Abordaje translaminar

Abordaje translaminar

En 1998, Di Lorenzo et al. propuso un procedimiento directo menos invasivo utilizando un abordaje translaminar (TLA) a través de una fenestración de la pars interarticularis, evitando así una facetectomía o hemilaminectomía en muchos casos. La creciente disponibilidad de modalidades de imágenes de alta definición (MRI, CT) ha contribuido a la creciente popularidad del abordaje translaminar, ya que la identificación de la ubicación exacta y la extensión de la lesión espinal es crucial para la planificación quirúrgica para limitar daños biomecánicos innecesarios y prevenir la conversión intraoperatoria a un abordaje convencional.

Varios estudios han demostrado la viabilidad, seguridad y eficacia de esta técnica para tratar con éxito la hernia discal lumbar que afecta a la región foraminal y preforaminal 1) 2) 3) 4) 5) 6) 7).

Este abordaje es más efectivo que el estándar, porque resuelve los síntomas; se asocia con menos dolor postoperatorio y tiempos de recuperación más rápidos sin el riesgo de inestabilidad iatrogénica, y también se puede utilizar en casos con signos previos de inestabilidad radiográfica. La posibilidad de preservar el ligamento amarillo es una de las principales ventajas de esta técnica. Por estas razones, el abordaje translaminar es una técnica válida en términos de seguridad y eficacia. Vanni y cols., analizaron ampliamente la técnica destacando consejos y trucos 8).

Bibliografía

1)

Di Lorenzo N, Porta F, Onnis G, Cannas A, Arbau G, Maleci A. Pars interarticularis fenestration in the treatment of foraminal lumbar disc herniation: a further surgical approach. Neurosurgery. 1998 Jan;42(1):87-9; discussion 89-90. PubMed PMID: 9442508.

2)

Cossandi C, Fanti A, Gerosa A, Bianco A, Fornaro R, Crobeddu E, Forgnone S, Panzarasa G, Di Cristofori A. Translaminar approach for treatment of hidden zone foraminal lumbar disc herniations: considerations on the surgical technique and pre-operative selection of patients with a long term follow-up. World Neurosurg. 2018 May 18. pii: S1878-8750(18)31025-8. doi: 10.1016/j.wneu.2018.05.072. [Epub ahead of print] PubMed PMID: 29783010.

3)

Papavero L, Langer N, Fritzsche E, Emami P, Westphal M, Kothe R. The translaminar approach to lumbar disc herniations impinging the exiting root. Neurosurgery. 2008 Mar;62(3 Suppl 1):173-7; discussion 177-8. doi: 10.1227/01.neu.0000317389.83808.16. PubMed PMID: 18424983.

4) , 8)

Vanni D, Galzio R, Kazakova A, Guelfi M, Pantalone A, Salini V, Magliani V. Technical note: microdiscectomy and translaminar approach. J Spine Surg. 2015 Dec;1(1):44-9. doi: 10.3978/j.issn.2414-469X.2015.10.03. Review. PubMed PMID: 27683678; PubMed Central PMCID: PMC5039873.

5)

Vogelsang JP. The translaminar approach in combination with a tubular retractor system for the treatment of far cranio-laterally and foraminally extruded lumbar disc herniations. Zentralbl Neurochir. 2007 Feb;68(1):24-8. PubMed PMID: 17487805.

6)

Bernucci C, Giovanelli M. Translaminar microsurgical approach for lumbar herniated nucleus pulposus (HNP) in the “hidden zone”: clinical and radiologic results in a series of 24 patients. Spine (Phila Pa 1976). 2007 Jan 15;32(2):281-4. PubMed PMID: 17224827.

7)

Soldner F, Hoelper BM, Wallenfang T, Behr R. The translaminar approach to canalicular and cranio-dorsolateral lumbar disc herniations. Acta Neurochir (Wien). 2002 Apr;144(4):315-20. PubMed PMID: 12021876.

