Tsivyan’s Surgery of the Spine

Objective. To identify factors leading to the loss of correction and re-dislocation of the vertebrae after isolated anterior reconstruction and stabilization in the surgical treatment of subaxial cervical dislocations.

Material and Methods. A retrospective cohort STROBE-type study was carried out using data of 175 patients with dislocations of vertebrae in the subaxial cervical spine who were operated on in 2010–2019. The key parameters of the study were the relevant indices of the cervical sagittal balance and morphological characteristics of the injury: thoracic inlet angle (TIA), T1 vertebra slope, neck tilt, regional cervical C2–C7 lordosis, fracture of the vertebral body, and fracture of the articular process at the level of dislocation. Statistical analysis of the obtained data was carried out in the RStudio program.

Results. At preoperative TIA value of 74.5°, the risk of correction loss corresponds to 28 %. In the group with TIA < 74.5° and that with TIA ≥ 74.5°, the risk of correction loss is 17.3 % (95 % CI: 7–37 %) and 85.7 % (95 % CI: 60–96 %), respectively. With an increase in TIA by 10°, the chance of recurrence increases by 23.3 times. The effect of the articular process fracture  on the loss of correction is equivalent to an increase in TIA by 10°, namely, it increases the chance of recurrence by 20.7 times. The parameter “duration of injury” has an effect on the loss of correction, but it is statistically insignificant (p > 0.05).

Conclusion. The parameter of the cervical sagittal balance, thoracic inlet angle, as well as the fracture of the articular process at the level of injury are statistically significant factors that determine the initial stability in isolated anterior surgical reconstruction and stabilization of the lower cervical spine for Allen type 3 flexion-distraction injuries.

Objective. To identify key organizational factors that determine the effectiveness of the system for delivering medical care to victims with acute spinal cord injury in the setting of large constituent entity of the Russian Federation, and to develop appropriate proposals for improving the national clinical guidelines.

Material and Methods. The study included data on 2,283 patients with acute spinal cord injury who were treated within the framework of three successively existed organizational models of the health care delivery system: I – decentralized unprofiled (306 patients); II – decentralized profiled (454 patients); and III – centralized profiled (1523 patients). Using the methods of nonparametric statistics, the medical and statistical indicators were compared in patients examined when evaluating the results of treatment: 44, 75 and 148 patients from each organizational model, respectively (p > 0.05).

Results. The effectiveness of the treatment of victims with acute spinal cord injury depends on the interaction of organizational factors that determine the structure and operation of the health care system at the level of the federation subject as a whole (centralization factor) and at the level of the relevant hospital (profiling factor). Specialized departments/centers for emergency spine surgery housed by multidisciplinary emergency hospitals – level I trauma centers (profiling factor) operate to maximum effect only when a centralized model of health care is organized in the subject of the federation (centralization factor).

Conclusion. Within the framework of national clinical guidelines for the treatment of patients with acute spinal cord injury, the principles of their routing and the requirements to be met by the involved hospitals should be clearly regulated.

Objective. To analyze the efficacy of posterior and anterior multilevel vertebrotomy in adolescents with Lenke type 1 and 2 idiopathic scoliosis operated on using pedicle screw and hybrid instrumentation with varying implant density (ID).

Material and Methods. The immediate and long-term results of surgical treatment of 271 adolescents with Lenke type 1 or 2 idiopathic scoliosis (with primary thoracic curve) operated on using one of three surgical techniques: instrumental correction and posterior fusion (n = 212), the same technique supplemented with discectomy and interbody fusion (n = 30), and that with posterior vertebrotomy (n = 29). In all three groups, the relationship between age, initial Cobb angle, mobility, ID, and treatment outcomes assessed using X-ray data and SRS-24 questionnaire was studied, including the construction of linear regression models.

Results. In all groups, significant predictors of deformity correction were initial Cobb angle and ID, while the indicators of mobility and age did not demonstrate significance. The study showed no effect of anterior and posterior vertebrotomy on the magnitude of correction and its maintenance in the long-term period, as well as on the patient-reported outcomes (SRS-24). The combination of all indicators in the model explains 51 % to 74 % of the achieved correction variability. The explanatory power of the ID for the achieved correction is at least three times less than the explanatory power of the initial Cobb angle.

