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Open access

Full-endoscopic decompression for thoracic myelopathy caused by ossification of the ligamentum flavum: patient series

Vit Kotheeranurak, Phattareeya Pholprajug, Guang-Xun Lin, Pritsanai Pruttikul, Wicharn Yingsakmongkol, Tawechai Tejapongvorachai, and Jin-Sung Kim

BACKGROUND

This study aimed to describe the least invasive surgical technique of endoscopic decompression for thoracic myelopathy caused by ossification of the ligamentum flavum (OLF) and to review the literature available on the diagnosis and treatment of OLF.

OBSERVATIONS

The mean age of the patients was 51.2 (range, 40–62) years, and the mean preoperative, 2-week postoperative, and last follow-up modified Japanese Orthopaedic Association scores were 6.6 (range, 4–10), 9.6 (range, 7–11), and 13 (range, 10–14), respectively. All patients were discharged within 48 hours after the surgery. The mean follow-up period was 13.2 (range, 7–18) months. No complication was found perioperatively, and none of the patients had postoperative instability during the follow-up period.

LESSONS

Based on this clinical case series and literature review, the authors conclude that endoscopic decompression surgery is feasible and effective for managing thoracic myelopathy caused by OLF while minimizing surrounding tissue damage. Additionally, it enables shorter periods of hospital stay.

Open access

A modern multidisciplinary approach to a large cervicothoracic chordoma using staged en bloc resection with intraoperative image-guided navigation and 3D-printed modeling: illustrative case

Nathan J. Pertsch, Owen P. Leary, Joaquin Q. Camara-Quintana, David D. Liu, Tianyi Niu, Albert S. Woo, Thomas T. Ng, Adetokunbo A. Oyelese, Jared S. Fridley, and Ziya L. Gokaslan

BACKGROUND

Cervicothoracic junction chordomas are uncommon primary spinal tumors optimally treated with en bloc resection. Although en bloc resection is the gold standard for treatment of mobile spinal chordoma, tumor location, size, and extent of involvement frequently complicate the achievement of negative margins. In particular, chordoma involving the thoracic region can require a challenging anterior access, and en bloc resection can lead to a highly destabilized spine.

OBSERVATIONS

Modern technological advances make en bloc resection more technically feasible than ever before. In this case, the successful en bloc resection of a particularly complex cervicothoracic junction chordoma was facilitated by a multidisciplinary surgical approach that maximized the use of intraoperative computed tomography–guided spinal navigation and patient-specific three-dimensional–printed modeling.

LESSONS

The authors review the surgical planning and specific techniques that facilitated the successful en bloc resection of this right-sided chordoma via image-guided parasagittal osteotomy across 2 stages. The integration of emerging visualization technologies into complex spinal column tumor management may help to provide optimal oncological care for patients with challenging primary tumors of the mobile spine.

Open access

Spontaneous closure of an incidental high-flow paravertebral arteriovenous fistula caused by vertebral giant cell tumor curettage: illustrative case

Yen-Heng Lin, Yu-Cheng Huang, and Fon-Yih Tsuang

BACKGROUND

Paravertebral arteriovenous fistula (AVF) after spinal surgery is rarely reported in the literature. Its natural course is largely unknown.

OBSERVATIONS

The authors report a 31-year-old woman with a high-flow AVF after T12 vertebral giant cell tumor curettage. Eight months after the initial surgery, revision en bloc surgery was planned. Preoperative computed tomography angiography was performed for vascularity assessment, which incidentally revealed a large paravertebral early-enhanced venous sac. High-flow AVF was confirmed through subsequent spinal angiography. Endovascular embolization was scheduled before the surgery to avoid massive blood loss. However, the AVF closed spontaneously 1 month after the spinal angiography. The plan was changed to preoperative embolization; subsequently, three-level en bloc spondylectomy was performed smoothly.

LESSONS

Iatrogenic AVF is possible, prompting investigation by vascular imaging when suspected. Embolization is a preferred treatment method when feasible. However, for iatrogenic etiology, the prothrombotic property of the contrast medium may induce the resolution. Multidisciplinary discussion can be very helpful before aggressive spinal surgery.

Open access

Delayed-onset white cord syndrome after anterior and posterior cervical decompression surgery for symptomatic ossification of spinal ligaments: illustrative cases

Ranjit D. Singh, Mark P. Arts, and Godard C. W. de Ruiter

BACKGROUND

White cord syndrome is an extremely rare complication of cervical decompressive surgery, characterized by serious postoperative neurological deficits in the absence of apparent surgical complications. It is named after the characteristic ischemic-edematous intramedullary T2-hyperintense signal on postoperative magnetic resonance imaging and is believed to be caused by ischemic-reperfusion injury. Neurological deficits typically manifest immediately after surgery, and delayed occurrence has been reported only once.

