No abstract

Corrective surgery for kyphotic deformities of the spine in ankylosing spondylitis is a major surgery for rare indications. The authors report 31 lumbar osteotomies.

Anterior lumbar spine approaches may be indicated for fusion in degenerative lumbar spine disorders or to fill discal and bone gaps after fracture reduction. We present an anterior extraperitoneal approach applicable to any discal and vertebral levels from T12 to S1. The anatomic study, based on 25 cadavers, highlights retroperitoneal dissection principles for easy kidney and duodenopancreatic mobilisation and direct left anterior access to the entire lumbar spine. We established a precise description of the lumbar veins and the anastomoses between the left renal vein and hemiazygos system, in order to define different topographic and anatomic factors related to safe and easily reproducible approaches for cage or graft implementation. Independent of the level and previous intraperitoneal surgery, lumbar spine access with this approach safeguards the kidney, ureter, spleen, hypogastric plexus and duodenopancreatic system. Regarding operating time, blood-loss and possibilities for freshening and grafting, this technique seems an effective counterbalance to the difficulties and complex technology of endoscopic approaches. The clinical study includes our first 42 cases in traumatic and degenerative lesions. Avoiding the neurologic or hemorrhagic risk inherent in classical posterior lumbar interbody fusion (PLIF) techniques, it can be considered as a reasonable and valid alternative. This technique could be used in the near future for mini invasive discal prosthesis insertion.

Intraoperative ultrasonography (IOUs) was used to evaluate the location and compressive effects of intraspinal fragments in thoracolumbar fractures and the efficacy of reduction maneuvers in patients operated on for isolated or attached intraspinal fragments or for global posterior wall disruption. Dynamic IOUs was used to evaluate the effects of traction and lordosis. Fifty-eight patients were evaluated using a 7.5 MHz ultrasound probe, including 27 treated by impaction, 19 by removal of apparently isolated fragments, and 12 by traction followed by lordosis for global posterior wall disruption. IOUS had limitations and problems caused by split fragments and residual pedicular attachments that can compromise intraoperative maneuvers. The risk of secondary displacement of isolated fragments treated by impaction was very high. In particular, the pinching effect produced by T-shaped fractures was commonly responsible for secondary displacement. IOUS evaluation of canal clearance after fragment removal was satisfactory, but did not provide quantitative data. IOUS was easier to perform and apparently more reliable than intraoperative myelography. The dynamic IOUS data suggest that, except for severely tilted fragments that are completely free or remain attached to a pedicle, residual discal attachments significantly influence the likelihood of successful reduction.

Dislocations of the first two cervical vertebrae are rare and very often fatal. We report a case of vertical atlantoaxial dislocation with no neurological signs and with a favourable outcome.A 62-year-old man was driving his car with his seat belt fastened when he had a violent head-on collision with a farming machine at the level of the plough. Axial traction responsible for hyperextension of the cervical spine and stretching of the left brachial plexus occurred. On arrival at the emergency unit, he had respiratory distress and blood aspiration due to a facial trauma. The Glasgow score was 3 and a CT scan of the brain showed mild intraventricular bleeding on the right.Plain radiographs of the cervical spine disclosed isolated C1-C2 dislocation, with a vertical C1-C2 gap exceeding 20 mm (Fig. 1). An emergency arteriogram of the aortic arch showed no abnormalities (Fig. 2).Immediate external reduction was carried out by applying firm pressure along the axis of the head under fluoroscopy (Fig. 3). Post-reduction stability was assessed during small flexion-extension motions.Tracheotomy and reconstructive maxillofacial surgery were immediately carried out, allowing secondary spinal stabilisation using a posterior approach in the prone position. Traumatic dura mater tears were identified and treated by biological glue. Posterior atlantoaxial fixation was performed using a combination of atlantoaxial grafting and wiring.Temporary fixation using an occipital-C4 plate (Howmedica) was performed (Fig. 4) to reduce the need for external immobilisation (cervical brace only). On day 9, an infection secondary to an occipital pressure sore was diagnosed. Microbiological studies of cerebrospinal fluid obtained by lumbar puncture were negative. On day 11, a revision was performed, but the fixation material was left in place.The patient was discharged from the intensive care unit after 3 months. He was still on antibiotic therapy, but had no tracheotomy or evidence of local infection. He had a persistent neurological deficit in the left upper limb, shown by electromyography to be secondary to the brachial plexus stretching. There was no evidence of spinal cord injury.One year later, the occipito-cervical plates were removed. Range of motion in all planes was excellent and the patient was fully pain free. The residual neurological deficit in the left upper limb was very mild (muscle score at 4+). DiscussionWe found no similar case of vertical atlantoaxial dislocation in the literature [2,10]. Furthermore, our clinical case calls for comments regarding three important points, namely:1. Interpretation of the lesion-inducing process 2. Patient status and absence of medulla oblongata or spinal cord neurological signs 3. Surgical strategy Abstract An unusual case of vertical atlantoaxial dislocation without medulla oblongata or spinal cord injury is reported. The pathogenic process suggested occipito-axial dislocation. The case was treated surgically with excellent results on mobility and pain.