Conclusion. Anterior discectomy with interbody fusion and posterior vertebrotomy as methods of spine release in surgery for adolescent idiopathic scoliosis do not provide additional correction of the thoracic scoliosis. Herein, the number of anchoring elements used for polysegmental fixation (implant density) does not play a role in maintaining the corrective effect.

The aim of the study is to analyze comprehensive information on the use of epidural injections in the treatment and diagnosis of patients with herniated intervertebral discs. Epidemiology and modern concepts of the pathogenesis of pain syndrome formation in patients with herniated intervertebral discs, algorithms and methods of conservative and surgical treatment of such patients are highlighted. Information on the methods and features of various routes of epidural injections used for these drugs is presented, as well as a comparative assessment of their effectiveness and safety. The diagnostic and prognostic significance of transforaminal epidural block is discussed separately.

Objective. To perform comparative analysis of the results of surgical treatment of patients with intervertebral disc herniation of different age groups.

Material and Methods. The results of treatment of 2,448 patients (1,307 men and 1,141 women) with lumbar intervertebral disc herniation were analyzed. Out of them, 393 (16 %) people were elderly and senile patients with a mean age of 66 years. Evaluation of the treatment results in patients with herniated intervertebral discs was carried out in two groups: Group I – young and middle-aged patients; and Group II – elderly and senile patients. Mandatory preoperative evaluation included clinical and neurological examination, radiation diagnostic methods (X-ray, CT, CT-myelography, MRI), and survey using scales and questionnaires (VAS, ODI, CCI).

Results. Body mass index (BMI), blood loss, duration of surgery, and length of hospital stay were statistically significantly greater in patients of Group II. In terms of pain, quality of life before and within 5 years after surgical treatment, patients of groups I and II have no statistically significant differences. The total complication rate was 4.9 %, while in patients of Group II complications developed statistically significantly more often (1.7 times) than in patients of Group I (p = 0.02). The most common complication was unintentional durotomy, which occurred in 3.6 % of cases, without statistically significant differences between groups. Epidural hematomas requiring revision intervention were observed in 13 patients, statistically significantly more often in patients of Group II (p = 0.04). The volume of blood loss in patients of Group II is significantly greater (p < 0.001). The cumulative index of reoperations over the 5-year follow-up period in Group I was 11.5 %, in Group II – 13.6 %. During the first year, reoperations in Group I amounted to 6.0 %, in Group II – 8.7 % (p = 0.05), which indicates the possible effect of age on the frequency of repeated operations. Convincing data on the effect of BMI and the comorbidity index on this indicator have not been obtained. The most common cause of reoperation in patients with herniated discs in both groups was hernia recurrence at the operated level, while the relapse rate in Group II was slightly higher – 46 % (n = 37) compared with 36 % (n = 168) in Group I.

Conclusion. No difference was found between the clinical outcomes of surgical treatment of herniated intervertebral discs in patients of different age groups during a 5-year follow-up period. Elderly and senile age is a predictor of a higher frequency of early and intraoperative complications, an increase in the surgery duration and in the volume of intraoperative blood loss. Obesity and concomitant somatic pathology do not affect the clinical outcomes of surgical treatment and the cumulative index of repeated operations in patients with herniated discs of the lumbar spine.

Objective. To evaluate clinical outcomes, safety, and technical peculiarities of percutaneous endoscopic transforaminal and interlaminar removal of the lumber spine cranially migrated disc hernias.

Material and Methods. In 2015–2018, percutaneous endoscopic transforaminal and interlaminar removal of cranially migrated hernias of the lumbar spine was performed in 53 patients (23 men and 30 women): 2 (3.8 %) at L2–L3 level, 13 (24.5 %) at L3–L4, 18 (34.0 %) at L4–L5, and 20 (37.7 %) at L5–S1. The age of patients ranged from 25 to 76 years and averaged 43.4 ± 11.6 years. Transforaminal approach was performed at the L4–L5 level and higher (62.3 % of cases), and interlaminar approach – at the L5–S1 level (37.7 %). Based on MRI, hernias with cranial migration were divided into zones: zone I – hernias with migration to the lower edge of the superjacent vertebra pedicle – 21 (39.6 %) patients; and zone II – hernias with migration above this border – 32 (60.4 %). Results were evaluated using ODI, VAS, and the McNab scale. Statistical analysis of VAS indicators (leg and back pain) and ODI scores before and after surgery was performed using the R and Microsoft Excel 2007 software.

