectomy can be performed through a non-expandable retractor allowing sufficient access to all parts of the tumor.

Adjuvant systemic treatments reduce the risk of breast cancer recurrence following the local treatment of primary stage I-III breast cancers. For patients with hormone-positive breast cancers receiving hormonal therapy, the risk of distant recurrence is under 20% and therefore, many patients may potentially be spared of chemotherapy. Consequently, several molecular signatures based on gene expression were developed to better determine which breast cancer patients would benefit from chemotherapy. We present the case of a 62-year-old woman diagnosed with an early stage hormone receptor-positive breast cancer that was treated with a partial mastectomy. Oncotype DX (Genomic Health, Redwood City, CA) molecular testing was performed on the surgical specimen, which reported a recurrence score of 0. The patient commenced adjuvant radiotherapy during which she developed symptoms suggestive of bone metastasis and was subsequently diagnosed with a spinal cord compression that required neurosurgery and radiotherapy. Pathology review of the specimen from the spine surgery revealed a metastatic breast carcinoma with neuroendocrine differentiation. Molecular assays such as Oncotype DX are increasingly used to prognosticate patient outcomes and help determine who may avoid chemotherapy. This case report seeks to illustrate that such assays should not be used in the presence of rare histological subtypes like neuroendocrine breast cancers, which are often under-reported. The current status of personalized medicine and gene assays in breast cancer is reviewed and potential strategies are suggested to identify these rare cases to better orient diagnostic and treatment decisions.