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Patrick W. Hitchon, Souheil Haddad and Adel Afifi

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Souheil F. Haddad, Patrick W. Hitchon and John C. Godersky

✓ Pathological overgrowth of the epidural fat in the spine has been described and reported nearly exclusively in patients either with Cushing's syndrome or on chronic intake of glucocorticoids for a variety of clinical disorders. The authors report four patients with documented spinal lipomatosis (three pathologically and one radiologically). Only one of these patients received corticosteroids, and none had an underlying endocrinological abnormality. All four patients were adult males with a mean age at onset of symptoms of 43 years (range from 18 to 60 years). The symptoms ranged from simple neurogenic claudication and radicular pain to frank myelopathy. Myelography followed by computerized tomography were instrumental in the diagnosis of the first three patients; the fourth was diagnosed by magnetic resonance imaging. The thoracic spine was involved in two cases and the lumbosacral area in the other two. The different treatment modalities were tailored according to the symptomatology of the patients. These included weight reduction of an overweight patient with minimal neurological findings in one case and decompressive laminectomy and fat debulking to achieve adequate cord decompression in the remaining three cases. Two patients improved significantly, the condition of one stabilized, and the fourth required a second decompression at other spinal levels. The various modalities of treatment and their potential complications are discussed.

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Ambur Reddy, Patrick W. Hitchon, Sami Al-Nafi and Kent Choi

The authors report a case of entero-paraspinous fistula 2 years after T-12 corpectomy and instrumentation for spinal metastasis from renal cell carcinoma. The pathogenesis in the present case seems to have arisen from local recurrence of T-12 metastatic carcinoma in spite of radiation and corpectomy. As a result of previous nephrectomy and anterolateral dissection for the T-12 corpectomy, the jejunum adhered to the surgical site. Recurrent tumor at T-12 invaded the adherent small bowel loop, resulting in a fistulous communication between the small bowel lumen and the spinal wound. Loss of retroperitoneal fat, scarring, and adhesions from previous surgeries contributed to this complication by having the jejunum close to the T-12 corpectomy site, and eventually to its invasion by recurrent tumor. Avoidance of such a complication is difficult; however, total excision of the spinal malignancy, and when possible, creating a barrier cuff of fascia or fat around the spine to protect abdominal contents, are potential solutions.

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Hamdi G. Sukkarieh, Patrick W. Hitchon, Olatilewa Awe and Jennifer Noeller

OBJECT

The authors sought to determine patient-related outcomes after minimally invasive surgical (MIS) lumbar intraspinal synovial cyst excision via a tubular working channel and a contralateral facet-sparing approach.

METHODS

All the patients with a symptomatic lumbar intraspinal synovial cyst who underwent surgery at the University of Iowa Hospitals and Clinics with an MIS excision via a contralateral approach were treated between July 2010 and August 2014. There was a total of 13 cases. Each patient was evaluated with preoperative neurological examinations, lumbar spine radiography, MRI, and visual analog scale (VAS) scores. The patients were evaluated postoperatively with neurological examinations and VAS and Macnab scores. The primary outcomes were improvement in VAS and Macnab scores. Secondary outcomes were average blood loss, hospital stay duration, and operative times.

RESULTS

There were 5 males and 8 females. The mean age was 66 years, and the mean body mass index was 28.5 kg/m2. Sixty-nine percent (9 of 13) of the cysts were at L4–5. Most patients had low-back pain and radicular pain, and one-third of them had Grade 1 spondylolisthesis. The mean (± SD) follow-up duration was 20.8 ± 16.9 months. The mean Macnab score was 3.4 ± 1.0, and the VAS score decreased from 7.8 preoperatively to 2.9 postoperatively. The mean operative time was 123 ± 30 minutes, with a mean estimated blood loss of 44 ± 29 ml. Hospital stay averaged 1.5 ± 0.7 days. There were no complications noted in this series.

CONCLUSIONS

The MIS excision of lumbar intraspinal synovial cysts via a contralateral approach offers excellent exposure to the cyst and spares the facet joint at the involved level, thus minimizing risk of instability, blood loss, operative time, and hospital stay. Prospective randomized trials with longer follow-up times and larger cohorts are needed to conclusively determine the superiority of the contralateral MIS approach over others, including open or ipsilateral minimally invasive surgery.

