Treatment of fractures of the vertebral limbus and spinal stenosis in five adolescents and five adults.

Fractures of the vertebral limbus occur between the vertebral ring apophyses and the cartilaginous rim of the superior or inferior margins of the vertebral end plates. These fractures are typically seen in adolescents or young adults, since fusion in this area is not complete until the ages of 18 to 25. Of 85 cases reported, 24 occurred in adolescents. The authors present the clinical, neurodiagnostic, and surgical management of fractures of the vertebral limbus and coincident segmental spinal stenosis in a group of 5 adolescents and 5 adults. An additional category for fractures of the vertebral limbus is proposed, namely, a lesion that is not confined to the superior or inferior margins of the vertebral end plates, but that spans the full length of the vertebral body.

Unilateral S-1 root compression syndrome caused by fracture of the sacrum.

Unilateral S-1 nerve root compression after an S-1 sacral fracture was found in an 18-year-old man after a motor vehicle accident. The positive myelogram, myelogram-computed tomogram, and magnetic resonance studies led to surgical intervention. Marked bony callous formation contiguous with the S-1 alar fracture protruded into the canal and was responsible for tethering the S-1 nerve root. A right L-5 hemilaminectomy, an L-4, L-5 and L-5, S-1 medial facetectomy, and foraminotomy facilitated nerve root decompression. Postoperatively, the patient was markedly improved. The authors suggest a more aggressive attitude in the diagnostic, radiographic, and surgical management of sacral fractures now that more specific technical facilities are available to define the precise character of the lesions involved.

Degenerative spondylolisthesis with an intact neural arch: a review of 60 cases with an analysis of clinical findings and the development of surgical management.

The treatment over the past 12 years of 60 patients with degenerative spondylolisthesis with an intact neural arch is reviewed. The patients averaged 65 years of age, with women outnumbering men by a ratio of 2:1. Symptoms in the lower extremities had been present for 3 months to 10 years, although varying back pain had existed for longer periods. Two-thirds showed signs of motor dysfunction. Sensory alterations and a positive Las ègue's sign could be demonstrated in only one-half of the patients studied. Four of 5 patients developed intermittent neurogenic claudication, with varying evidence of painful radiculopathy. The marked disability caused by claudication contrasted sharply with the lesser neurological changes, and these patients required early surgical decompression. Diagnostic studies included electromyography, plain x-ray films, tomography, computed tomographic scanning, and myelography. The latter outlined a relative stenosis caused by olisthesis as well as arthrotic and spondylotic changes that determined the extent of decompressive operation required. The L-4, L-5 interspace was involved in 56 patients, L-3, L-4 was involved in 2, and L-5, S-1 was involved in 2. The ideal operation with L-4, L-5 olisthesis included complete laminectomy of L-4 and L-5 with unroofing of the lateral recesses and foraminotomy. This more extensive procedure was justified because of the failures encountered in previous patients in whom inadequate decompression had been performed. Among failures, obesity, diabetes, hyperlordosis, and extensive long-standing dysfunction were prominent. The relief of symptoms of intermittent neurogenic claudication was the most gratifying response observed. There was no unusual morbidity.

Moderate grade astrocytoma presenting in a 4-month-old child with a family history of von Recklinghausen's neurofibromatosis spanning four generations: a case report.

Intracranial gliomas are found in association with von Recklinghausen's neurofibromatosis. However, few truly neonatal lesions have been identified and studied. This case report concerns a 4-month-old child who was found to have a massive thalamic glioma of moderate grade. Four paternal generations had suffered from different manifestations of this transmissible autosomal-dominant (Ad) phakomatosis.

Coexisting cervical and lumbar spinal stenosis: diagnosis and management.

An attempt has been made to identify and manage patients symptomatic from both cervical and lumbar spinal stenosis. The order of operative intervention was related to the degree of myelopathy and radiculopathy. Patients requiring cervical surgery first had absolute stenosis with a spinal canal equal to or less than 10 mm in anteroposterior diameter. Those requiring lumbar surgery first presented with stenosis and a canal between 11 and 13 mm in depth. In the latter group, patients presented with radiculopathy in their upper and lower extremities. A significant portion (50%) had intermittent neurogenic claudication (INC). Motor and sensory changes were severe in those with absolute as compared to relative stenosis. After cervical laminectomy, myelopathy improved or stabilized, and the subsequent lumbar decompression could be completed with less risk. Cervical cord decompression often resulted in improvement in lumbar symptoms with resolution of pain, spasticity, and sensory deficits of myelopathic origin. However, latent symptoms of INC caused by lumbar stenosis were not affected by cervial decompression and increased in severity. Electrodiagnostic studies were helpful in that somatosensory evoked potentials showed conduction delays in the cervical cord in patients with significant disease. The identification of motor neuron disease and peripheral neuropathies was essential. The surgical management included extensive, multiple level laminectomy, unroofing of the lateral recesses, and foraminotomy. Neurolysis and untethering of the spinal cord was essential. Significant improvement was shown by 90% of these patients.

Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results.

This study was undertaken to determine and compare indications and relative benefits of various surgical approaches in 170 patients (average age 55 years) with far-lateral herniated lumbar discs, identified by magnetic resonance (MR) imaging and computerized tomography (CT) and operated on between 1984 and 1994. Essentially three surgical procedures were performed: complete facetectomy in 73 patients, laminotomy with medial facetectomy in 39 patients, and intertransverse discectomy (also known as ITT) in 58 patients. Follow-up periods averaged 5 years (range 0.5-10 years). Outcomes were scored as excellent (no deficit), good (mild radiculopathy), fair (moderate radiculopathy), and poor (unchanged or worse). Overall, excellent and good results were achieved in 73 and 51 patients, respectively, and fair and poor results in 26 and 20, respectively. There was little difference among the results encountered for the three major surgical groups: 79% of the intertransverse (ITT) group had good-to-excellent outcomes, as compared with 70% of the facetectomy group, and 68% of the group who underwent at minimum laminotomy, and additional hemilaminectomy or laminectomy with medial facetectomy. Results were the same for the 121 patients followed for more than 2 years and for the 49 patients studied for under 2 years. In the management of far-lateral discs, total facetectomy provides the best exposure, but increases the risk of instability. Laminotomy and medial facetectomy uncover the lateral and subarticular recess and preserve stability, but visualization of the far-lateral compartment is often inadequate. The intertransverse approach offers extensive far-lateral but not medial intraforaminal exposure, while also preserving stability. Full facetectomy, laminotomy with medial facetectomy, and the intertransverse approaches yielded nearly comparable outcomes in far-lateral disc surgery. Only the full facetectomy exposes the entire course of the nerve root both medially and laterally, whereas the intertransverse procedure provides direct exposure of the fat-lateral compartment alone. It is important to select the correct approach or combination of approaches to address attendant complicating factors such as spinal stenosis, spondyloarthrosis, and degenerative spondylolisthesis identified on CT and MR studies.

Ossification of the cervical anterior longitudinal ligament contributing to dysphagia. Case report.

The authors evaluated the clinical, radiological, and surgical management of ossification of the anterior longitudinal ligament (OALL) that contributed to dysphagia in a patient with simultaneous cervical ossification of the posterior longitudinal ligament (OPLL). A 57-year-old man presented with increasing dysphagia and moderate myelopathy. Imaging studies, including esophagoscopy, revealed marked esophageal compression due to OALL that extended between the C2-5 levels and significant C5-7 OPLL that compressed the distal cervical spinal cord. The use of rongeurs and a high-speed drill facilitated excision of the C2-5 OALL mass, and a routine anterior corpectomy with fusion was performed at the C5-7 level. Postoperatively, the patient's dysphagia and symptoms of myelopathy immediately resolved. The strut graft became fully fused 3 months postoperatively, as demonstrated on dynamic x-ray films, and the patient has remained asymptomatic 4 months postoperatively. Patients with dysphagia and coexisting myelopathy benefit from simultaneous surgery for resection of OALL and OPLL masses.

Can airway complications following multilevel anterior cervical surgery be avoided?

OBJECT: The authors conducted a study to determine how to avoid emergency postoperative reintubation and its associated morbidity in patients who have undergone multilevel anterior-posterior cervical spine surgery. METHODS: In a group effort between the departments of anesthesia and neurosurgery, a protocol was developed to avoid having to reintubate patients postoperatively. As a preventative measure, patients remained intubated overnight; on the 1st postoperative day or thereafter, based on direct fiberoptic visualization of reactive tracheal swelling, an anesthesiologist extubated the patients. Fifty-eight patients underwent multilevel anterior corpectomy with fusion (ACF; with 41 receiving plates and 17 not receiving plates), posterior wiring and fusion (PWF), and application of a halo. On average, ACF involved three levels, whereas PWF included 6.5 levels. Surgery typically lasted 10 hours, and an average 2.6 U of blood was required. Forty patients were successfully extubated on the 1st, five on the 2nd, three on the 3rd, two on the 4th, two on the 5th, and three on the 7th postoperative day. Three elective tracheostomies were performed on the 7th postoperative day. Risk factors associated with delayed extubation or tracheostomy in 18 patients included: operative time longer than 10 hours (12 patients), obesity greater than 220 lbs (12 patients), transfusion of more than 4 U of blood (10 patients), ACF reoperations (nine patients), ACF including C-2 (seven patients), four-level ACF (five patients), and asthma (five patients). In the only case in which emergency reintubation was required, three risk factors were present. CONCLUSIONS: Emergency reintubation following anterior-posterior cervical surgery and fusion can be avoided by maintaining intubation overnight and subsequently having an anesthesiologist remove the tube after healing is fiberoptically confirmed. Familiarity with major risk factors contributing to airway compromise, combined with this protocol, should minimize the significant morbidity associated with reintubation following multilevel anterior-posterior cervical fusion.

