Background:The paraspinal, posterolateral, or Wiltse approach is an old technique that observes the principles of an MIS procedure. The aim of this study was to provide a step-by-step description from the literature of the Wiltse paraspinal approach and analyze its main advantages and limitations.Methods:Here, we provide a step-by-step description of the Wiltse approach. Utilizing PubMed and Lilacs and the Mesh terms “Wiltse approach,” “paraspinal approach,” “muscle sparing approach,” and “lumbar spine,” we identified 10 papers. We then put together, based on these publications, a step-by-step analysis of the preparation, patient positioning, skin incision, fascial opening, dissection, bone identification, retractors, deperiostization, decompression, discectomy, instrumentation, arthrodesis, and closure for the Wiltse technique.Results:Most papers underscored the minimally invasive aspects of the typical Wiltse approach. Advantages included minimal intraoperative bleeding, a shorter hospital length of stay, and a low infection rate.Conclusion:The classical approach described by Wiltse is essentially minimally invasive, sparing both the muscle planes and soft tissues, allowing for ample far lateral lumbar decompression, including discectomy and fusion, with a low complication rate.
Sacral chordomas are infrequent tumors that arise from remnants of the notochord. They are most often found in the sacrum and skull-base.1,2 These lesions rarely metastasize and usually have an indolent and oligosymptomatic clinical course. Chordomas show low sensitivity to standard radiation therapy and chemotherapy. Operative resection with wide resection margins offers the best long-term prognosis, including longer survival and local control.1,3 However, achieving a complete resection with oncological margins may be difficult because of the anatomic complexity of the sacrococcygeal region.4 The main complications of sacral resection include infections, wound closure defects, and anorectal and urogenital dysfunction. The rate of these complications is significantly increased when the tumor involves the S2 level or above. We report the case of a 64-yr-old male who presented with progressive sacrococcygeal pain and a feeling of incomplete evacuation. A heterogeneous, osteolytic lesion was found at the sacrococcygeal region. Full body imaging tests were negative for other lesions. A computed tomography (CT) guided biopsy was made. We usually use the midline approach in case we have to include the needle path in the resection. The pathology confirmed a sacrococcygeal, low-grade chordoma. We decided to perform an en bloc resection. A posterior, partial sacrectomy was planned distal to the S4 level.
Introduction Hangman fracture is the second most frequent axis fracture, alter odontoid fracture. The most widely used classification is that of Levine and Edwards, based on lateral X-ray. Type I are those fractures with < 3 mm displacement. Type II fractures are those with > 3 mm displacement. Type IIa show little or no displacement, but a severe angle. Type III fractures are those with severe displacement, angle, and unifacet or bifacet dislocation. In several cases, Hangman fracture is associated with other lesions which require priority attention. Patient and Methods: We present the case of a 46-year-old female patient who suffered from polytrauma because of a car accident. She was driving using her seatbelt, but no airbag was available in the car. On entry to the hospital, she presented Glasgow 15/15, Asia E, diabetes antecedents, HTA, and BMI 69.4 kg/m . Also, femur and right ankle fracture plus C2 traumatic spondylolisthesis type IIa. Neurological tests were normal. There was acute cervical and right lower limb pain. Initially, “damage control” was performed: stabilization of extraspinal lesions with external tutor in femur and ankle osteodesis. Since the patient presented morbid obesity, and due to the need of stabilizing her CD fracture, closed reduction and percutaneous osteosynthesis with bilateral fluoroscopically guided pedicle screw. It is absolutely necessary to have a clear front and lateral visualization of the cervical spine to plan the screw trajectory and the incision. Results A correct closed reduction of the fracture was attained. We projected each screw trajectory through radioscopy. An incision was done at C6 level and minimally invasive surgery was practiced, using two bilateral cannulated pedicle screws with correct fracture compression. Postoperatory X-ray and TAC showed correct position of both screws and fracture reduction. The patient had a satisfactory global evolution, with total relief of cervical pain, withdrawal of cervical orthosis, and precocious movement. In X-ray controls at 30, 60, and 90 days, correct fracture reduction was observed. TAC performed 6 months after the accident showed fracture consolidation. Conclusion We consider that, in certain selected cases, fluoroscopically guided percutaneous surgery is a good alternative when trying to give patients the best solution available. In our case, the patient received its benefits since she continued her orthopedical rehabilitation of other associated lesions without any inconvenience for the cervical surgery, with great pain relief, avoiding deep approach through the body midline; receiving minimal scars and with correct fracture reduction and consolidation. Patient selection is relevant to such an intervention. The learning curve is slow, so one must be used to the conventional technique to then do percutaneous technique.
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