Object In this paper the authors evaluate through in vitro biomechanical testing the performance of an interspinous fusion device as a stand-alone device, after lumbar decompression surgery, and as supplemental fixation to expandable cages in a posterior lumbar interbody fusion (PLIF) construct. Methods Nine L3–4 human cadaveric spines were biomechanically tested under the following conditions: 1) intact/control; 2) L3–4 left hemilaminotomy with partial discectomy (injury); 3) interspinous spacer (ISS); 4) bilateral pedicle screw system (BPSS); 5) bilateral hemilaminectomy, discectomy, and expandable posterior interbody cages with ISS (PLIF-ISS); and 6) PLIF-BPSS. Each test consisted of 100 N of axial preload with ± 7.5 Nm of torque in flexion-extension, right/left lateral bending, and right/left axial rotation. Significant changes in range of motion (ROM), neutral zone stiffness (NZS), elastic zone stiffness (EZS), and energy loss (EL) were explored among conditions using nonparametric Friedman test and Wilcoxon signed-rank comparisons (p ≤ 0.05). Results The injury increased ROM in flexion (p = 0.01), left bending (p = 0.03), and right/left rotation (p < 0.01) and also decreased NZS in flexion (p = 0.01) and extension (p < 0.01). Both the ISS and BPSS reduced flexion-extension ROM and increased flexion-extension stiffness (NZS and EZS) with respect to the injury and intact conditions (p < 0.05), but the ISS condition provided greater resistance than BPSS in extension for ROM, NZS, and EZS (p < 0.01). The BPSS increased the rigidity (ROM, NZS, and EZS) of the intact model in lateral bending and axial rotation (p ≤ 0.01), except in EZS for left rotation (p = 0.23, Friedman test). The incorporation of posterior cages marginally increased (p = 0.05) the EZS of the BPSS construct in flexion but these interbody devices provided significant stability to the ISS construct in lateral bending and axial rotation for ROM (p = 0.02), in lateral bending for NZS (p = 0.02), and in flexion/axial rotation for EZS (p ≤ 0.03); however, both PLIF constructs demonstrated equivalent ROM and stiffness (p ≥ 0.16), except in lateral bending where the PLIF-BPSS was more stable (p = 0.02). In terms of EL, the injury increased EL in flexion-extension (p = 0.02), the ISS increased EL for lateral bending and axial rotation (p ≤ 0.03), and the BPSS decreased EL in lateral bending (p = 0.02), with respect to the intact condition. The PLIF-ISS decreased lateral bending EL with respect to the ISS condition (p = 0.02), but not enough to be smaller or, at least, equivalent, to that of the PLIF-BPSS construct (p = 0.02). Conclusions The ISS may be a suitable device to provide immediate flexion-extension balance after a unilateral laminotomy, but the BPSS provides greater immediate stability in lateral bending and axial rotation motions. Both PLIF constructs performed equivalently in flexion-extension and axial rotation, but the PLIF-BPSS construct is more resistant to lateral bending motions. Further biomechanical and clinical evidence is required to strongly support the recommendation of a stand-alone interspinous fusion device or as supplemental fixation to expandable posterior interbody cages.

The establishment of this animal tumor model will facilitate the testing of new therapeutic paradigms for the treatment of BSTs.

