Orthopaedic Surgery Elicits a Systemic Anti-Inflammatory Signature.

Little information is available on the functional activity of leukocytes after arthroplasty or the expansion of populations with immune suppressive properties during the acute post-operative period. Synovial fluid and matched pre- and post-surgical blood samples were collected from total hip and knee arthroplasty patients (THA and TKA, respectively) to examine the impact of surgery on peripheral blood leukocyte frequency, bactericidal activity, and inflammatory mediator expression. For spinal surgeries, inflammatory mediator production by peripheral blood mononuclear cells (PBMCs) pre- and post-surgery was examined. An expansion of immune suppressive granulocytic myeloid-derived suppressor cells (G-MDSCs) was observed following arthroplasty, which correlated with significantly increased serum interleukin-10 (IL-10) levels. Analysis of synovial fluid from THA and TKAs revealed reduced granulocyte colony-stimulating factor (G-CSF) and soluble CD40 ligand (sCD40L) and increased interleukin-6 (IL-6), monocyte chemoattractant protein 2 (CCL2) and Fms-like tyrosine kinase 3 ligand (Flt-3L) compared to pre- and post-surgical serum. For the spinal surgery cohort, stimulation of PBMCs isolated post-surgery with bacterial antigens produced significantly less pro-inflammatory (IL-1α, IL-1ß, interleukin-1 receptor antagonist (IL-1RA), IL-12p40, growth-related oncogene-α/GRO-α (CXCL1) and 6Ckine (CCL21)) and more anti-inflammatory/tissue repair mediators (IL-10, G-CSF and granulocyte-macrophage colony-stimulating factor (GM-CSF)) compared to PBMCs recovered before surgery. The observed bias towards systemic anti-inflammatory changes without concomitant increases in pro-inflammatory responses may influence susceptibility to infection following orthopaedic surgery in the context of underlying co-morbidities or risk factors.

Bilateral Hypoglossal Nerve Palsy After Occipitocervical Fusion.

A 63-year-old man sustained a Jefferson fracture and was treated nonoperatively by a separate treating surgeon. Because of the symptomatic malalignment and nonunion after 6 months of nonsurgical management, the patient was seen for a second opinion. Occiput to C3 arthrodesis was performed. Postoperatively, the patient was diagnosed with a bilateral hypoglossal nerve palsy. Hypoglossal nerve injuries after cervical spine fractures and posterior cervical procedures are a very rare occurrence. This is the first case report of a bilateral hypoglossal nerve palsy following occipitocervical arthrodesis.

Surgical Management of Cervical Spondylotic Myelopathy.

Cervical spondylotic myelopathy (CSM) is a common cause of neurologic impairment in adults worldwide. Numerous studies have investigated the pathophysiology of CSM, which has provided surgeons with insight on the important factors that lead to the symptoms and deficits observed in patients who have CSM. However, further analysis of many unknown aspects of CSM is required to fully understand the disease and potential alternative treatment modalities. The diagnosis of CSM is based on a patient's history and physical examination and then confirmed with imaging studies. Progression, symptomatology, and imaging findings may vary by patient. Because of the variability of CSM, the disease course and a patient's response to treatment are difficult to predict. CSM can be managed either nonsurgically or it can be managed surgically via posterior or anterior cervical approaches, each of which has its own indications and possible complications.

Bacterial Spine Infections in Adults: Evaluation and Management.

Bacterial spinal infections in adults can have notable adverse consequences, including pain, neurologic deficit, spinal instability and/or deformity, or death. Numerous factors can predispose a person to spinal infection, many of which affect the immune status of the patient. These infections are typically caused by direct seeding of the spine, contiguous spread, or hematogenous spread. Infections are generally grouped based on anatomic location; they are broadly categorized as vertebral osteomyelitis, discitis, and epidural abscess. In some cases, the diagnosis may not be elucidated early without a reasonable index of suspicion. Diagnosis is based on history and physical examination, laboratory data, proper imaging, and culture. Most infections can be treated with an appropriate course of antibiotics and bracing if needed. Surgical intervention is usually reserved for infections resistant to medical management, the need for open biopsy/culture, evolving spinal instability or deformity, and neurologic deficit or deterioration.

Bone graft and bone graft substitutes in spine surgery: current concepts and controversies.

Iliac crest bone graft has long been the standard adjunct used in spine fusion surgery. This graft provides osteogenic, osteoinductive, and osteoconductive elements that aid in creation of a fusion mass. However, morbidity associated with bone graft harvest has led surgeons to seek other potential adjuncts, including bone morphogenetic proteins, demineralized bone matrix, and graft expanders such as synthetic bone graft and allograft. Knowledge of fusion biology is required to understand the benefits and limitations of these agents, which promote fusion via one of four mechanisms: osteogenesis, osteoinduction, osteoconduction, and osteopromotion. Although bone morphogenetic proteins have shown a clear ability to aid in bone formation and successful fusion, recent concern regarding their safety has tempered enthusiasm regarding their use.

Esophageal and vertebral artery injuries during complex cervical spine surgery--avoidance and management.

Vertebral artery and esophageal injuries are rare but feared complications of cervical spine surgery. Appropriate understanding of treatment algorithms for prompt intervention in the event of a vertebral artery injury minimizes the risk of exsanguination and/or profound neurologic consequences. Esophageal injuries are often more subtle, and although intraoperative injuries can sometimes be diagnosed at the time of surgery, they frequently do not present until the week after surgery. They can additionally be seen as a late complication of instrumentation usage and/or failure. Expedient diagnosis and management of these injuries minimize their impact and allow for optimal treatment outcome.