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Langston T. Holly and Ulrich Batzdorf

Object. In this report the authors review their experience in the treatment of seven patients with symptomatic cerebellar ptosis following craniovertebral decompression (CVD) for Chiari I malformation.

Methods. The mean age of the patients was 37 years and the average amount of time between the initial suboccipital craniectomy and evaluation for cerebellar ptosis was 6.8 years. Five patients presented primarily with intractable headache and the remaining two patients with neurological deficits caused by recurrent syringomyelia. Three different surgical modalities were used to treat these patients: ventriculoperitoneal shunt placement (one patient), syringoperitoneal shunt placement (two patients), and partial suboccipital cranioplasty with or without intradural exploration (four patients). The mean follow-up period was 51 months. The three patients who underwent shunt placement procedures experienced poor results, with no evidence of symptom relief and continued neurological deterioration. In contrast, all four patients who underwent cranioplasty experienced good or excellent clinical outcomes. Postoperative magnetic resonance imaging studies revealed a reduction in the size of the syrinx cavity in patients who simultaneously underwent intradural exploration.

Conclusions. The emergence of symptomatic cerebellar ptosis following CVD for Chiari I malformation is primarily caused when the suboccipital craniectomy is too large for the specific patient. The cerebellar ptosis usually presents with severe headache and/or neurological deficit due to persistent or recurrent syringomyelia. Partial suboccipital cranioplasty, with or without intradural exploration, is effective in treating this condition.

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Langston T. Holly and Ulrich Batzdorf

Object. The authors review their experience in the diagnosis and management of 32 patients with slitlike syrinx cavities.

Methods. There were 18 men and 14 women with a mean age of 40 years. Presenting symptoms that prompted magnetic resonance (MR) imaging evaluation were mechanical spinal pain (13 patients), radicular pain (seven patients), paresthesia (six patients), numbness (five patients), and muscle spasm (one patient). In 12 patients neurological examination demonstrated normal status, and in the remainder only minimal sensory or motor abnormalities were found. The mean diameter of the syrinx cavity was 2 mm (range 1–5 mm), and on average it covered three vertebral levels. The cavities were limited to the cervical region in 16 patients, the thoracic in 12, and both regions in four patients.

The mean follow-up time for changes in clinical condition and repeated MR imaging features were 38 and 32 months, respectively. Thirty-one patients were treated nonoperatively, and one was treated surgically. During the follow-up period clinical improvement was documented in six patients, worsened status in seven, and no change was demonstrated in the clinical status of 19 patients. None of the syrinx cavities changed in size. In 16 patients medical workup revealed alternative diagnoses that were determined to be the true causes of each patient's symptoms.

Conclusions. Slitlike cavities likely do not represent true syringomyelia but rather remnants of the central canal detected in a small percentage of adults. Review of the authors' experience indicates that these cavities are asymptomatic and are unlikely to change in size. They can be considered an incidental finding, and in many of these patients another condition explaining the patient's symptoms may be found.

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Langston T. Holly and Kevin T. Foley

✓ The authors sought to evaluate the feasibility and accuracy of three-dimensional (3D) fluoroscopic guidance for percutaneous placement of thoracic and lumbar pedicle screws in three cadaveric specimens.

After attaching a percutaneous dynamic reference array to the surgical anatomy, an isocentric C-arm fluoroscope was used to obtain images of the region of interest. Light-emitting diodes attached to the C-arm unit were tracked using an electrooptical camera. The image data set was transferred to the image-guided workstation, which performed an automated registration. Using the workstation display, pedicle screw trajectories were planned. An image-guided drill guide was passed through a stab incision, and this was followed by sequential image-guided pedicle drilling, tapping, and screw placement. Pedicle screws of various diameters (range 4–6.5 mm) were placed in all pedicles greater than 4 mm in diameter. Postoperatively, thin-cut computerized tomography scans were obtained to determine the accuracy of screw placement.

Eighty-nine (94.7%) of 94 percutaneous screws were placed completely within the cortical pedicle margins, including all 30 lumbar screws (100%) and 59 (92%) of 64 thoracic screws. The mean diameter of all thoracic pedicles was 6 mm (range 2.9–11 mm); the mean diameter of the five pedicles in which wall violations occurred was 4.6 mm (range 4.1–6.3 mm). Two of the violations were less than 2 mm beyond the cortex; the others were between 2 and 3 mm.

Coupled with an image guidance system, 3D fluoroscopy allows highly accurate spinal navigation. Results of this study suggest that this technology will facilitate the application of minimally invasive techniques to the field of spine surgery.

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Langston T. Holly and Ulrich Batzdorf

Object

Intradural arachnoid cysts are relatively uncommon pouches of cerebrospinal fluid (CSF) found within the subarachnoid space. The authors present a series of eight symptomatic patients in whom syrinx cavities were associated with arachnoid cysts, and they discuss treatment strategies for this entity.

Methods

The population comprised eight men whose mean age was 50 years (range 35–81 years). All patients experienced gait difficulty, and it was the chief complaint in seven; arm pain was the primary complaint in one. No patient had a history of spinal trauma, meningitis, or previous spinal surgery at the level of the syrinx cavity or arachnoid cyst. In each patient imaging revealed a syrinx cavity affecting two to 10 vertebral levels. Posterior thoracic arachnoid cysts were found in proximity to the syrinx cavity in each case. There was no evidence of cavity enhancement, Chiari malformation, tethered cord, or hydrocephalus.

All patients underwent thoracic laminectomy and resection of the arachnoid cyst wall, and postoperative neurological improvement was documented in each case. The mean follow-up duration was 19 months (range 4–37 months). Follow-up magnetic resonance imaging demonstrated the disappearance of the arachnoid cyst and a significant decrease in syrinx cavity size in each patient.

