Arthrodesis of the sacroiliac joint (SIJ) for surgical treatment of SIJ dysfunction has regained interest among spine specialists. Current techniques described in the literature most often utilize intraoperative fluoroscopy to aid in implant placement; however, image guidance for SIJ fusion may allow for minimally invasive percutaneous instrumentation with more precise implant placement. In the following cases, we performed percutaneous stereotactic navigated sacroiliac instrumentation using O-arm^® multidimensional surgical imaging with StealthStation^® navigation (Medtronic, Inc. Minneapolis, MN). Patients were positioned prone and an image-guidance reference frame was placed contralateral to the surgical site. O-arm^® integrated with StealthStation^® allowed immediate auto-registration. The skin incision was planned with an image-guidance probe. An image-guided awl, drill and tap were utilized to choose a starting point and trajectory. Threaded titanium cage(s) packed with autograft and/or allograft were then placed. O-arm^® image-guidance allowed for implant placement in the SIJ with a small skin incision. However, we could not track the cage depth position with our current system, and in one patient, the SIJ cage had to be revised secondary to the anterior breach of sacrum.

Study design

Prospective study.

Objective

Because single-level disk arthroplasty or arthrodesis in the lower subaxial spine improves headaches after surgery, we studied whether this effect may be better appreciated after two-level arthroplasty.

Methods

We performed an independent post hoc analysis of two concurrent prospective randomized investigational device exemption trials for cervical spondylosis, one for single-level treatment and the other for two adjacent-level treatments.

Results

For the one-level study, baseline mean headache scores significantly improved at 60 months for both the cervical disk arthroplasty (CDA) and anterior cervical diskectomy and fusion (ACDF) groups (p < 0.0001). However, mean improvement in headache scores was not statistically different between the investigational and control groups from 6 months through 60 months. For the two-level study, baseline mean headache scores significantly improved at 60 months for both the CDA and ACDF groups (p < 0.0001). The CDA group demonstrated greater improvement from baseline at all points; this difference was statistically significant at 6, 12, 24, 36, and 48 months but not at 18 and 60 months.

Conclusion

Both CDA and ACDF at either one or two levels are associated with sustained headache relief from baseline. Patients undergoing two-level arthroplasty had significantly greater improvement in headache at all points except for at 18 and 60 months. This difference in improvement was not observed in patients undergoing single-level arthroplasty. The mechanism of greater headache relief after two-level arthroplasty remains unclear.

Background

Tarlov cyst disease is a collection of cerebrospinal fluid between the endoneurium and perineurium of spinal, usually sacral, nerve roots. These cysts can become symptomatic in 20% of patients, causing lower back pain, radiculopathy, bladder and bowel dysfunction necessitating medical or surgical intervention. Different surgical and non-surgical modalities have been described for the treatment of symptomatic Tarlov cysts. However, there has been no published study that examined types of surgical techniques side by side. Our study presents a preliminary experience in the surgical management of symptomatic Tarlov cysts using two surgical techniques: cyst fenestration and nerve root imbrication.

Methods

Retrospective chart review and analysis was done for all patients who underwent surgical intervention for symptomatic Tarlov cyst(s) in the period 2007-2013. Operative reports, preoperative and postoperative clinic visit reports were reviewed. The surgical techniques of cyst fenestration and nerve root imbrication were each described in terms of intraoperative parameters, hospital course and outcome. Modified MacNab criteria were used for evaluation of the final clinical outcome.

Results

Thirty-six surgical patients were identified. Three had repeat surgery (total of 39 operations). The median age was 51 years (range, 26-84 years). Eighty-six percent were females. The presenting symptoms were low back pain (94%), sensory radiculopathy (69%), bladder and bowel dysfunction (61%), sexual dysfunction (17%) and motor dysfunction (8%). Cyst fenestration was performed in 12 patients (31%) and nerve root imbrication was done in 27 (69%). All patients in the fenestration group but only 67% in the imbrication group had fibrin glue injection into the cyst or around the reconstructed nerve root. The overall surgery-related complication rate was 28%. The complication rate was 5/12 (42%) in the fenestration group and 6/27 (22%) in the imbrication group. At the time of the last clinic visit, improved clinical outcome was noted in 9/11 (82%) and 20/25 (80%) in the fenestration and the imbrication group, respectively.

Conclusions

Cyst fenestration and nerve root imbrication are both surgical techniques to treat symptomatic Tarlov cyst(s), and both can result in clinical improvement.