Study Design:Retrospective consecutive case series.Objective:The objective of this case series was to demonstrate the safety of a modified transfacet pedicle–sparing decompression and instrumented fusion in patients with thoracic disc herniations (TDHs).Methods:Consecutive patients undergoing operative management of TDH from July 2007 to December 2011 using a posterior unilateral modified transfacet pedicle–sparing approach were identified. All patients underwent open or minimally invasive modified transfacet pedicle–sparing discectomy and segmental instrumentation with interbody fusion, performed by four different surgeons. Pre- and postoperative visual analog scale (VAS) pain scores, Nurick grade, and American Spinal Injury Association Impairment Scale (AIS) were analyzed from a retrospective chart review. Estimated blood loss and complications were also obtained.Results:Fifty-one patients were included that had operations for TDH. Thirty-nine patients had single level decompression and 12 had multilevel decompression. The total number of levels operated on was 64. Five patients were treated with minimally invasive surgery. A herniated disc level of T11-12 (n = 17) was treated most often. One major complication of epidural hematoma occurred. Minor complications such as malpositioned hardware, postoperative hematoma, wound infection, pseudoarthrosis, and pulmonary complications occurred in a few patients. Follow-up ranged from 1 to 46 months with 1 patient lost to follow-up. From preoperative to final postoperative: mean VAS scores improved from 8.31 to 4.05, AIS in all patients remained stable or improved, and Nurick scores improved from 3 to 2.6 on average. No intraoperative or permanent neurological deficit occurred.Conclusion:In our surgical series, 51 consecutive patients underwent modified transfacet pedicle–sparing approach to TDHs and experienced improvement of functional status as well as improvement of objective pain scales with no neurological complications. The posterior unilateral modified transfacet pedicle–sparing decompression and instrumented fusion approach to the thoracic spine is a safe and reproducible procedure for the treatment of TDHs.

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Background Advancements in cancer treatment have led to more cases of leptomeningeal disease, which requires a multimodal approach. Methods Treatment modalities are reviewed from a neurosurgical standpoint, focusing on intrathecal chemotherapy and shunting devices. Potential complications and how to avoid them are discussed. Results The Ommaya reservoir and the chemoport are used for administering intrathecal chemotherapy. Use of ventriculo-lumbar perfusion can efficiently deliver chemotherapeutic agents and improve intracerebral pressure. Shunting systems, in conjunction with all of their variations, address the challenge of hydrocephalus in leptomeningeal carcinomatosis. Misplaced catheters, malfunction of the system, and shunt-related infections are known complications of treatment. Conclusions From an oncological perspective, the surgical treatment for leptomeningeal disease is limited; however, neurosurgery can be used to aid in the administration of chemotherapy and address the issue of hydrocephalus. Minimizing surgical complications is important in this sensitive patient population.

Tophaceous gout has classically been described as an affliction of the extremities. It has however been reported as early as 1947 to involve the spinal column. We report a 63-year-old male, previously scheduled for Anterior Cervical Discectomy and Fusion to correct an existing cervical myelopathy at the C3-C4 spinal level, who presented to the emergency room with progressive weakness of the lower extremities and inability to ambulate for three days. Physical examination suggested a possible worsening of his cervical myelopathy but magnetic resonance imaging (MRI) findings remained unchanged from comparison studies. On the day of surgery, he became febrile and complained of excruciating back pain and we therefore initiated an infectious etiology workup and obtained a lumbar spine MRI. Results of imaging suggested a lumbar epidural abscess with effacement of the thecal sac. Emergent L4-L5 decompression led to an evacuation of a "chalky" substance, which was sent for pathology evaluation. This patient was diagnosed with tophaceous gout of the lumbar spine upon final pathological review. We aim to present the management of this case and review the literature associated with this diagnosis with the goal of improving the approach taken to diagnose and treat this pathology. KeywOrds: Epidural abscess, Spinal gout, Spinal stenosis, Tophaceous gout, Spinal infection ÖZTofüslü gut, klasik olarak ekstremitelerin hastalığı olarak tanımlanmakla birlikte 1947 yılında omurganın da tutulumu rapor edilmiştir. Bu olgu sunumunda C3-C4 seviyesinde servikal miyelopati nedeniyle anterior servikal diskektomi ve füzyon planlanan ancak acil servise alt ekstremitelerde progresif güç kaybı ve 3 gündür yürüyememe şikayeti ile başvuran 63 yaşında erkek hastayı sunuyoruz. Fizik muayene hastanın servikal miyelopatisinde muhtemel bir ilerlemeyi işaret ediyordu ancak manyetik rezonans görüntüleme (MRG) bulgularında bir değişiklik olmadığı görüldü. Ameliyat günü hastanın ateşi çıktı ve bel ağrısı ön plana çıktı. Bunun üzerine hastada enfeksiyon kaynağı araştırılmaya başlandı ve lomber spinal MRG yapıldı. Görüntülemenin sonucunda lomber spinal epidural apse ve dural kesede bası tesbit edildi. Acil L4-L5 dekompresyon yapıldı ve tebeşir renkli materyal boşaltılarak patolojik inceleme için gönderildi. Patolojik inceleme sonucunda hastada lomber omurgada tofüslü gut tanısı konuldu. Makalemizde bu olgunun yönetimini sunmayı amaçladık ve ilgili literatürü tanı ve tedavideki yaklaşımı kolaylaştırmak için taradık.