OBSERVATIONS

The authors presented two cases of delayed white cord syndrome after anterior and posterior cervical decompression surgery for symptomatic ossification of the posterior longitudinal ligament and ligamentum flavum, respectively. Neurological deficits manifested on postoperative day 2 (case 1) and day 8 (case 2). The patients’ conditions were managed with high-dose corticosteroids, mean arterial pressure augmentation, and early physical therapy, after which they showed partial neurological recovery at discharge, which improved further by the 3-month follow-up visit.

LESSONS

The authors’ aim was to raise awareness among spine surgeons about this rare but severe complication of cervical decompressive surgery and to emphasize the mainstays of treatment based on current best evidence: high-dose corticosteroids, mean arterial pressure augmentation, and early physical therapy.

Open access

Spontaneous regression and near disappearance of a calcified herniated thoracic disc in a 44-year-old male: illustrative case

Andrew Utter, David Cavanaugh, Kelly F. Van Schouwen, Madison Mascagni, Madeline Walker, and Marcus Stone

BACKGROUND

Herniation of an intervertebral disc (IVD) is found predominantly in the lumbar and cervical spine of both children and adults, but herniated IVDs of the thoracic spine are a rare occurrence. However, approximately 40% of herniated thoracic disc cases are calcified. Approximately 0.65% of all spinal herniations are calcified herniated thoracic discs (CHTDs). CHTDs can be treated conservatively or invasively, depending on the symptoms and degree of neurological deficit present.

OBSERVATIONS

The authors report a 44-year-old male with near complete reabsorption and disappearance of a CHTD. A review of the available literature indicates that there are only seven adult patients in whom this phenomenon has been reported.

LESSONS

Determining the best form of invasive treatment is a challenge for surgeons given the complexity of this condition. While the disappearance of calcified herniated discs of the lumbar and cervical spine has been reported, reports of the regression of CHTDs are rare. The disappearance of CHTDs is more commonly reported in children who undergo conservative treatment, while surgery is reserved for children who experience progressive pain and neurological deficit. Given the success of conservative treatment of CHTDs in children, conservative treatment methods should be considered when treating mildly symptomatic adults.

Open access

Spinal navigation applied to the anterior approach for the resection of thoracic disc herniation: patient series

Angelo Rusconi, Paolo Roccucci, Stefano Peron, and Roberto Stefini

BACKGROUND

Thoracic disc herniation (TDH) represents a challenge for spine surgeons. The goal of this study is to report the surgical technique and clinical results concerning the application of navigation to anterior transthoracic approaches.

OBSERVATIONS

Between 2017 and 2019, 8 patients with TDH were operated in the lateral decubitus by means of mini-open thoracotomy. An adapted patient referent frame was secured to the iliac wing. The high-speed drill was also navigated. Intraoperative three-dimensional scans were used for level identification, optimized drilling trajectory, and assessment of complete resection. At 12 months follow up, all patients were ambulatory. Seven out of 8 patients (87%) experienced a postoperative neurological improvement. We observed 2 postoperative complications: 1 case of pleural effusion and 1 case of abdominal wall weakness.

LESSONS

In order to increase the safety of anterior transthoracic discectomy, the authors applied the concepts of spinal navigation to the thoracotomy setting. The advantages of this technique include decrease in wrong-level procedure, continuous matching of intraoperative and navigation anatomical findings, better exposure of the TDH, optimized vertebral body drilling, and minimized risk of neurological damage. In conclusion, the authors consider spinal navigation as an important resource for the surgical treatment of patients with TDH.

Open access

Management of thoracic spinal cord injury in a professional American football athlete: illustrative case

Joseph C. Maroon, Andrew Faramand, Nitin Agarwal, Amanda L. Harrington, Vikas Agarwal, John Norwig, and David O. Okonkwo

BACKGROUND

A case of catastrophic thoracic spinal cord injury (SCI) sustained by a professional American football player with severe scoliosis is presented.

OBSERVATIONS

A 25-year-old professional football player sustained an axial loading injury while tackling. Examination revealed a T8 American Spinal Injury Association Impairment Scale grade A complete SCI. Methylprednisolone and hypothermia protocols were initiated. Computed tomography scan of the thoracic spine demonstrated T8 and T9 facet fractures on the left at the apex of a 42° idiopathic scoliotic deformity. Magnetic resonance imaging (MRI) demonstrated T2 spinal cord hyperintensity at T9. He regained trace movement of his right lower extremity over 12 hours, which was absent on posttrauma day 2. Repeat MRI revealed interval cord compression and worsening of T2 signal change at T7-T8 secondary to hematoma. Urgent decompression and fusion from T8 to T10 were performed. Additional treatment included high-dose omega-3 fatty acids and hyperbaric oxygen therapy. A 2-month inpatient spinal cord rehabilitation program was followed by prolonged outpatient physical therapy. He currently can run and jump with minimal residual distal left lower limb spasticity.