Lumbar surgery for 56 limbus fractures emphasizing noncalcified type III lesions.

The clinical, radiologic, and surgical procedures performed for 56 out of 59 patients with Type I-IV fractures of the vertebral limbus were reviewed, stressing the diagnostic and operative management of noncalcified Type III (NC III) lesions. Forty-four calcified Type I-IV (CA I-IV) limbus fractures, interpreted as routine disc herniations on magnetic resonance imaging scans, were correctly identified as limbus fragments on computed tomographic and myelographic/computed tomographic studies, whereas 15 NC III lesions were mistaken for disc herniations alone on all three radiographic examinations. The preoperative recognition of the CA I-IV and NC III fracture types proved essential to the successful resection of five Type I, five Type II, 36 Type III, and ten Type IV fragments through extended laminotomies, hemilaminectomies, and laminectomies with the down biting curette, tamp, and mallet technique. In the absence of routine disc herniations, expanded standard dissectomies to the superior or inferior pedicular levels allowed for the identification and removal of NC III fractures.

Identification of ossification of the posterior longitudinal ligament extending through the dura on preoperative computed tomographic examinations of the cervical spine.

STUDY DESIGN: To establish the diagnosis of dural penetration on preoperative computed tomographic studies of the cervical spine in patients with ossification of the posterior longitudinal ligament (OPLL). OBJECTIVES: To define before surgery the pathognomonic computed tomographic findings of OPLL extending to and through the dura. SUMMARY OF BACKGROUND DATA: On preoperative computed tomographic studies, Hida et al have described the single-layer sign characterized by a solid mass of hyperdense OPLL and the double-layer sign defined by two (anterior and posterior) ossified rims surrounding a central nonossified but hypertrophied posterior longitudinal ligament. Only 1 of the 9 patients exhibiting the single-layer sign but 10 of 12 patients showing the double-layer sign had no separate dural plane identified at surgery. METHODS: Only 2 of 54 patients undergoing multilevel cervical circumferential OPLL procedures had absent dura at surgery. Computed tomographic examinations for all patients were retrospectively reviewed to determine unique signs of dural penetration. RESULTS: Dura was absent in 1 of 12 patients who had the single-layer CT sign that was additionally characterized by an irregular C angular configuration. Only 1 of 4 patients exhibiting the double-layer computed tomographic sign had absent dura at surgery. The remaining 38 patients had the smooth-layer sign, characterized by more regular margins of classic (22 patients) or early OPLL (16 patients). CONCLUSIONS: The double-layer computed tomographic sign is more pathognomonic for dural penetration than the single-layer sign. The smooth-layer sign, indicating a clean dural plane, is more typical in North American patients.

The surgical management of ossification of the posterior longitudinal ligament in 43 north americans.

From 1989 to 1992, 43 of 174 (25%) consecutive North Americans had cervical ossification of the posterior longitudinal ligament (OPLL). After the non-random selection of anterior corpectomies and fusions, anterior discectomies and fusions, or five-level laminectomies, the preoperative and postoperative outcomes of the OPLL patients were compared using Ranawat's neurological classes and grades. Patients who had anterior OPLL surgery exhibited superior outcomes compared with those who had laminectomies. Specifically, the 20 patients who underwent corpectomies and had the most severe preoperative deficits, had the best postoperative results; the 13 discectomy patients, with the least severe preoperative deficits, had intermediate recoveries, whereas the ten laminectomy patients, with intermediate preoperative neurologic dysfunction, had biased future surgical choices to favor more anterior approaches.

Ossification of the posterior longitudinal ligament in evolution in 12 patients.

Ossification of the posterior longitudinal ligament (OPLL) in evolution (OEV), an early form of OPLL, was newly discovered in 12 of 43 (28%) patients who had OPLL and underwent operations from 1989-1992. Magnetic resonance imaging and CT studies of OEV patients who were younger, in their mid-forties, and had less severe spastic myeloradiculopathy, showed hypertrophied posterior longitudinal ligaments containing punctate ossification at disc spaces and contiguous endplates, with occasional extension behind vertebral bodies. However, both location and neuroradiologic appearance allowed OEV to be confused readily with disc or spondylotic disease. Only heightened awareness of the clinical and radiographic findings of OEV allowed the correct diagnosis. The appropriately extended anterior discectomies or corpectomies with fusions contributed to better outcomes.