Biventricular hydrocephalus caused by a Giant Basilar Apex Aneurysm (GBAA) is a rare finding that presents unique and challenging treatment decisions. We report a case of GBAA causing a life-threatening biventricular hydrocephalus in which both the aneurysm and hydrocephalus were given definitive treatment through a staged, minimally invasive approach.An obtunded 82-year-old male was found to have biventricular hydrocephalus caused by an unruptured GBAA obstructing the foramina of Monro. The patient was treated via staged, minimally invasive technique that first involved endoscopic fenestration of the septum pellucidum to create communication between the lateral ventricles. A programmable ventriculo-peritoneal shunt was then placed with a high-pressure setting. The patient was then loaded with dual anti-platelet therapy prior to undergoing endovascular coiling of the GBAA with adjacent stenting of the Posterior Cerebral Artery. He remained on dual anti-platelet therapy and the shunt setting was lowered at the bedside to treat the hydrocephalus. At 6-month follow up, the patient had returned to his cognitive baseline, speaking fluently and appropriately.Biventricular hydrocephalus caused by a GBAA can successfully be treated in a minimally invasive fashion utilizing a combination of endoscopy and endovascular therapy, even when a stent-assisted coiling is needed. KEywoRds: Coil embolization, Endoscopy, Endovascular, Giant aneurysm, Obstructive hydrocephalus ÖZDev Baziller Apeks Anevrizmasının (GBAA) neden olduğu biventriküler hidrosefali nadir bir bulgudur. Tedavi kararları eşsiz ve zordur. Hem anevrizma hem hidrosefalinin, minimal invaziv yaklaşımla kademeli olarak kesin tedavi edildiği; yaşamı tehdit edici bir biventriküler hidrosefaliye neden olan GBAA olgusu sunuldu.Zihinsel olarak donuk, 82 yaşında bir erkekte, Monro foramenini tıkayan rüptüre olmamış bir GBAA nedeniyle biventriküler hidrosefali bulundu. Hasta kademeli, minimal invaziv bir teknikle tedavi edildi ve önce lateral ventriküller arasında geçiş oluşturmak üzere septum pellusidumun endoskopik fenestrasyonu yapıldı. Sonra yüksek basınçlı ortamda programlanabilir bir ventriküloperitoneal şant yerleştirildi. GBAA'ya endovasküler sarmal yerleştirme ve yanında posterior serebral artere stent konulması öncesinde hastaya ikili antitrombosit tedavi yüklendi. İkili antitrombosit tedaviye devam edildi ve hidrosefaliyi tedavi etmek üzere şant ayarı yatak yanında azaltıldı. 6 aylık takipte hasta kognitif olarak başlangıç durumuna dönmüştü ve akıcı ve uygun bir şekilde konuşuyordu.GBAA'nın neden olduğu biventriküler hidrosefali, stent yardımlı sarmal yerleştirilmesi gerektiği zaman bile, endoskopi ve endovasküler tedavinin bir kombinasyonu kullanılarak minimal invaziv şekilde başarıyla tedavi edilebilir.

Aim. To study the characteristics of the quantitative and qualitative characteristics of bone mineral density in women. Materials and methods. Quantitative computed tomography with additional quantitative and qualitative assessments was performed in 127 women of different ages without clinical signs of osteoporosis. Results. We had calculated the size and the ratio of cortical bone and spongy tissue at the lumbar vertebrae considering the density range characterized as the maximum and minimum of mineralized areas that represent not only quantitative but also qualitative state of the bone tissue. Conclusions. The obtained data can be used to assess the changes in the quality of bone in osteoporosis and osteopenia.