Conclusions

Spinal arachnoid cysts can be associated with syringomyelia, likely due to alterations in normal CSF dynamics. In symptomatic patients these cysts should be resected and the normal CSF flow restored. The results of the present series indicate that neurological improvement and reduction in syrinx cavity size can be achieved in patients with syringomyelia associated with intradural arachnoid cysts.

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Victor Chang and Langston T. Holly

Traumatic fractures of the thoracolumbar spine are relatively common occurrences that can be a source of pain and disability. Similarly, osteoporotic vertebral fractures are also frequent events and represent a significant health issue specific to the elderly. Neurologically intact patients with traumatic thoracolumbar fractures can commonly be treated nonoperatively with bracing. Nonoperative treatment is not suitable for patients with neurological deficits or highly unstable fractures. The role of operative versus nonoperative treatment of burst fractures is controversial, with high-quality evidence supporting both options. Osteoporotic vertebral fractures can be managed with bracing or vertebral augmentation in most cases. There is, however, a lack of high-quality evidence comparing operative versus nonoperative fractures in this population. Bracing is a low-risk, cost-effective method to treat certain thoracolumbar fractures and offers efficacy equivalent to that of surgical management in many cases. The evidence for bracing of osteoporotic-type fractures is less clear, and further investigation will be necessary to delineate its optimal role.

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Benjamin M. Ellingson and Langston T. Holly

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Langston T. Holly and Ulrich Batzdorf

Object

Intradural arachnoid cysts are relatively uncommon pouches of cerebrospinal fluid (CSF) found within the subarachnoid space. The authors present a series of eight symptomatic patients in whom syrinx cavities were associated with arachnoid cysts, and they discuss treatment strategies for this entity.

Methods

The population comprised eight men whose mean age was 50 years (range 35–81 years). All patients experienced gait difficulty, and it was the chief complaint in seven; arm pain was the primary complaint in one. No patient had a history of spinal trauma, meningitis, or previous spinal surgery at the level of the syrinx cavity or arachnoid cyst. In each patient imaging revealed a syrinx cavity affecting two to 10 vertebral levels. Posterior thoracic arachnoid cysts were found in proximity to the syrinx cavity in each case. There was no evidence of cavity enhancement, Chiari malformation, tethered cord, or hydrocephalus.

All patients underwent thoracic laminectomy and resection of the arachnoid cyst wall, and postoperative neurological improvement was documented in each case. The mean follow-up duration was 19 months (range 4–37 months). Follow-up magnetic resonance imaging demonstrated the disappearance of the arachnoid cyst and a significant decrease in syrinx cavity size in each patient.

Conclusions

Spinal arachnoid cysts can be associated with syringomyelia, likely due to alterations in normal CSF dynamics. In symptomatic patients these cysts should be resected and the normal CSF flow restored. The results of the present series indicate that neurological improvement and reduction in syrinx cavity size can be achieved in patients with syringomyelia associated with intradural arachnoid cysts.

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Sean S. Armin, Langston T. Holly and Larry T. Khoo

For decades, lumbar disc herniation and lumbar stenosis have been treated surgically via traditional open techniques. With recent emphasis on minimally invasive approaches in spine surgery, a number of new techniques has been introduced that are aimed at treating these 2 common pathological conditions. Currently the most widely used and efficacious minimally invasive technique for treating these disorders is direct decompression with minimally invasive surgery. Due to the scarcity of large randomized studies, however, it is difficult to compare the effectiveness and possible superiority of this technique with traditional decompression. Further studies are needed to evaluate this issue.

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Nouzhan Sehati, Larry T. Khoo and Langston T. Holly

Object

Lumbar synovial cysts are a potential cause of radiculopathy and back pain, and the definitive treatment is the complete excision of the cyst. This report summarizes the authors' preliminary clinical experience with the minimally invasive resection of lumbar synovial cysts.

Methods

Nineteen patients (nine men and 10 women) with symptomatic synovial cysts underwent minimally invasive resection. The mean patient age was 64 years of age (range 43–80 years). The presenting symptom was radiculopathy in 16 patients, low-back pain in two, and lower-extremity weakness in one. There were 16 cases of a cyst located at the L4–5 level, two at L3–4, and one at L5–S1. The mean cyst diameter was 13.7 mm (range 3–30 mm).

The mean follow-up time was 16 months (range 4–29 months). Clinical outcomes were graded, based on the Macnab modified criteria, as excellent, good, fair, or poor. Eighteen patients (95% of cases) reported either excellent (10 patients) or good (eight patients) results, and a fair result was reported by one patient (5% of cases). The mean operative time was 158 minutes (range 75–270 minutes), and the average intraoperative blood loss was 31 ml (range 10–100 ml). Two patients had intraoperative dural tears that resulted in cerebrospinal fluid leaks that resolved following primary closure.

Conclusions

Synovial cysts can be safely and effectively treated using minimally invasive surgical techniques. Long-term follow up is required to determine whether this approach results in less need for fusion than conventional surgical approaches.

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Langston T. Holly, James D. Schwender, David P. Rouben and Kevin T. Foley

✓The authors provide an overview of the minimally invasive transforaminal lumbar interbody fusion (TLIF) procedure including indications, technique, and complications. This novel technique is a method of achieving circumferential lumbar fusion using a unilateral dorsal approach. Minimally invasive TLIF uses a tubular retractor that is inserted via a muscle-dilating exposure, thereby minimizing the approach-related morbidity. This procedure is ideal for refractory mechanical low-back and radicular pain associated with spondylolisthesis, degenerative disc disease, and recurrent disc herniation. The authors' clinical experience and review of the medical literature indicate that TLIF can be effectively and safely performed in a minimally invasive fashion.