decompression

Percutaneous lumbar disc decompression (PLDD) has emerged as an effective and minimally invasive treatment option for lumbar disc herniation. This review aims to provide pain specialists with a comparative overview of Iran’s commonly utilized PLDD techniques: Laser, radiofrequency (RF), and quantum PLDD. The review discusses patient selection criteria, procedural characteristics, and outcomes to facilitate informed clinical decision-making.

There is still no standard of care to manage thoracolumbar burst fractures. With all the recent advances, posterior approaches are still one of the mainstays of treatment. On the other hand, while spinal canal decompression in neurological impaired patients is an important goal of treatment, its technique remains controversial.
This study compared the effects of direct laminectomy decompression against ligamentotaxis/indirect canal decompression on neurological and radiographic improvements.  

A prospective double-blind randomized clinical trial was conducted on 60 thoracolumbar burst-fracture patients meeting our inclusion and exclusion criteria. They were randomized into 2 treatment arms: (1) direct decompression using laminectomy and (2) indirect decompression using ligamentotaxis/distraction. Each patient was observed for 6 months, and their neurological and radiographical data were collected prospectively. Statistical analysis was done by the Student t test, Friedman test, Mann Whitney-U test, Wilcoxon ranked test, and 1-way analysis of variance.  

Among 60 patients enrolled in our study, each treatment arm had an improvement in Frankel scores but there was no difference between the groups at any given time. After 6 months of surgery, local sagittal kyphosis improved in both groups (from 32.2 to 7.43 and 29.93 to 8.77 for the indirect and direct groups, respectively), as well as anterior vertebral height ratio (from 57.73 to 70.7 and 62.17 to 66.27 for the indirect and direct group, respectively) and posterior vertebral height ratio (from 61.17 to 74.87 and 64 to 67.5 for the indirect and direct group, respectively). For between-group comparisons after 6 months, there was a significant difference only for posterior vertebral height ratio (P = 0.040).  

Posterior approaches with ligamentotaxis have shown to be safe and may present the same outcome as direct decompression techniques using wide laminectomy.

The treatment choice in the management of odontogenic cysts in the mixed dentition period depends upon the size, location of the cyst, the bone integrity of the cystic wall, and its proximity to vital structures. Enucleation is indicated with smaller cysts, achieved by careful removal of a complete cyst without rupturing the cystic lining. Marsupializationand decompression are the treatments of choice for larger cysts as it can help to preserve the tooth bud of the successor tooth and reduce morbidity. Marsupialization is achieved by opening and deroofing the cyst, and making the cystic lining continuous with the oral cavity or surrounding structures by suturing the edges of the incised mucosa to the cystic wall. This helps in maintaining the patency of the cystic lesion. In the decompression, a cylindrical device (drain) is placed in the lesion, which maintains communication between oral cavity to cystic lesion. This decreases the intracystic pressure and results in bone formation. We present two cases of odontogenic cyst in children, where we used a modified decompression technique. We developed a modified surgical stent with the use of a Hawley’s appliance, which led to cystic decompression, and eventual eruption of the successor tooth. Notably, this modified technique also reduced both patient discomfort and the number of clinical visits, making it an effective treatment option. The unique design of the appliance also acted as a space maintainer for the eruption of successor tooth, which is very critical in mixed dentition for future prevention of space loss and eventual malocclusion. The advantage of our design was its easy removal and insertion with minimal discomfort.

Early decompression within the first 24 hours after spinal cord injury (SCI) is proposed in currentguidelines. However, the possible benefits of earlier decompression are unclear. Thus, the present meta-analysisaims to investigate the existing evidence regarding the efficacy of ultra-early decompression surgery (within 12hours after SCI) in improving patients’ neurological status.

A search was performed in Medline, Em-base, Scopus and Web of Science electronic databases, until the end of August 2021. Cohort studies and clinicaltrials were included in the present study. Exclusion criteria were absence of an early or late surgery group, fail-ure to report neurological status based on the American spinal injury association impairment scale (AIS) grade,failure to perform the surgery within the first 12 hours after SCI, and duplicate reports and review articles. Twoindependent reviewers performed data collection, and risk of bias and certainty of evidence assessments. Theoutcome was reported as odds ratio (OR) and 95% confidence interval (CI).