Update: Anterior cervical discectomy and fusion complications

Anterior cervical discectomy and fusion complications

A 2-page survey was distributed to attendees at the 2015 Cervical Spine Research Society (CSRS) meeting. Respondents were asked to categorize 18 anterior cervical discectomy and fusion-related adverse events as either: “common and acceptable,” “uncommon and acceptable,” “uncommon and sometimes acceptable,” or “uncommon and unacceptable.” Results were compiled to generate the relative frequency of these responses for each complication. Responses for each complication event were also compared between respondents based on practice location (US vs. non-US), primary specialty (orthopedics vs. neurosurgery) and years in practice.

Of 150 surveys distributed, 115 responses were received (76.7% response rate), with the majority of respondents found to be US-based (71.3%) orthopedic surgeons (82.6%). Wrong level surgery, esophageal injury, retained drain, and spinal cord injury were considered by most to be unacceptable and uncommon complications. Dysphagia and adjacent segment disease occurred most often, but were deemed acceptable complications. Although surgeon experience and primary specialty had little impact on responses, practice location was found to significantly influence responses for 12 of 18 complications, with non-US surgeons found to categorize events more toward the uncommon and unacceptable end of the spectrum as compared with US surgeons.

These results serve to aid communication and transparency within the field of spine surgery, and will help to inform future quality improvement and best practice initiatives 1).

Vocal cord palsy

Cervical adjacent segment disease

Hoarseness

Hoarseness, approximately in 5% 2).

Dysphagia

Soft tissue damage due to the use of automatic retractors in MACDF is not minor and leads to general discomfort in the patient in spite of good neurological results. These problems most often occur when automatic retractors are used continuously for more than 1 hour, as well as when they are used in multiple levels. Dysphagia, dysphonia and local pain decreased with the use of transient manual blades for retraction, and with intermittent release following minimally invasive principles 3).

Postoperative dysphagia is a significant concern.

Dexamethasone, although potentially protective against perioperative dysphagia and airway compromise, could inhibit fusion, a generally proinflammatory process.

Postoperative hemorrhage

Cerebrospinal fluid (CSF) leaks

Cerebrospinal fluid (CSF) leaks, although uncommon, may occur and can be a potentially serious complication. Little is known regarding the fusion rate after durotomy in ACDF.

In a single-institution retrospective review, 14 patients who experienced CSF leak after ACDF between 1995 and September 2014 were identified.

The median follow-up was 13.1 months. The diagnoses included spondylosis/degenerative disc disease (n = 10), disc herniation with radiculopathy (n = 3), and kyphotic deformity (n = 1). Of ACDFs, 7 were 1-level, 5 were 2-level, and 2 were 3-level procedures. The posterior longitudinal ligament was intentionally opened in all cases, and the microscope was used in 9 cases. Durotomy was discovered intraoperatively in all cases and was generally repaired with a combination of fibrin glue and synthetic dural replacement. Lumbar drainage was used in 5 patients, and 3 patients reported orthostatic headaches, which resolved within 1 month. Two patients reported hoarseness, and 8 patients reported dysphagia; all cases were transient. Follow-up imaging for fusion assessment was available for 12 patients, and a 100% fusion rate was achieved with no postoperative infections.

ACDFs with CSF leak had a 100% fusion rate in this series, with generally excellent clinical outcomes, although it is difficult to conclude definitively that there is no effect on fusion rates because of the small sample size. However, given the relative rarity of this complication, this study provides important data in the clinical literature regarding outcomes after CSF leak in ACDFs 4).

Pharyngoesophageal perforation

Spinal subdural hematoma

A spinal subdural hematoma is a rare clinical entity with considerable consequences without prompt diagnosis and treatment. Throughout the literature, there are limited accounts of spinal subdural hematoma formation following spinal surgery. This report is the first to describe the formation of a spinal subdural hematoma in the thoracic spine following surgery at the cervical level. A 53-year-old woman developed significant paraparesis several hours after anterior cervical discectomy and fusion of C5-6. Expeditious return to operating room for anterior cervical revision decompression was performed, and the epidural hematoma was evacuated without difficulty. Postoperative imaging demonstrated a subdural hematoma confined to the thoracic level, and the patient was returned to the operating room for a third surgical procedure. Decompression of T1-3, with evacuation of the subdural hematoma was performed. Postprocedure, the patient’s sensory and motor deficits were restored, and, with rehabilitation, the patient gained functional mobility. Spinal subdural hematomas should be considered as a rare but potential complication of cervical discectomy and fusion. With early diagnosis and treatment, favorable outcomes may be achieved 5).