While management of appendicular fractures has been well described in the setting of osteopetrosis, there is limited information on managing fractures of the axial spine. Here we present an osteopetrotic patient with multiple traumatic multiple, comminuted, unstable cervical spinal fractures managed with non-operative stabilization, and provide a review of the pathophysiology, genetic characteristics, and special considerations that must be explored when determining operative versus non-operative management of spinal injury in osteopetrosis. A PubMed query was performed for English articles in the literature published up to June 2016, and used the following search terms alone and in combination: "osteopetrosis", "spine", "fractures", "osteoclasts", and "operative management". Within four months after initial injury, treatment with halo vest allowed for adequate healing. The patient was asymptomatic with cervical spine dynamic radiographs confirming stability at four months. On four-year follow up examination, the patient remained without neck pain, and CT scan demonstrated partially sclerotic fracture lines with appropriate anatomical alignment. In conclusion, external halo stabilization may be an effective option for treatment of multiple unstable acute traumatic cervical spine fractures in patients with osteopetrosis. Given the challenge of surgical stabilization in osteopetrosis, further research is necessary to elucidate the optimal form of treatment in this select patient population.

Study Design Retrospective case series. Objective Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier disease involves hyperostosis of the spinal column. Hyperostosis involving the anterior margin of the cervical vertebrae can cause dysphonia, dyspnea, and/or dysphagia. However, the natural history pertaining to the risk factors remain unknown. We present the surgical management of two cases of dysphagia secondary to cervical hyperostosis and discuss the etiology and management of DISH based on the literature review. Methods This is a retrospective review of two patients with DISH and anterior cervical osteophytes. We reviewed the preoperative and postoperative images and clinical history. Results Two patients underwent anterior cervical osteophytectomies due to severe dysphagia. At more than a year follow-up, both patients noted improvement in swallowing as well as their associated pain. Conclusion The surgical removal of cervical osteophytes can be highly successful in treating dysphagia if refractory to prolonged conservative therapy.

The aim of this study is to evaluate the capability of femtosecond Laser Induced Breakdown Spectroscopy (fsLIBS) to discriminate between normal and cancerous bone, with implications to femtosecond laser surgery procedures. The main advantage of using femtosecond lasers for surgery is that the same laser that is being used to ablate can also be used for a feedback system to prevent ablation of certain tissues. For bone tumor removal, this technique has the potential to reduce the number of repeat surgeries that currently must be performed due to incomplete removal of the tumor mass. In this paper, we performed fsLIBS on primary bone tumor, secondary tumor in bone, and normal bone. These tissues were excised from consenting patients and processed through the UC Davis Cancer Center Biorepository. For comparison, each tumor sample had a matched normal bone sample. fsLIBS was performed to characterize the spectral signatures of each tissue type. A minimum of 20 spectra were acquired for each sample. We did not detect significant differences between the fsLIBS spectra of secondary bone tumors and their matched normal bone samples, likely due to the heterogeneous nature of secondary bone tumors, with normal and cancerous tissue intermingling. However, we did observe an increase in the fsLIBS magnesium peak intensity relative to the calcium peak intensity for the primary bone tumor samples compared to the normal bone samples. These results show the potential of using femtosecond lasers for both ablation and a real-time feedback control system for treatment of primary bone tumors.

Background

Anterior cervical discectomy and fusion (ACDF) is a common surgery to treat cervical degenerative disc disease. Use of an anterior spacer and plate system (ASPS) results in increased disc height, higher fusion rate, lower subsidence rate, and lower complication rate than a spacer alone.1,2 However, anterior cervical plating is associated with complications, such as dysphagia, plate-screw dislodgment, soft tissue injury, neural injury, and esophageal perforation.3-9 To potentially reduce these drawbacks, integrated spacer and plate (ISP) systems have gained popularity.

Methods

From November 2009 to October 2013, a total of 84 consecutive patients who underwent 2-level ACDF using ISP or ASPS were reviewed for clinical and radiographic outcomes. Patient-reported visual analog scale (VAS) and Neck Disability Index (NDI) scores, fusion rates, and hardware failure were determined at 1, 3, 6, 12, and 24 months after surgery.

Results

Forty-three patients received ISP and 41 patients received ASPS. There were no significant differences in patient demographics between the 2 groups. Perioperative characteristics were similar, except for operative time. Postoperatively, no significant differences in VAS or NDI scores or fusion status were found. At the proximal surgical level only, there was a trend toward an earlier observed radiographic fusion rate in ASPS vs ISP, but this finding was not statistically significant (P = 0.092). One case of long-term dysphagia was reported in each group. Neither group had implant failures up to 2 years.

Conclusions

The ISP system for 2-level ACDF compared to traditional ASPS has comparable clinical and radiographic outcomes up to 2 years postoperatively. There may be a trend toward an earlier observed radiographic fusion in the ASPS group, but there was no difference in long-term dysphagia rate.

Clinical relavance

Integrated spacer and traditional anterior spacer for 2-level ACDF has similar clinical and radiographical outcome.

Level of evidence: 4