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Andrea Pietrantonio, Sokol Trungu, Isabella Famà, Stefano Forcato, Massimo Miscusi and Antonino Raco

OBJECTIVE

Lumbar spinal stenosis (LSS) is the most common spinal disease in the geriatric population, and is characterized by a compression of the lumbosacral neural roots from a narrowing of the lumbar spinal canal. LSS can result in symptomatic compression of the neural elements, requiring surgical treatment if conservative management fails. Different surgical techniques with or without fusion are currently treatment options. The purpose of this study was to provide a description of the long-term clinical outcomes of patients who underwent bilateral laminotomy compared with total laminectomy for LSS.

METHODS

The authors retrospectively reviewed all the patients treated surgically by the senior author for LSS with total laminectomy and bilateral laminotomy with a minimum of 10 years of follow-up. Patients were divided into 2 treatment groups (total laminectomy, group 1; and bilateral laminotomy, group 2) according to the type of surgical decompression. Clinical outcomes measures included the visual analog scale (VAS), the 36-Item Short-Form Health Survey (SF-36) scores, and the Oswestry Disability Index (ODI). In addition, surgical parameters, reoperation rate, and complications were evaluated in both groups.

RESULTS

Two hundred fourteen patients met the inclusion and exclusion criteria (105 and 109 patients in groups 1 and 2, respectively). The mean age at surgery was 69.5 years (range 58–77 years). Comparing pre- and postoperative values, both groups showed improvement in ODI and SF-36 scores; at final follow-up, a slightly better improvement was noted in the laminotomy group (mean ODI value 22.8, mean SF-36 value 70.2), considering the worse preoperative scores in this group (mean ODI value 70, mean SF-36 value 38.4) with respect to the laminectomy group (mean ODI 68.7 vs mean SF-36 value 36.3), but there were no statistically significant differences between the 2 groups. Significantly, in group 2 there was a lower incidence of reoperations (15.2% vs 3.7%, p = 0.0075).

CONCLUSIONS

Bilateral laminotomy allows adequate and safe decompression of the spinal canal in patients with LSS; this technique ensures a significant improvement in patients’ symptoms, disability, and quality of life. Clinical outcomes are similar in both groups, but a lower incidence of complications and iatrogenic instability has been shown in the long term in the bilateral laminotomy group.

Free access

Massimo Miscusi, Sokol Trungu, Luca Ricciardi, Stefano Forcato, Alessandro Ramieri and Antonino Raco

OBJECTIVE

Over the last few decades, many surgical techniques for lumbar interbody fusion have been reported. The anterior-to-psoas (ATP) approach is theoretically supposed to benefit from the advantages of both anterior and lateral approaches with similar complication rates, even in L5–S1. At this segment, the anterior lumbar interbody fusion (ALIF) requires retroperitoneal dissection and retraction of major vessels, whereas the iliac crest does not allow the lateral transpsoas approach. This study aimed to investigate clinical-radiological outcomes and complications of the ATP approach at the L5–S1 segment in a single cohort of patients.

METHODS

This is a prospective single-center study, conducted from 2016 to 2019. Consecutive patients who underwent ATP at the L5–S1 segment for degenerative disc disease or revision surgery after previous posterior procedures were considered for eligibility. Complete clinical-radiological documentation and a minimum follow-up of 12 months were set as inclusion criteria. Clinical patient-reported outcomes, such as the visual analog scale for low-back pain, Oswestry Disability Index, and 36-Item Short Form Health Survey (SF-36) scores, as well as spinopelvic parameters, were collected preoperatively, 6 weeks after surgery, and at the last follow-up visit. Intraoperative and perioperative complications were recorded. The fusion rate was evaluated on CT scans obtained at 12 months postoperatively.

RESULTS

Thirty-two patients met the inclusion criteria. The mean age at the time of surgery was 57.6 years (range 44–75 years). The mean follow-up was 33.1 months (range 13–48 months). The mean pre- and postoperative visual analog scale (7.9 ± 1.3 vs 2.4 ± 0.8, p < 0.05), Oswestry Disability Index (52.8 ± 14.4 vs 22.9 ± 6.0, p < 0.05), and SF-36 (37.3 ± 5.8 vs 69.8 ± 6.1, p < 0.05) scores significantly improved. The mean lumbar lordosis and L5–S1 segmental lordosis significantly increased after surgery. The mean pelvic incidence–lumbar lordosis mismatch and pelvic tilt significantly decreased. No intraoperative complications and a postoperative complication rate of 9.4% were recorded. The fusion rate was 96.9%. One patient needed a second posterior revision surgery for residual foraminal stenosis.

CONCLUSIONS

In the present case series, ATP fusion for the L5–S1 segment has resulted in valuable clinical-radiological outcomes and a relatively low complication rate. Properly designed clinical and comparative trials are needed to further investigate the role of ATP for different L5–S1 conditions.

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Luca Ricciardi, Sokol Trungu, Alba Scerrati, Pasquale De Bonis, Oriela Rustemi, Mauro Mazzetto, Giorgio Lofrese, Francesco Cultrera, Cédric Y. Barrey, Alessandro Di Bartolomeo, Amedeo Piazza, Massimo Miscusi and Antonino Raco

OBJECTIVE

Anderson type II odontoid fractures are severe conditions, mostly affecting elderly people (≥ 70 years old). Surgery can be performed as a primary treatment or in cases of failed conservative management. This study aimed to investigate how duration from injury to surgery, as well as clinical, radiological, and surgical risk factors, may influence the union rate after anterior odontoid screw placement for Anderson type II odontoid fractures.

METHODS

The authors conducted a retrospective multicenter study. Demographic, clinical, surgical, and radiological data of patients who underwent anterior odontoid screw placement for Anderson type II fractures were retrieved from institutional databases. Study exclusion criteria were prolonged corticosteroid drug therapy (> 4 weeks), polytraumatic injuries, oncological diagnosis, and prior cervical spine trauma.

RESULTS

Eighty-five patients were included in the present investigation. The union rate was 76.5%, and 73 patients (85.9%) did not report residual instability. Age ≥ 70 years (p < 0.001, OR 6), female gender (p = 0.016, OR 3.61), osteoporosis (p = 0.009, OR 4.02), diabetes (p = 0.056, OR 3.35), fracture diastasis > 1 mm (p < 0.001, OR 8.5), and duration from injury to surgery > 7 days (p = 0.002, OR 48) independently influenced union rate, whereas smoking status (p = 0.677, OR 1.24) and odontoid process angulation > 10° (p = 0.885, OR 0.92) did not.

CONCLUSIONS

Although many factors have been reported as influencing the union rate after anterior odontoid screw placement for Anderson type II fractures, duration from injury to surgery > 7 days appears to be the most relevant, resulting in a 48 times higher risk for nonunion. Early surgery appears to be associated with better radiological outcomes, as reported by orthopedic surgeons in other districts. Prospective comparative clinical trials are needed to confirm these results.