Carotid artery compression

Legatt et al., report herein a case of anterior cervical discectomy and fusion (ACDF) surgery in which findings on somatosensory evoked potential(SSEP) monitoring led to the correction of carotid artery compression in a patient with a vascularly isolated hemisphere (no significant collateral blood vessels to the carotid artery territory). The amplitude of the cortical SSEP component to left ulnar nerve stimulation progressively decreased in multiple runs, but there were no changes in the cervicomedullary SSEP component to the same stimulus. When the lateral (right-sided) retractor was removed, the cortical SSEP component returned to baseline. The retraction was then intermittently relaxed during the rest of the operation, and the patient suffered no neurological morbidity. Magnetic resonance angiography demonstrated a vascularly isolated right hemisphere. During anterior cervical spine surgery, carotid artery compression by the retractor can cause hemispheric ischemia and infarction in patients with inadequate collateral circulation. The primary purpose of SSEP monitoring during ACDF surgery is to detect compromise of the dorsal column somatosensory pathways within the cervical spinal cord, but intraoperative SSEP monitoring can also detect hemispheric ischemia. Concurrent recording of cervicomedullary SSEPs can help differentiate cortical SSEP changes due to hemispheric ischemia from those due to compromise of the dorsal column pathways. If there are adverse changes in the cortical SSEPs but no changes in the cervicomedullary SSEPs, the possibility of hemispheric ischemia due to carotid artery compression by the retractor should be considered 6).

Heterotopic Ossification

Heterotopic ossification (HO) has been reported following total hip, knee, cervical arthroplasty, and lumbar arthroplasty, as well as following posterolateral lumbar fusion using recombinant human morphogenetic protein 2 (rhBMP-2). Data regarding HO following anterior cervical discectomy and fusion (ACDF) with rhBMP-2 are sparse. A subanalysis was done of the prospective, multicenter, investigational device exemption trial that compared rhBMP-2 on an absorbable collagen sponge (ACS) versus allograft in ACDF for patients with symptomatic single-level cervical degenerative disc disease.

To assess differences in types of HO observed in the treatment groups and effects of HO on functional and efficacy outcomes, clinical outcomes from previous disc replacement studies were compared between patients who received rhBMP-2/ACS versus allograft. Rate, location, grade, and size of ossifications were assessed preoperatively and at 24 months, and correlated with clinical outcomes. RESULTS Heterotopic ossification was primarily anterior in both groups. Preoperatively in both groups, and including osteophytes in the target regions, HO rates were high at 40.9% and 36.9% for the rhBMP-2/ACS and allograft groups, respectively (p = 0.350). At 24 months, the rate of HO in the rhBMP-2/ACS group was higher than in the allograft group (78.6% vs 59.2%, respectively; p < 0.001). At 24 months, the rate of superior-anterior adjacent-level Park Grade 3 HO was 4.2% in both groups, whereas the rate of Park Grade 2 HO was 19.0% in the rhBMP-2/ACS group compared with 9.8% in the allograft group. At 24 months, the rate of inferior-anterior adjacent-level Park Grade 2/3 HO was 11.9% in the rhBMP-2/ACS group compared with 5.9% in the allograft group. At 24 months, HO rates at the target implant level were similar (p = 0.963). At 24 months, the mean length and anteroposterior diameter of HO were significantly greater in the rhBMP-2/ACS group compared with the allograft group (p = 0.033 and 0.012, respectively). Regarding clinical correlation, at 24 months in both groups, Park Grade 3 HO at superior adjacent-level disc spaces significantly reduced range of motion, more so in the rhBMP-2/ACS group. At 24 months, HO negatively affected Neck Disability Index scores (excluding neck/arm pain scores), neurological status, and overall success in patients in the rhBMP-2/ACS group, but not in patients in the allograft group.