LESSONS

This is the first known football-related thoracic SCI with idiopathic scoliosis. Aggressive medical and surgical intervention with intensive rehabilitation formed the treatment protocol, with a favorable outcome achieved.

Open access

Gout in the thoracic spine causing acute paraplegia: illustrative case

Lacin Koro, Ryan Khanna, Dominick Richards, and Dean G. Karahalios

BACKGROUND

Although spinal involvement by gout is not uncommon, spinal gout leading to symptomatic spinal cord compression in the thoracic spine is very rare and poses a diagnostic challenge by mimicking symptoms of more common diagnoses such as epidural abscess and malignancy. An even more unique presentation is spinal gout causing thoracic cord compression leading to acute paraplegia.

OBSERVATIONS

The authors present an illustrative case of a 35-year-old man with thoracic spinal compression by tophaceous gout who developed rapid progression to complete paraplegia over a 5-day period. Magnetic resonance imaging of the thoracic spine revealed a cystic-appearing lesion within the dorsal extradural space of the lower thoracic spine extending from T8 to T10 accompanied by compression of the spinal cord. An emergent T9–10 laminectomy was performed, and the occupying lesion in the thoracic spine was resected. The diagnosis of spinal tophaceous gout was made by pathological examination.

LESSONS

Although varying clinical manifestations of spinal gout have been reported in the literature, the patient’s age and the rapid progression to complete paraplegia over a 5-day period reveals a unique presentation that broadens understanding of the manner in which this condition can present and allow more rapid diagnosis and treatment.

Open access

Surgical repair of a large intrathoracic meningocele associated with neurofibromatosis type 1 after failed cystoperitoneal shunts: illustrative case

Christopher H. F. Sum, Lai-Fung Li, Benedict B. T. Taw, Wai-Man Lui, Ko-Yung Sit, Velda L. Y. Chow, and Yat-Wa Wong

BACKGROUND

Surgical treatment of intrathoracic meningoceles, commonly associated with neurofibromatosis type 1 (NF1), aims to reduce sac size for symptomatic relief. The procedures can be divided into cerebrospinal fluid diversion and definitive repair. The authors describe the management of an intrathoracic meningocele in a 56-year-old female with preexisting NF1.

OBSERVATIONS

The patient presented with progressive dyspnea. Magnetic resonance imaging revealed a left hemithoracic meningocele arising from the thecal sac at C7–T2. Two attempts at diversion by cystoperitoneal shunts resulted in recurrence. For definitive repair, T2–3 costotransversectomy was performed, and intradural closure of the meningocele opening was performed utilizing spinal dura and autologous fascia lata graft. Trapezius muscle regional flap was turned for reinforcement. Persistent leak warranted reoperation 7 days later. A transthoracic approach was undertaken using video-assisted thoracoscopic resection of the sac at aortic arch level, with reinforcement by latissimus dorsi flap and synthetic materials. Mechanical pleurodesis was performed. Intradural repair of the meningocele opening was revised.

LESSONS

Inherent dural abnormality makes repair difficult for meningoceles associated with NF1. A combined intradural and thoracoscopic approach with regional muscle flap and synthetic material reinforcement is a unique method for definitive treatment. Some essential points of perioperative management are highlighted.

Open access

Thoracic ossification of the ligamentum flavum causing acute myelopathy in a patient with cervical ossification of the posterior longitudinal ligament: illustrative case

Kishan S. Shah and Christopher M. Uchiyama

BACKGROUND

Ossification of the ligamentum flavum (OLF) has been well characterized as a distinct entity but also in tandem with ossification of the posterior longitudinal ligament (OPLL) in noncontiguous spinal regions. The majority of OLF cases are reported from East Asian countries where prevalent, but such cases are rarely reported in the North American population.

OBSERVATIONS

The authors present a case of a Thai-Cambodian American who presented with symptomatic thoracic OLF in tandem with asymptomatic cervical OPLL. A “floating” thoracic laminectomy, resection of OLF, and partial dural ossification (DO) resection with circumferential release of ossified dura were performed. Radiographic dural reexpansion and spinal cord decompression occurred despite the immediate intraoperative appearance of persistent thecal sac compression from retained DO.

LESSONS

Entire spinal axis imaging should be considered for patients with spinal ligamentous ossification disease, particularly in those of East Asian backgrounds. A floating laminectomy is one of several surgical approaches for OLF, but no consensus approach has been clearly established. High surgical complication rates are associated with thoracic OLF, most commonly dural tears/cerebrospinal fluid (CSF) leaks. DO commonly coexists with OLF, is recognizable on computed tomographic scans, and increases the risk of CSF leaks.