Activity

This case highlights the importance of obtaining a CT scan preoperatively to not only to further characterize the fracture but also for surgical planning and recognition of anatomic anomalies as this may significantly impact the operative strategy.Giant cell tumors (GCT) are rare and account for approximately 5% of all primary bone tumors. GCTs in the spine make up less than 10% of all GCTs, and less than 5% of all primary spinal tumors. Less than 10% of spinal GCTs occur above the sacrum and cases involving the thoracic spine are seldom reported in the literature. In our case the patient presented with acute paraplegia of bilateral lower extremities after being seen in the emergency department a day earlier. An MRI and CT scan demonstrated near complete destruction of T8 vertebral body with a possible pathologic lesion and fracture associated with dorsal and ventral spinal cord compression and significant signal change within the spinal cord. She underwent T7-T9 laminectomy with excisional biopsy and was subsequently diagnosed with a primary GCT of the thoracic spine. She was definitively treated with resection and T4-12 fusion and 120 mg of denosumab. At four years post follow-up there has been no recurrence of the tumor to date. This is a more acute presentation than has previously been reported. Patients with GCT of the spine typically present with pain and may have further progression to neurologic deficit. This patient’s rapid onset of paraplegia is more acute than has been previously reported in the literature. The authors believe that prompt surgical excision and treatment with denosumab can completely resolve GCT of the thoracic spine.Intrathecal morphine (ITM) is routinely used in many surgical specialties as an adjunct to postoperative analgesia. Patients undergoing lumbar spinal surgery commonly experience early postoperative pain. There have been multiple reports of the benefits of ITM in lumbar spine surgery where it has been shown to significantly reduce the need for intravenous opioid analgesia, improve time to mobilization, and shorten length of hospital stay. ITM is yet to become standard of care in Lumbar Spine Surgery likely due to concerns of it causing a cerebrospinal fluid (CSF) leak. In recent times anterior lumbar spine surgery (ALSS) and lateral lumbar spine surgery (LLSS) have increased in popularity although they are still performed in fewer numbers in comparison to the posterior [posterior lumbar interbody fusion (PLIF)] or transformational [transforaminal lumbar interbody fusion (TLIF)] approaches. Although the number of ALSS and LLSS procedures are increasing, to our knowledge there have been no reports of ITM administered via either approach reported in the literature. Herein we describe an intra-operative technique for injection of morphine into the dural sac via the Anterior and Lateral approaches to the lumbar spine. We propose that this technique can be performed easily and quickly with standard surgical equipment that is commonly available. Through use of this technique, patients undergoing spine surgery may benefit from ITM with minimal risk of iatrogenic CSF leak.Sacroiliac joint (SIJ) pathology is a common cause of significant pain and disability, and operative treatment consisting of SIJ fusion can be performed in cases where non-operative measures fail to provide sustained relief. Through the years, SIJ fusion has evolved from an open invasive procedure, to more recently, being performed through minimally invasive techniques. Intraoperative navigation systems and robotic guidance are becoming popularized for SIJ fusion, as well as other routine and complex spinal cases. The utility of navigation and robotics is the enhanced ability of the surgeon to place instrumentation more accurately, with less dissection, blood less, and overall operative time. We present a technique guide for robotic instrumented SIJ fusion with intraoperative navigation that we have put into practice at our institution and found to be very beneficial to patients for the above reasons. We describe the setup and utilization of these technologies intraoperatively, and provide specific case examples to highlight our technique. The described methods have been found to be effective and reproducible, allowing for minimally invasive SIJ screw placement with high accuracy and safety. We emphasize that utilizing intraoperative navigation and robotics is not meant to substitute for surgeon knowledge of case steps or anatomy, but rather to enhance safety and efficacy. To our knowledge, robotic SIJ fusion has not been previously described in the literature.

Wrong-level surgery is a rare but unresolved issue in spine surgery. Some proposed protocols with high success rates, but it remains a risk with potential complications for the patient. Surgical navigation offers more accurate surgery, without additional irradiation related to the imaging device, in order to optimize the surgical guidance.

We describe our institutional technique with a needle placed under fluoroscopy at 3 cm from the incision line at the disc level to be operated, in order to guide the surgical approach; and we report a prospective evaluation of all patients during a six-month period operated by microdiscectomy for symptomatic lumbar discus hernia, whose hernia level was landmarked with this technique. We collected demographic, clinical-such as visual analog scale (VAS) of pain and Oswestry disability index (ODI) scores-operative and irradiation data for effective dose calculation.

Thirty patients were included in the study. No wrong-level procedure was performed. UC2288 in vitro Mean time for landmarking was 2.22 [1-5] minutes. Average operative time was 54.5 [30-150] minutes. The effective dose related to the imaging device use was 0.032 (0.007-0.092) mSv. The effective dose was also correlated to body mass index and disc level (P=0.05). The operative duration, complication rate and postoperative VAS and ODI scores were similar to the current literature.

We advocate the use of percutaneous needle guidance, avoiding wrong-level microdiscectomy and helping the surgeon as a “navigation-like” device with minimal additional irradiation for the patient.

We advocate the use of percutaneous needle guidance, avoiding wrong-level microdiscectomy and helping the surgeon as a “navigation-like” device with minimal additional irradiation for the patient.