Implantation of rhBMP-2/ACS at 1.5 mg/ml with polyetheretherketone spacer and titanium plate is effective in inducing fusion and improving pain and function in patients undergoing ACDF for symptomatic single-level cervical degenerative disc disease. At 24 months, the rate and dimensions (length and anteroposterior diameter) of HO were higher in the rhBMP-2/ACS group. At 24 months, range of motion was reduced, with Park Grade 3 HO in both treatment groups. The impact of Park Grades 2 and 3 HO on Neck Disability Index success, neurological status, and overall success was not consistent among the treatment groups. The study data may offer a deeper understanding of HO after ACDF and may pave the way for improved device designs 7).

Subsidence

There is evidence documenting relatively frequent complications in stand-alone cage assisted ACDF, such as cage subsidence and cervical kyphosis 8).

Subsidence irrespective of the measurement technique or definition does not appear to have an impact on successful fusion and/or clinical outcomes. A validated definition and standard measurement technique for subsidence is needed to determine the actual incidence of subsidence and its impact on radiographic and clinical outcomes 9).


The results of a observational study were in accordance with those of the published randomized controlled trials (RCTs), suggesting substantial pain reduction both after anterior cervical interbody fusion (AIF) and Cervical total disc replacement, with slightly greater benefit after arthroplasty. The analysis of atypical patients suggested that, in patients outside the spectrum of clinical trials, both surgical interventions appeared to work to a similar extent to that shown for the cohort in the matched study. Also, in the longer-term perspective, both therapies resulted in similar benefits to the patients 10).

Case series

Analysis of 1000 consecutive patients undergoing Anterior cervical discectomy and fusion (ACDF) in an outpatient setting demonstrated surgical complications occur at a low rate (<1%) and can be appropriately diagnosed and managed in 4-hour ASC PACU window. Comparison with inpatient ACDF surgery cohort demonstrated similar results, highlighting that ACDF can be safely performed in an outpatient ambulatory surgery setting without compromising surgical safety. To decrease cost of care, surgeons can safely consider performing 1- and 2-level ACDF in an ASC environment 11).


A retrospective case series of 37 patients, paying special attention to immediate complications related to the use of mechanical retraction of soft tissue (dysphagia, dysphonia, esophageal lesions and local hematoma); and a comparative analysis of the outcomes after changes in the retraction method.

All selected cases had a positive neurological symptom response in relation to neuropathic pain. Dysphagia and dysphonia were found during the first 72 h in 94.1% of the cases in which automatic mechanical retraction was used for more than one hour during the surgical procedure. A radical change was noted in the reduction of the symptoms after the use of only manual protective blades without automatic mechanical retraction: 5.1% dysphagia and 0% dysphonia in the immediate post-operative period, P = 0.001.

Soft tissue damage due to the use of automatic retractors in MACDF is not minor and leads to general discomfort in the patient in spite of good neurological results. These problems most often occur when automatic retractors are used continuously for more than 1 hour, as well as when they are used in multiple levels. Dysphagia, dysphonia and local pain decreased with the use of transient manual blades for retraction, and with intermittent release following minimally invasive principles 12).

1)

Wilson JR, Radcliff K, Schroeder G, Booth M, Lucasti C, Fehlings M, Ahmad N, Vaccaro A, Arnold P, Sciubba D, Ching A, Smith J, Shaffrey C, Singh K, Darden B, Daffner S, Cheng I, Ghogawala Z, Ludwig S, Buchowski J, Brodke D, Wang J, Lehman RA, Hilibrand A, Yoon T, Grauer J, Dailey A, Steinmetz M, Harrop JS. Frequency and Acceptability of Adverse Events After Anterior Cervical Discectomy and Fusion: A Survey Study From the Cervical Spine Research Society. Clin Spine Surg. 2018 Apr 27. doi: 10.1097/BSD.0000000000000645. [Epub ahead of print] PubMed PMID: 29708891.
2)

Morpeth JF, Williams MF. Vocal fold paralysis after anterior cervical diskectomy and fusion. Laryngoscope. 2000 Jan;110(1):43-6. PubMed PMID: 10646714.
3) , 12)