Results. Data collection was carried out using patient questionnaires at in-person examination, telephone interviews and electronic communications. Follow-up data of different terms were monitored in all patients. In one case (when mastering this technology), at the second stage, microdiscectomy was performed at the L4–L5 level for a residual hernia fragment in migration zone II, and in another case, a conversion into microdiscectomy was performed at L3–L4 level with a hernia in zone II due to lack of venous bleeding control in a patient receiving anticoagulants. In other patients, the mean VAS scores of preoperative radicular and axial pain decreased from 7.5 ± 1.4 and 3.8 ± 1.2 to 1.4 ± 1.2 and 3.5 ± 1.3, respectively, on the next day, to 1.7 ± 1.4 and 3.2 ± 1.1 in 1 month, to 1.5 ± 1.3 and 2.8 ± 1.4 in 6 months, to 1.6 ± 1.2 and 2.0 ± 1.3 in 12 months, and to 1.6 ± 1.2 and 2.0 ± 1.3 in 24 months after surgery. In the long-term follow-up period, no radicular leg pain was observed in any patient. According to the McNab scale, up to 6 months treatment results were assessed as excellent by 19 (35.8 %) patients, and as good – by 32 (60.3 %). In the case of lumbar pain in the long term period, blockade of facet joints and radiofrequency ablation of the medial nerve branch were performed. Relapse of hernias and instability of the operated spinal segment were not revealed. The average ODI score improved from 66.4 ± 7.2 to 20.5 ± 3.2 in 1 month, to 13.6 ± 2.1 in 6 months, to 12.4 ± 2.3 in 12 months, and to 12.4 ± 2.3 in 24 months after surgery.

Conclusion. Percutaneous endoscopic transforaminal and interlaminar discectomy for cranially migrated lumbar disc hernia, while adhering the surgical technique target and exclusion criteria, is a safe and effective method, avoids excessive resection of the bone-ligamentous structures of the spine, can prevent iatrogenic instability of the spinal motion segment, and promotes early postoperative activation and recovery of the patient. Cranially migrated disc henias have a low probability of recurrence.

Objective. To analyze the literature on cervical spine tumors located in the region of the vertebral artery.

Material and Methods. Sixty five publications containing data on the surgical treatment of 101 patients with tumors of the cervical spine located in the area of V1–V3 vertebral artery segments were selected for the literature review.

Results. The analysis of publications was performed according to the following criteria: demographic data, complaints, histological type of tumor, involvement of the vertebral artery, the performed occlusion test, final embolization or ligation of the artery during surgery, and postoperative complications. The group of patients described in selected publications consisted of 66 men and 35 women, whose average age at the time of surgery was 38.7 years. Acute development of neurological symptoms at the prehospital stage caused by vertebral artery compression was observed in two cases. The C2–C4 vertebrae were most often affected, and the malignant process was confirmed in 70.3 % of cases. In 27 cases, patients underwent an occlusion test of the involved vertebral artery. At the preoperative stage, the final embolization of the artery was performed in 9 cases, the artery was tied during the main operation and removed together with the tumor – in 25, and damaged – in 7. Neurological disorders associated with stopping blood flow through the vertebral artery were noted in two cases. In a number of cases, patients underwent vascular anastomosis with preservation of blood flow at follow-up examination.

Conclusion. Taking into account the obtained data and careful preoperative planning will improve the treatment of this group of patients, increase survival, and reduce the risks of possible neurological disorders and tumor recurrence.

Objective. To specify risk factors for the development of surgical site infection in patients operated on for injuries and degenerative diseases of the thoracic and lumbosacral spine through the posterior median approach.

