Preliminary clinical results suggest that minimally invasive lumbar fusion will have a beneficial impact on the care of patients with spinal disorders. Outcome studies with long-term follow-up will be necessary to validate its success and allow minimally invasive lumbar fusion to become more widely accepted.

Forty-nine patients underwent minimally invasive transforaminal lumbar interbody fusion (TLIF) from October 2001 to August 2002 (minimum 18-month follow-up). The diagnosis was degenerative disc disease with herniated nucleus pulposus (HNP) in 26, spondylolisthesis in 22, and a Chance-type seatbelt fracture in 1. The majority of cases (n = 45) were at L4-L5 or L5-S1. A paramedian, muscle-sparing approach was performed through a tubular retractor docked unilaterally on the facet joint. A total facetectomy was then conducted, exposing the disc space. Discectomy and endplate preparation were completed through the tube using customized surgical instruments. Structural support was achieved with allograft bone or interbody cages. Bone grafting was done with local autologous or allograft bone, augmented with recombinant human bone morphogenetic protein-2 in some cases. Bilateral percutaneous pedicle screw-rod placement was accomplished with the Sextant system. There were no conversions to open surgery. Operative time averaged 240 minutes. Estimated blood loss averaged 140 mL. Mean length of hospital stay was 1.9 days. All patients presenting with preoperative radiculopathy (n = 45) had resolution of symptoms postoperatively. Complications included two instances of screw malposition requiring screw repositioning and two cases of new radiculopathy postoperatively (one from graft dislodgement, the other from contralateral neuroforaminal stenosis). Narcotic use was discontinued 2-4 weeks postoperatively. Improvements in average Visual Analogue Pain Scale and Oswestry Disability Index (preoperative to last follow-up) scores were 7.2-2.1 and 46-14, respectively. At last follow-up, all patients had solid fusions by radiographic criteria. Results of this study indicate that minimally invasive TLIF is feasible and offers several potential advantages over traditional open techniques.

Study Design:Guideline development.Objectives:The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate, and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy.Methods:Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness, and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing, and predictors of symptom development. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the management of degenerative cervical myelopathy (DCM).Results:Our recommendations were as follows: (1) “We recommend surgical intervention for patients with moderate and severe DCM.” (2) “We suggest offering surgical intervention or a supervised trial of structured rehabilitation for patients with mild DCM. If initial nonoperative management is pursued, we recommend operative intervention if there is neurological deterioration and suggest operative intervention if the patient fails to improve.” (3) “We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically.” (4) “Non-myelopathic patients with cord compression and clinical evidence of radiculopathy with or without electrophysiological confirmation are at a higher risk of developing myelopathy and should be counselled about this risk. We suggest offering either surgical intervention or nonoperative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation. In the event of myelopathic development, the patient should be managed according to the recommendations above.”Conclusions:These guidelines will promote standardization of care for patients with DCM, decrease the heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.

✓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.

Objective:To develop recommendations on the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome.Methods:A systematic review of the literature was conducted to address key relevant questions. A multidisciplinary guideline development group used this information, along with their clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weak recommendation is presented as “we suggest.”Results:Conclusions from the systematic review included (1) isolated studies reported statistically significant and clinically important improvements following early decompression at 6 months and following discharge from inpatient rehabilitation; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at 6 and 12 months in patients managed with early versus late surgery; and (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups. Our recommendations were: “We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome” and “We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level.” Quality of evidence for both recommendations was considered low.Conclusions:These guidelines should be implemented into clinical practice to improve outcomes in patients with acute SCI and central cord syndrome by promoting standardization of care, decreasing the heterogeneity of management strategies, and encouraging clinicians to make evidence-informed decisions.

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Object. Diagnosing and managing cervical spine trauma in head-injured patients is problematic due to an altered level of consciousness in such individuals. The reported incidence of cervical spine trauma in head-injured patients has generally ranged from 4 to 8%. In this retrospective study the authors sought to define the incidence of cervical injury in association with moderate or severe brain injury, emphasizing the identification of high-risk patients. Methods. The study included 447 consecutive moderately (209 cases) or severely (238 cases) head injured patients who underwent evaluation at two Level 1 trauma centers over a 40-month period. Of the 447 patients, 24 (5.4%) suffered a cervical spine injury (17 men and seven women; mean age 39 years; median Glasgow Coma Scale [GCS] score of 6, range 3–14). Of these 24 patients, 14 (58.3%) sustained spinal cord injuries (SCIs), 14 sustained injuries in the occiput—C3 region, and 10 underwent a stabilization procedure. Of the 14 patients with SCIs, nine experienced an early hypotensive and/or hypoxic insult. Regarding the mechanism of injury, cervical injuries occurred in 21 (8.2%) of 256 patients involved in motor vehicle accidents (MVAs), either as passengers or pedestrians, compared with three (1.6%) of 191 patients with non-MVA-associated trauma (p < 0.01). In the subset of 131 MVA passengers, 13 (9.9%) sustained cervical injuries. Patients with an initial GCS score less than or equal to 8 were more likely to sustain a cervical injury than those with a score higher than 8 (odds ratio [OR] 2.77, 95% confidence interval [CI] = 1.11–7.73) and were more likely to sustain a cervical SCI (OR 5.5, 95% CI 1.22–24.85). At 6 months or more postinjury, functional neurological recovery had occurred in nine patients (37.5%) and eight (33.3%) had died. Conclusions. Head-injured patients sustaining MVA-related trauma and those with an initial GCS score less than or equal to 8 are at highest risk for concomitant cervical spine injury. A disproportionate number of these patients sustain high cervical injuries, the majority of which are mechanically unstable and involve an SCI. The development of safer and more rapid means of determining cervical spine integrity should remain a high priority in the care of head-injured patients.

Preliminary clinical results suggest that minimally invasive lumbar fusion will have a beneficial impact on the care of patients with spinal disorders. Outcome studies with long-term follow-up will be necessary to validate its success and allow minimally invasive lumbar fusion to become more widely accepted.