Ramos-Zúñiga R, Díaz-Guzmán LR, Velasquez S, Macías-Ornelas AM, Rodríguez-Vázquez M. A microsurgical anterior cervical approach and the immediate impact of mechanical retractors: A case control study. J Neurosci Rural Pract. 2015 Jul-Sep;6(3):315-9. doi: 10.4103/0976-3147.158748. PubMed PMID: 26167011; PubMed Central PMCID: PMC4481782.
4)

Elder BD, Theodros D, Sankey EW, Bydon M, Goodwin CR, Wolinsky JP, Sciubba DM, Gokaslan ZL, Bydon A, Witham TF. Management of Cerebrospinal Fluid Leakage During Anterior Cervical Discectomy and Fusion and Its Effect on Spinal Fusion. World Neurosurg. 2015 Nov 30. pii: S1878-8750(15)01588-0. doi: 10.1016/j.wneu.2015.11.033. [Epub ahead of print] PubMed PMID: 26654925.
5)

Protzman NM, Kapun J, Wagener C. Thoracic spinal subdural hematoma complicating anterior cervical discectomy and fusion: case report. J Neurosurg Spine. 2015 Oct 13:1-5. [Epub ahead of print] PubMed PMID: 26460756.
6)

Legatt AD, Laarakker AS, Nakhla JP, Nasser R, Altschul DJ. Somatosensory evoked potential monitoring detection of carotid compression during ACDF surgery in a patient with a vascularly isolated hemisphere. J Neurosurg Spine. 2016 Nov;25(5):566-571. PubMed PMID: 27285667.
7)

Arnold PM, Anderson KK, Selim A, Dryer RF, Kenneth Burkus J. Heterotopic ossification following single-level anterior cervical discectomy and fusion: results from the prospective, multicenter, historically controlled trial comparing allograft to an optimized dose of rhBMP-2. J Neurosurg Spine. 2016 Sep;25(3):292-302. doi: 10.3171/2016.1.SPINE15798. Epub 2016 Apr 29. PubMed PMID: 27129045.
8)

Cloward RB: The anterior approach for removal of ruptured cervical disks. 1958. J Neurosurg Spine 6:496-511, 2007
9)

Karikari IO, Jain D, Owens TR, Gottfried O, Hodges TR, Nimjee SM, Bagley CA. Impact of Subsidence on Clinical Outcomes and Radiographic Fusion Rates in Anterior Cervical Discectomy and Fusion: A Systematic Review. J Spinal Disord Tech. 2014 Feb;27(1):1-10. PubMed PMID: 24441059.
10)

Staub LP, Ryser C, Röder C, Mannion AF, Jarvik JG, Aebi M, Aghayev E. Total disc arthroplasty versus anterior cervical interbody fusion: use of the spine tango registry to supplement the evidence from RCTs. Spine J. 2015 Dec 7. pii: S1529-9430(15)01763-5. doi: 10.1016/j.spinee.2015.11.056. [Epub ahead of print] PubMed PMID: 26674445.
11)

McGirt MJ, Mehrlich M, Parker SL, Asher AL, Adamson TE. 165 ACDF in the Outpatient Ambulatory Surgery Setting: Analysis of 1000 Consecutive Cases and Comparison to Hospital Inpatient ACDF. Neurosurgery. 2015 Aug;62 Suppl 1:220. doi: 10.1227/01.neu.0000467129.12773.a3. PubMed PMID: 26182011.