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Arnold H. Menezes, Patrick W. Hitchon and Brian J. Dlouhy

A family with familial spinal extradural arachnoid cyst is presented. A 14-year-old boy had an extensive T-8 through L-2 dorsal extradural arachnoid cyst with spinal cord compression and slowly progressive myelopathy. His mother had presented 4 years earlier with acute excruciating back pain due to the combination of a lumbar extradural arachnoid cyst at L2–4 and an extruded disc at L3–4. The literature is reviewed in light of the pathogenesis, imaging, and surgical technique required for treatment.

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George M. Greene, Patrick W. Hitchon, Robert L. Schelper, William Yuh and Gregg N. Dyste

✓ Twenty-seven patients underwent 29 computerized tomography (CT)-guided stereotactic biopsy procedures for untreated or recurrent malignant astrocytomas. Biopsies were obtained from the hypodense center, enhancing margin, and hypodense periphery as seen on contrast-enhanced CT scans, with diagnostic yields of (number of biopsies yielding tumor/number of biopsies obtained): 34/61 (56%), 68/101 (67%), and 8/22 (36%) from these three zones, respectively. Although tumor was identified in all three zones, diagnostic yield was significantly higher in the hypodense center and enhancing margin. Comparison of patients with untreated tumors to those with recurrent tumors demonstrated no statistical difference in tumor distribution, although there was a trend toward a higher yield from the hypodense periphery in the recurrent tumor group. Tumor was found up to 15 mm beyond the CT-enhancing margin, in addition to extending beyond the area of abnormality on T2-weighted magnetic resonance images. These findings suggest that serial stereotactic biopsies should be targeted to the hypodense center and enhancing margin for improved diagnostic yield. Biopsy material obtained from the hypodense periphery that demonstrates tumor also indicates that a tumor volume beyond the confines of the CT-enhancing margin should be considered when calculating dosimetry for interstitial radiation.

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Aditya V. Ingalhalikar, Chandan G. Reddy, Tae Hong Lim, James C. Torner and Patrick W. Hitchon

Object

The artificial disc has been proposed as an alternative to spinal fusion for degenerative disc disease. The primary aim of this biomechanical study was to compare motion and intradiscal pressure (IDP) in a ball-and-socket artificial disc–implanted cadaveric lumbar spine, at the operative and adjacent levels, using a displacement-controlled setup. A secondary comparison involved a “salvage” construct, consisting of pedicle screws (PSs) added in supplementation to the artificial disc construct.

Methods

Ten human cadaveric lumbosacral spines (L2–S1) were potted at L-2 and S-1. All measurements were initially made in the intact spine, followed by implantation of the artificial disc, and finally by the salvage PS condition. For the artificial disc condition, a Maverick ball-and-socket artificial disc was implanted at L4–5. For the PS condition, CD Horizon PSs were placed at L4–5, and the artificial disc was left in place. A displacement-controlled, custom-designed testing apparatus was used to impart motion in the sagittal and coronal planes. Motion at both the implanted level (L4–5) and immediately adjacent levels (L3–4 and L5–S1) was measured. Intradiscal pressure at the rostral adjacent level (L3–4) was also measured. The Tukey test was used for statistical analysis (p < 0.05).

Results

In flexion, no significant difference was noted between the artificial disc and the intact spine with regard to motion at the operative level, motion at adjacent levels, or IDP. In lateral bending, while the artificial disc significantly decreased operative-level motion (p < 0.05), no significant difference was noted in adjacent-level motion or IDP. With regard to extension, the artificial disc significantly increased operative level motion and decreased the rostral adjacent level (L3–4) motion and IDP (p < 0.05). Caudal adjacent-level (L5–S1) motion was not significantly different.

In flexion and lateral bending, the addition of PSs significantly decreased motion at the implanted level when compared with the intact spine and the artificial disc (p < 0.05). This decrease in motion at the index level was associated with a compensatory increase in motion at both adjacent levels in flexion only (p < 0.05), but not in lateral bending (p > 0.05). The IDP was significantly increased in lateral bending but not in flexion. With regard to extension, the significant decrease in IDP that was noted with the artificial disc persisted despite the addition of PSs (p < 0.05).

Conclusions

The artificial disc either maintains or reduces adjacent-level motion and pressure, compared with the intact spine. The addition of PSs to the artificial disc construct leads to significantly increased motion at adjacent levels in flexion and significantly increased IDP in lateral bending. At the operative level, the artificial disc is associated with hypermobility in extension, which is restored to the intact state after the addition of supplementary PSs.