There have been a few reports of patients with
a combination of lumbar and thoracic spinal stenosis. We describe six
patients who suffered unexpected acute neurological deterioration
at a mean of 7.8 days (6 to 10) after lumbar decompressive surgery.
Five had progressive weakness and one had recurrent pain in the
lower limbs. There was incomplete recovery following subsequent
thoracic decompressive surgery. The neurological presentation can be confusing. Patients with
compressive myelopathy due to lower thoracic lesions, especially
epiconus lesions (T10 to T12/L1 disc level), present with similar
symptoms to those with lumbar radiculopathy or cauda equina lesions.
Despite the rarity of this condition we advise that patients who
undergo lumbar decompressive surgery for stenosis should have sagittal
whole spine MRI studies pre-operatively to exclude proximal neurological
compression. Cite this article:
There have been few reports regarding the efficacy
of posterior instrumentation alone as surgical treatment for patients
with pyogenic spondylitis, thus avoiding the morbidity of anterior
surgery. We report the clinical outcomes of six patients with pyogenic
spondylitis treated effectively with a single-stage posterior fusion
without anterior debridement at a mean follow-up of 2.8 years (2
to 5). Haematological data, including white cell count and level
of C-reactive protein, returned to normal in all patients at a mean
of 8.2 weeks (7 to 9) after the posterior fusion. Rigid bony fusion
between the infected vertebrae was observed in five patients at
a mean of 6.3 months (4.5 to 8) post-operatively, with the remaining
patient having partial union. Severe back pain was immediately reduced
following surgery and the activities of daily living showed a marked
improvement. Methicillin-resistant Single-stage posterior fusion may be effective in patients with
pyogenic spondylitis who have relatively minor bony destruction.
We have analysed a number of radiological measurements in an attempt to clarify the predisposing factors for degenerative spondylolisthesis of the lumbosacral junction. We identified 57 patients with a slip and a control group of 293 patients without any radiological abnormality apart from age-related changes. The relative thickness of the L5 transverse process, the sacral table angle and the height of the iliac crest were measured and evaluated. The difference in these measurements between men and women was analysed in the control group. We found that the transverse process of L5 was extremely slender, the sacral table more inclined, and the L5 vertebra was less deeply placed in the pelvis in patients with a slip compared with the control group. The differences in these three parameters were statistically significant. We believe that the L5 vertebra is predisposed to slip when these factors act together on a rigidly-stabilised sacrum. This occurs more commonly in women, probably as a result of constitutional differences in the development of the male and female spine.
Multiple thoracic disc herniations are rare and there are few reports in the literature. Between December 1998 and July 2002, we operated on 12 patients with multiple thoracic disc herniations. All underwent an anterior decompression and fusion through a transthoracic approach. The clinical outcomes were assessed using the Frankel neurological classification and the Japanese Orthopaedic Association (JOA) score. Under the Frankel classification, two patients improved by two grades (C to E), one patient improved by one grade (C to D), while nine patients who had been classified as grade D did not change. The JOA scores improved significantly after surgery with a mean recovery rate of 44.8% ± 24.5%. Overall, clinical outcomes were excellent in two patients, good in two, fair in six and unchanged in two. Our results indicate that anterior decompression and fusion for multiple thoracic disc herniations through a transthoracic approach can provide satisfactory results.
Surgical intervention is rarely indicated in the osteoporotic patient with compression fractures and kyphosis. In rare instances, the vertebral fracture is of the burst type, with spinal canal compromise and neurologic deficits, including paraplegia. These patients must be considered for surgical intervention. Reconstruction of such a spine poses technical challenges, because of concerns about adequacy of fixation and source of autogenous bone which is also osteoporotic. In addition, these patients frequently have serious medical conditions that increase the possibility of perioperative complications. Spinal shortening is a surgical procedure in which circumferential resection of vertebra is followed by closure of two adjacent vertebrae and fusion. It is mechanically more stable than augumentative spinal reconstruction and needs less bone graft. Eight spinal shortenings were performed in eight patients for the treatment of paralysis due to osteoporotic vertebral collapse. Patients are ranged from 68 to 83 (average 74 years). Affected vertebrae were L1 in four, Th12 in three and Th9 in one case. After bone resection of affected vertebra from posteriorly through transpedicular route, shortening and correction of kyphosis was performed. Osteotomy was fixed by long segment instrumentation and short segment bone graft with Hartshill rectangular rod, sublaminar wiring and laminectomized local bone. Paraparesis which was present before surgery disappeared and spinal stability was obtained. Bony union was observed after six months. Surgical complication was seen in one case with hepatisis. A massive bleeding necessitating clamp of drain tube saved her life in the expense of neurological deterioration. We now consider this patient was out of indication for spinal shortening. With the follow-ups ranged from 9 to 36 months (average 19 months), neural function was preserved. It was concluded that spinal shortening using instrumentation is a safe and effective procedure for the treatment of osteoporotic vertebral collapse with paralysis.