Ursodeoxycholic acid

Ursodeoxycholic acid

Tauroursodeoxycholic acid (TUDCA) is the taurine conjugate of ursodeoxycholic acid (UDCA), a US Food and Drug Administration-approved hydrophilic bile acid for the treatment of certain cholestatic liver diseases. There is a growing body of research on the mechanism(s) of TUDCA and its potential therapeutic effect on a wide variety of non-liver diseases. Both UDCA and TUDCA are potent inhibitors of apoptosis, in part by interfering with the upstream mitochondrial pathway of cell death, inhibiting oxygen-radical production, reducing endoplasmic reticulum (ER) stress, and stabilizing the unfolded protein response (UPR). Several studies have demonstrated that TUDCA serves as an anti-apoptotic agent for a number of neurodegenerative diseases, including amyotrophic lateral sclerosisAlzheimer’s diseaseParkinson’s disease, and Huntington’s disease. In addition, TUDCA plays an important role in protecting against cell death in certain retinal disorders, such as retinitis pigmentosa. It has been shown to reduce ER stress associated with elevated glucose levels in diabetes by inhibiting caspase activation, up-regulating the UPR, and inhibiting reactive oxygen species. Obesity, stroke, acute myocardial infarction, spinal cord injury, and a long list of acute and chronic non-liver diseases associated with apoptosis are all potential therapeutic targets for T/UDCA. A growing number of pre-clinical and clinical studies underscore the potential benefit of this simple, naturally occurring bile acid, which has been used in Chinese medicine for more than 3000 years 1).


Ursodeoxycholic acid (UDCA) inhibits the pro-inflammatory responses by lipopolysaccharide (LPS) in RAW 264.7 macrophages. UDCA also suppresses the phosphorylation by LPS on extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinase (JNK), and p38 in MAPKs and NF-κB pathway. These results suggest that UDCA can serve as a useful antiinflammatory drug 2).


The aim of a study was to investigate the anti-inflammatory effects by ursodeoxycholic acid (UDCA) in rats with a spinal cord injury (SCI). A moderate mechanical compression injury was imposed on adult Sprague-Dawley (SD) rats. The post-injury locomotor functions were assessed using the Basso, Beattie, and Bresnahan (BBB) locomotor scale and the tissue volume of the injured region was analyzed using hematoxylin and eosin staining. The pro-inflammatory factors were evaluated by immunofluorescence (IF) staining, a quantitative real-time polymerase chain reaction (qRT-PCR), and enzyme-linked immunosorbent assay (ELISA). The phosphorylation of the extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinase (JNK), and p38 in mitogen-activated protein kinase (MAPK) signaling pathways related to inflammatory responses were measured by Western blot assays. UDCA improved the BBB scores and promoted the recovery of the spinal cord lesions. UDCA inhibited the expression of glial fibrillary acidic protein (GFAP), tumor necrosis factor-α (TNF-α), ionized calcium-binding adapter molecule 1 (iba1), and inducible nitric oxide synthase (iNOS). UDCA decreased the pro-inflammatory cytokines of TNF-α, interleukin 1-β (IL-1β), and interleukin 6 (IL-6) in the mRNA and protein levels. UDCA increased the anti-inflammatory cytokine interleukin 10 (IL-10) in the mRNA and protein levels. UDCA suppressed the phosphorylation of ERK, JNK, and the p38 signals. UDCA reduces pro-inflammatory responses and promotes functional recovery in SCI in rats. These results suggest that UDCA is a potential therapeutic drug for SCI 3).

1)

Vang S, Longley K, Steer CJ, Low WC. The Unexpected Uses of Urso- and Tauroursodeoxycholic Acid in the Treatment of Non-liver Diseases. Glob Adv Health Med. 2014 May;3(3):58-69. doi: 10.7453/gahmj.2014.017. Review. PubMed PMID: 24891994; PubMed Central PMCID: PMC4030606.
2)

Ko WK, Lee SH, Kim SJ, Jo MJ, Kumar H, Han IB, Sohn S. Anti-inflammatory effects of ursodeoxycholic acid by lipopolysaccharide-stimulated inflammatory responses in RAW 264.7 macrophages. PLoS One. 2017 Jun 30;12(6):e0180673. doi: 10.1371/journal.pone.0180673. eCollection 2017. PubMed PMID: 28665991; PubMed Central PMCID: PMC5493427.
3)

Ko WK, Kim SJ, Jo MJ, Choi H, Lee D, Kwon IK, Lee SH, Han IB, Sohn S. Ursodeoxycholic Acid Inhibits Inflammatory Responses and Promotes Functional Recovery After Spinal Cord Injury in Rats. Mol Neurobiol. 2018 Mar 20. doi: 10.1007/s12035-018-0994-z. [Epub ahead of print] PubMed PMID: 29691718.