Data from 16 articles, whichstudied 868 patients, were included. Compared to early or late decompression surgery, ultra-early decompres-sion surgery significantly improves patients’ neurological status (OR = 2.25; 95% CI: 1.41 to 3.58). However,ultra-early surgery in thoracolumbar injuries is not significantly more effective than early to late surgery. More-over, ultra-early surgery in patients with a baseline AIS A increases the chance of neurologic resolvent up to 3.86folds (OR=3.86; 95% CI: 1.50 to 9.91). Contrastingly, ultra-early surgery does not result in significant improve-ment compared to early to late surgery in patients with AIS B (OR = 1.32; 95% CI: 0.51 to 3.45), AIS C (OR = 1.83;95% CI: 0.72 to 4.64), and AIS D (OR = 0.99; 95% CI: 0.31 to 3.17).

Current guidelines emphasizethat spinal decompression should be performed within 24 hours after SCI, regardless of injury severity and loca-tion. However, results of the present study demonstrated that certain considerations may be taken into accountwhen performing decompression surgery: 1) in patients with AIS A injury, decompression surgery should beperformed as soon as possible, since its efficacy in neurological improvement is 3.86 folds higher in the first 12hours after injury. 2) ultra-early decompression surgery in patients with cervical injury is more effective than inpatients with thoracic or lumbar injuries. 3) postponing decompression surgery to 24 hours in SCI patients withAIS B to D does not significantly affect the neurological outcome.

Background and Importance: 

Fracture-dislocation of the thoracic or lumbar spine (traumatic spondyloptosis) occurs in less than 5% of all spinal injuries mainly affecting the ventral direction.

A paraplegic young man was admitted to Shahid Kamyab Hospital in Mashhad City, Iran due to a motor vehicle accident. Computerized tomography (CT) showed a complete posterior dislocation of the T10 vertebral body on T9, with the superior articular processes of T9 bilaterally locked in the inferior endplate of T10 and complete fractures of the posterior elements.

The spinal dislocation was re-aligned by a combination of Harrington fixation and pedicular screws leading to spinal fusion. Six months after surgery, the patient was still paraplegic but the sensory symptoms in the lower extremities and clean intermittent catheterization improved.

Abdominal compartment syndrome (ACS) is a sustained intraabdominal pressure (IAP) of 20 mmHg or higher with new organ dysfunction. Decompression is required when IAP exceeds 25 mmHg even without evidence of organ dysfunction. Common abdominal surgical diseases and operations can be complicated by ACS, and clinicians should have the requisite capacity to detect and intervene early enough. Intensive care unit (ICU) care has traditionally been the mainstay of ACS management.

A 23-year-old male was referred with a combined mesh and Bogota bag anterior abdominal construct after a midline laparotomy 24 hours earlier, following which the abdominal wall could not be closed primarily without tension. This was the result of significant edema of the bowel and retroperitoneum. This patient, after adequate resuscitation, underwent a twostaged procedure, 6 days apart, to achieve skin closure. After an unremarkable skin healing, a mesh repair for the consequent incisional hernia was carried out 15 months later.

This patient’s ACS was successfullymanaged in a non-ICU setting and could demonstrate the possibility of successfully managing selected cases of laparotomy-related ACS in low-resource settings without ICU facilities.

Seven to ten percent of facial nerve paralysis occurs in patients with temporal bone fracture. It has become increasingly common due to the development of human activity. One of the main topics of discussion is facial nerve injury management resulting from temporal bone trauma.The purpose of this study is to report the paralysis of facial nerve after temporal bone fractures.

In this study, our goal was to record the facial profile of rhinoplasty applicants in Shiraz.

This retrospective study analyzed 20 cases of traumatic paralysis of facial nerve, which underwent facial nerve decompression.

Recovery rate was correlated to the delay of surgery. 83.3% of patients who underwent decompression surgery within the first 2 weeks after trauma had an excellent therapeutic outcome (HB grading I-II) and the difference was statistically significant (p=0.000).

Facial nerve paralysis surgical management after bone fracture is controversial. The decision must be taken according to the type of paralysis and the radiological electrophysiological and evolutionary data.

Large radicular lesions should be treated initially by orthograde root canal therapy. When the signs and symptoms of the infection (e.g. persistent purulent drainage) do not resolve after this treatment, then surgical approaches should be considered. In the cases of large radicular cysts, total enucleation of the cyst can endanger adjacent structures and teeth. Therefore, decompression or marsupialization techniques are recommended in order to decrease the size of the lesion. In this case report, a 55-year-old woman with previously initiated therapy was referred to endodontic department for management of a sinus tract associated with tooth #7. Root canal treatment was performed and intracanal irrigant (5.25% sodium hypochlorite) activated using passive ultrasonic application, various intracanal medicament (calcium hydroxide, double antibiotic paste) was used in multiple sessions, but intracanal purulent drainage was not resolved. After this, decompression was performed using needle cap to maintain the opening of the cyst and remained for three months. During this period the cavity was kept clean and rinsed by the patient with 0.2% chlorhexidine mouthwash. After three-year follow-up, radiographic examination revealed substantial osseous repair of the defect and clinical signs and symptoms were absent.