Material and Methods. The study included formalized case histories of 415 patients (207 men, 208 women) who were operated on for degenerative diseases (n = 385) or unstable injuries (n = 30) of the spine. The average age of patients was 47 ± 18 years. Out of them, 230 patients had concomitant chronic diseases requiring constant drug treatment. Before statistical processing, the data obtained in the study were classified according to a generally accepted method to determine the possibility of using different statistical methods when comparing groups. The patients were divided into two groups: Group I included patients with pyoinflammatory complications, and Group II – without pyoinflammatory complications.

Results. It was revealed that the following factors significantly affect the development of postoperative wound suppuration: the use of metal fixation, external drainage of the wound for more than four days, the use of monocoagulation from the level of subcutaneous fat, the installation of a retractor for a period of more than 1 hour, blood loss of more than 300 ml, leaving absorbable hemostatic materials in the wound, suturing of muscles in the area of laminectomy, and applying intradermal (cosmetic) sutures. Patient age, preoperative bed day number, skin isolation technique (or lack thereof), duration of surgery, and surgeon experience do not affect the risk of the surgical site infection.

Conclusion. Despite the fact that most of the identified risk factors for postoperative wound suppuration are reduced to more complex and prolonged intervention which is more difficult for a patient to tolerate, some of the identified risk factors are potentially removable.

Objective. To analyze possibilities and limitations of various stabilization technologies in the surgical treatment of cervical spine pathology.

Material and Methods. Study design: retrospective monocentric observational analysis. Level of evidence: 3b (UK Oxford, version 2009). Diagnostic and treatment data are presented for 433 patients operated on using stabilization systems: patients in Group 1 (n = 228) underwent anterior fixation, those in Group 2 (n = 175) – posterior fixation with polyaxial screw systems, and in Group 3 (n = 30) – combined (anterior and posterior) fixation.

Results. For anterior fixation, ACDF, ACCF and their combinations were used as stabilization technologies. In 18.0 % of patients, 49 complications were revealed which corresponded to the 1st and 2nd categories according to the recommendations of WHO, and to grades I–IVA of Clavien – Dindo classification. For posterior fixation in Group 2, stabilization was performed using screw instrumentation systems. In 13.7 % of patients, 25 complications of the 1st and 2nd categories according to WHO recommendations and grades I–V according to Clavien-Dindo classification were revealed. Combined fixation involved the use of both anterior and posterior stabilizations. Analysis of anterior and posterior fixation techniques, as well as their comparison, showed a wide range of posterior stabilization options for a surgeon: any age, length, localization and nosology. Moreover, the realization of these advantages is carried out only through the indispensable use of screw fixation. Posterior fixation has several limitations: the impossibility of anterior decompression, limited correction of segmental lordosis, accessibility and greater trauma to soft tissues.

Conclusion. Comparative analysis of methods for the cervical spine stabilization showed that posterior fixation is an integral part of the surgical treatment of the cervical spine pathology. The obtained results indicate the complementarity of the technologies for the cervical spine stabilization, without their interchangeability. These data can be useful when choosing stabilization techniques before planning surgical treatment of cervical spine pathology, which will allow changing the existing paradigm.

It is with gratitude that I dedicate my work to the teacher, Ya.L. Tsivyan, who not only provided a subject for research, but also, on his own example of a person devoted to his work, brought up a generation of scholars for whom life and science are inseparable.

The paper presents the results of many years of research on idiopathic scoliosis in the form of a report to the teacher. Several fundamental topics were considered:

1) for the first time in world practice, it was established, on the basis of a study of 50 patients with idiopathic scoliosis, that the etiological factor of scoliosis is ectopic localization of neural crest derivatives, which are not genetically determined to chondrogenic differentiation and the growth process, in the vertebral body growth plate;

2) a local disturbance of chondrogenesis in the  vertebral body growth plate  is the cause of the growth asymmetry and formation of spinal deformity in idiopathic scoliosis;

3) the degree of structural changes in the spine and the prognosis of the deformity progression  depend on the level of disturbance of the morphogenetic processes in the vertebral body growth plate embedded in embryogenesis;

4) it is supposed to confirm the proposed hypotheses by inhibition of the PAX3 gene in the chick embryo model of idiopathic scoliosis and to get answers to many more unclear questions concerning scoliotic disease.