SURGERY OF COMPLEX SPINAL PATHOLOGIES—MANAGEMENT ISSUES
Dr K SRIDHAR

The surgery on the spine is still in many parts of the world, a matter of controversy, with both the public and the medical community associating it with a poor outcome. Most surgical approaches were limited to posterior laminectomy for a wide range of conditions. However, with technological advancement and availability of better modalities of radio-diagnosis, better knowledge of the biomechanics of the spine and the use of Microsurgery, spinal surgery has now become a very sophisticated specialty offering excellent results. New approaches have been devised and with the use of microsurgical techniques, many spinal pathologies are now being dealt with safety and with minimal morbidity.

Some of the conditions that are being routinely dealt with are disc pathologies, spondylosis and Spondylolisthesis, OPLL, Caries spine, Fracture spine, spinal tumours, etc., With advent of better techniques and the availability of good implants for spinal stabilization, it is possible to mobilize the patient early. For example, now all cervical disc pathologies are approached anteriorly with less tissue handling and bleeding with shortened hospital stay. For lumbar disc pathologies, laminectomy has given way to microsurgical fenestration, which does not involve removal of bone. Following surgery patients are mobilized the same day and are discharged on the second or third day. Artificial discs and spacers have been introduced recently in an attempt to restore the natural anatomy following disc excision. Anterior pathologies involving the vertebral bodies are now being routinely dealt with by corpectomy which is done by the anterior cervical, transclavicular, or trans -thoracic or retroperitoneal approaches depending on the level of involvement. The experience gained over the years in these surgeries and the knowledge and use of different implant systems has allowed surgeons to undertake surgery of complex spinal problems with reasonably good results.

Surgery on the spine is performed to decompress the spinal cord and or nerve roots, and to reconstruct the spinal column which has been disrupted either due to pathology or because of surgery. Experience with spinal microsurgery has enabled us to approach lesions with minimal disruption of the spinal column. We now know that the stability of the spine is not dependent solely on the integrity of the spinal column but also on the functional capabilities of the paraspinal muscles and the ligaments of the spine, which participate in the “Flag pole” concept of spinal stability. This, along with experience with implant systems has encouraged more difficult reconstructions. These two factors have allowed us to undertake the management of certain complex pathologies, from which we have gained furthur knowledge and experience. We would like to share these experiences with you. The problems faced in these special complex cases are in the diagnosis and approach to the lesions, as well as in the reconstruction of the spine.

Case no I
A 36 year old male presented with persistent neck pain following a road traffic accident. A month later he started developing stiffness of all 4 limbs. The x-ray of the cervical spine was reported as normal. The MRI scan showed a C7-T1 total dislocation with pressure on the cord from both anterior and posterior. (Fig 1)

He was operated in a single stage anesthesia. Under skull traction, a posterior approach was first utilized to release the facets at C7-T1. The posterior elements of T1 were found to be floating and these were removed. The patient was then turned supine and through a classical anterior cervical approach and a trans-clavicular trans-sternal extention, corpectomy of T1 was done along with discectomy of the adjacent levels. The gap was bridged by a tricorticate bone graft, and stabilization was performed using an anterior monocortical locking cervical plating system. The patient was once again turned prone and a posterior fusion and stabilization was done using Hartshill rectangle and wires. Thus the spinal cord was decompressed and a 3600 stabilisation was done . (Fig 2)

The patient was mobilized on the 8th postoperative day and was discharged without any fresh deficits. The patient is asymptomatic at one year follow up and the radiology is showing good fusion and proper implant position.

Cervico-thoracic dislocations are notorious for being missed as the region is poorly visualized on plain lateral radiographs. Persistent pain or the development of neurological deficit is often the only indicator of a pathology, unless carefully looked for in the AP radiograph. The MR scans will clearly delineate these dislocations which may be complete with spondyloptosis. These patients require careful handling, as the region is difficult to immobilize even with skull traction. In most instances reduction does not take place and it is necessary to decompress the cord and stabilise the spine from both anterior and posterior.

Case 2 : (Fig 3,4)
A 5 year old girl presented with a spinal deformity and spastic paraparesis of recent onset. The deformity was extensive and there was a dysraphic state of the entire lumbar spine. The posterior elements were absent from L1 to S1, and the lateral ends of the rudimentary pedicles were both visualized and palpable through the skin due to the gross kyphosis. The radiology revealed the extent of the deformity and the associated abnormalities. The conus was stretched over the hump of the internal gibbus at L1-L2. The management problems of this child are discussed in the presentation including the problems of instrumentation in children.

Case 3:
A 45 year old man underwent lithotripsy under spinal anesthesia. He complained of persistent back pain following the procedure. An x-ray was taken and was reported normal and he was put on analgesics and bed rest. As he did not find relief and as pain worsened, the x-rays were repeated and an MR was done. These showed signal changes in the vertebral bodies and disc spaces indicative of infective discitis and spondylitis. There was also evidence of root pressure at multiple levels. He was operated upon to no avail. He presented to us at this stage with severe pain and radiology showing active infective spondylitis, with gross deformity.(Fig 5) The issues in management were the role of surgery in the management of the patient, whether or not instrumentation was indicated, what should be done for the gross deformity. We performed a relaminectomy and removed all seen infected material from the spinal canal, releasing the nerve roots and clearing all sequestra and debris. The patient was placed on complete bed rest and antibiotics. He gradually improved and the infection disappeared with healing of the bone. He has since been mobilized and is doing well.