An oscillating bone saw is rarely used to perform laminectomy. The purpose of this study was to describea relatively quick and harmless technique for multilevel laminectomy in patients with lumbar spinal stenosis (LSS) usingan oscillating bone saw to find out how this instrument affects the time of surgery and rate of complications. This prospective study was conducted on 45 patients with LSS who required multilevel laminectomy. Thebones were cut using an oscillating sagittal saw equipped with a fine 1-cm blade. Posterolateral fusion was performed ifany evidence of spinal instability occurred, or the correction of deformity was addressed. The time spent for laminectomyfrom initial cutting to the whole bone removal (T1) and the duration of laminectomy (i.e., from initiation to the end ofdecompression; T2) were recorded for the corresponding level. The volume of harvested autograft was also measured,and any dural injuries were reported. Posterolateral fusion was performed on 32 (71.1%) patients. The mean T1 and T2 per level were estimated at70.5±5.4 and 157.5±12.1 sec, respectively. In addition, the mean volume of harvested autograft per level was obtainedas 3.5±1.2 cc. No durotomy was observed during laminectomy using an oscillating bone saw. However, a dural tearoccurred in one patient when a Kerisson punch was utilized for ligamentum flavum removal and foraminotomy. Based on the findings, it can be concluded that laminectomy by means of the oscillating bone saw is asafe procedure that provides a sufficient volume of harvested autograft for fusion. This technique could also induce aremarkable reduction in the time of surgery.Level of evidence: IV

Various treatment modalities have been reported for keratocystic odontogenic tumors (KOT), with different recurrence rates. Marsupialization and decompression are two different conservative surgical techniques for the treatment of KOTs. This study aimed at comparing the recurrence rate between marsupialization and decompression in the treatment of KOTs with or without adjunctive treatments. This is a systematic review study. The research sources utilized were PubMed (MEDLINE), Google scholar, Ovid MEDLINE and Cochrane Library. The keywords which were selected based on Medical Subject Heading (MeSH) terms and PICOS criteria were odontogenic keratocyst, keratocyst odontogenic tumor AND marsupialization OR decompression OR cystectomy OR enucleation OR curettage. Statistical analyses were performed to compare the recurrence rate between marsupialization and decompression with or without adjunctive treatments, regarding various follow-up times. The number of subjects that underwent marsupialization was 182. There was a significant difference for the recurrence rate between the marsupialization and decompression groups without considering adjunctive treatments (p= 0.001). However, considering adjunctive treatments, there was no difference between marsupialization and the decompression groups (p= 0.18). It appears that decompression without any adjuvant treatment may have a lower recurrence rate than marsupialization. The recurrence rate was not different when enucleation or cystectomy was performed after decompression and marsupialization.

Despite the vast number of surveys, no consensus has been reached on the optimum timing of spinal decompression surgery. This systematic review and meta-analysis aimed to compare the effects of early and late spinal decompression surgery on neurologic improvement and post-surgical complications in patients with traumatic spinal cord injuries.

Two independent reviewers carried out an extended search in electronic databases. Data of neurological outcome and post-surgery complication were extracted. Finally, pooled relative risk (RR) with a 95% confidence interval (CI) was reported for comparing of efficacy of early and late surgical decompression.

Eventually 22 studies were included. The pooled RR was 0.77 (95% CI: 0.68-0.89) for at least one grade neurological improvement, and 0.84 (95% CI: 0.77-0.92) for at least two grade improvement. Pooled RR for surgical decompression performed within 12 hours after the injury was 0.26 (95% CI: 0.13-0.52; p<0.001), while it was 0.75 (95% CI: 0.63-0.90; p=0.002) when the procedure was performed within 24 hours, and 0.93 (95% CI: 0.76-1.14; p=0.48) when it was carried out in the first 72 hours after the injury. Surgical decompression performed within 24 hours after injury was found to be associated with significantly lower rates of post-surgical complications (RR=0.77; 95% CI: 0.68-0.86; p<0.001).

The findings of this study indicate that early spinal decompression surgery can improve neurologic recovery and is associated with less post-surgical complications. The optimum efficacy is observed when the procedure is performed within 12 hours of the injury.

Bone cement leakage is the most common, however, it can have potentially disastrous complications during vertebroplasty and balloon kyphoplasty (BK). Polymethylmethacrylate (PMMA) is the most commonly used bone filler, however, calcium phosphate (CP) has been successfully used in spine surgery as a vertebral filler because it is not associated with exothermal reaction and is biologically very close to the vertebral bone. CP leakage during vertebral augmentation is extremely rare.
A 72-year-old woman with an A2/AO type fracture of L1-vertebra underwent a transpedicular BK at the L1-vertebra with CP plus short segment pedicle screw construct (T12-L2) by minimally invasive surgery (MIS). Continuous neuromonitoring and fluoroscopy were used in this case, although no pathological signs were recorded because of the low radiopacity of CP. Two days later, incomplete paraplegia was presented due to intra and extradural cement leakage. The patient underwent an emergency T12-L2 wide decompression for removal of an epidural leak of CP plus durotomy for intradural CP removal. After removal of the cement, there was improvement of neurologic function. CP leakage should have occurred because of a violation of the medial right pedicle wall by the BK trockar and subsequently CP injection both intra and extradural. Since no direct intraoperative nerve root injury occurred, there was no pathologic sign during intraoperative neuromonitoring.
PMMA leakage is well documented in the literature as a common complication during BK. Calcium phosphate leakage during vertebral augmentation is rare. Furthermore, delayed onset of neurologic deficit due to CP leakage has never been reported in the current literature. Spine surgeons and interventional radiologists should always be aware of this potential disastrous complication.

Late-onset neurological impairment in unstable A3-A4/AO type thoracolumbar spinal fractures are rare, particularly if they are misdiagnosed as stable (25%). We present two neglected unstable burst fractures, who presented delayed trauma with neurologic deficit.
Case 1: A 62-year-old male, who sought our department three months after trauma claiming neurogenic claudication, following fracture of L2.
Case 2: A 50-year old male, who had a jerky fall from his vehicle with subsequent back pain for a few days. One-month after the trauma he presented urinary retention.
Unstable thoracolumbar A4 /AO type fractures, if left untreated or misdiagnosed, lead to vertebral body fragments retropulsed to the spinal canal under axial and bending forces resulting in progressively increased encroachment of the canal and finally compression on to cauda equina. Early recognition of an unstable A3-A4 /AO-type thoracolumbar fracture with C/T scan is mandatory along with appropriate treatment. This should be done in all cases, even in these without any neurological deficit and these with «normal» plain X-rays, because misdiagnosis and late onset neurological deficit is always a possibility. Physicians should be aware of this complication when treating thoracolumbar spine injuries with minor or absent symptoms and physiological neurologic findings.

Traumatic spinal cord injury (SCI) is a catastrophic event for patients with neurologic deficit and for the society in terms of economic issues. The prevalence of SCI seems to be increasing. There is not enough evidence regarding late neurologic decompression in patients with spinal cord injury.
Here, we report on two patients with spinal cord injury, who were referred to our department after several days of trauma and both underwent decompression and posterior instrumented fusion (posterolateral decompression ) with favorable results.
It seems that late neurologic decompression might have some benefits for patients with SCI.

Prior animal models have shown that rats sustaining 3-second immediate spinal cord compression had significantly better functional recovery and smaller lesion volumes than rats subjected to compression times of 1 hour, 6 hours, 3 weeks, and 10 weeks after spinal cord injury. We compare locomotor rating scales and spinal cord histopathology after 3 seconds and 10 minute compression times.. Ten rats were assigned into two early (3-second) and late (10-minute) compressive surgery groups. Compressive injury was produced using an aneurysmal clip method. Rats were followed-up for 11 weeks, and behavioral assessment was done by inclined plane test and tail-flick reflex. At the end of the study, the rats were sacrificed, and spinal cord specimens were studied in light and EM. Basso, Beattie and Bresnahan (BBB) locomotor rating scales were significantly better in the early compression group after the 4th week of evaluation (P<0.05) and persisted throughout the remainder of the study. Histopathology demonstrated decreased normal tissue, more severe gliosis and cystic formation in the late group compared to the early group (P<0.05). In EM study, injuries in the late group including injury to the myelin and axon were more severe than the early compression group, and there was more cytoplasmic edema in the late compression group. Spinal cord injury secondary to 3-second compression improves functional motor recovery, spares more functional tissue, and is associated with less intracellular edema, less myelin and axon damage and more myelin regeneration in rats compared to those with 10 minutes of compression. Inclined plane test and tail-flick reflex had no significant difference.