Limbus lumbar vertebral fractures in 27 adolescents and adults.

Fractures of the lumbar vertebral limbus involve varying degrees of fragmentation of the peripheral ring apophysis, located at the posterior superior or posterior inferior margins of the mid to lower lumbar vertebrae. Four types, uniquely found in adolescents and young adults, have been described. Type I lesions consist of avulsions of the posterior cortical vertebral rim. Type II fractures are composed of central cortical and cancellous bone fractures. Type III lesions are more lateralized chip fractures. Type IV fractures span the entire length and breadth of the posterior vertebral margin between the end plates. The clinical, neuroradiologic, and surgical management of 27 patients with these four types of lumbar limbus vertebral fractures are reviewed. The data regarding location and type of fracture were critical for planning piecemeal surgical resection with a downbiting curette, tamp, and mallet technique.

A comparison of surgeon's assessment to patient's self analysis (short form 36) after far lateral lumbar disc surgery. An outcome study.

STUDY DESIGN: Between 1984 and 1994, 170 patients had surgery for far lateral discs. Patients were assessed by the surgeon as having poor (no improvement, increased deficit), fair (mild improvement, moderate residual deficit), good (moderate improvement, mild residual deficit) or excellent (marked improvement, no deficit) physical outcomes. The Medical Outcome Trust's SF-36 survey was completed by 76 (45%) patients, using one interviewer. OBJECTIVES: Patient-based outcome studies are becoming increasingly important. A surgeon's assessment of outcome was compared with the patients' self assessment (Short Form 36) after far lateral lumbar disc surgery. SUMMARY OF BACKGROUND DATA: The SF-36 survey provides measures on eight dimensions: physical function, role physical, bodily pain, general health, vitality, social function, role-emotional, and mental health. METHODS: Patients averaged 60.1 years of age, and included 43 men and 33 women. Patients were last examined an average of 9.1 months after their surgery, and were interviewed by telephone an average of 2.8 years later. RESULTS: Patients completing the survey were evaluated on their last visit to the surgeon as having excellent (32 patients), good (24), fair (12), and poor (8) outcomes. Overall correlations between the surgeon's assessment and all 76 patients' SF-36 scores were modest. However, for those patients examined within 4.5 years of the surgeon's assessment (n = 56), correlations were statistically significant for 6 of the SF-36 measures. Only general health and social function showed correlations less than 0.25. CONCLUSIONS: The surgeon's assessment was a particularly good predictor of SF-36 measures if the surgeon assessed the patient within the past 4.5 years. The SF-36 should be useful for large-scale outcome studies.

Traumatic myelopathy in a seventeen-year-old child with cervical spinal stenosis (without fracture or dislocation) and a C2-C3 Klippel-Feil fusion. A case report.

A 17-year-old white male patient sustained a cervical hyperextension injury while body surfing. Plain cervical radiographs, tomography, and CAT scan showed neither fracture nor subluxation, but congenital narrowing of the spinal canal and fusion of C2-C3 (Klippel-Feil). Clinically, he had a central cord syndrome, characterized by a motor dominant myelopathy. The conservative management of this patient with a central cord injury in the presence of spinal stenosis and a Klippel-Feil syndrome resulted in almost full recovery although he was quadriplegic initially. This constellation of findings rarely has been reported in adolescence.

Evaluation of intraoperative somatosensory-evoked potential monitoring during 100 cervical operations.

Continuous intraoperative somatosensory-evoked potential monitoring during scoliosis surgery, along with improved instrumentation techniques, has contributed to the reduction of neurologic injury from 4-6.9% to 0-0.7%. To assess whether somatosensory-evoked potential monitoring might play a similar role in cervical surgery, the authors compared the morbidity and mortality rates associated with 218 patients who were not monitored and were operated on between 1985-1989 with those found in 100 consecutive somatosensory-evoked potential monitored procedures done from 1989-1991. The cervical procedures were conducted for disc disease, stenosis, spondylosis, and ossification of the posterior longitudinal ligament. Eight of 218 unmonitored patients became quadriplegic (3.7%) and 1 died (0.5%); no instances of quadriplegia and no deaths were encountered among the 100 monitored patients. The reduction of neurologic deficit was attributed in part to early somatosensory-evoked potential detection of vascular or mechanical compromise of the spinal cord or nerve roots and to the immediate alteration of anesthetic or surgical technique in response to somatosensory-evoked potential changes, i.e., reversal of systemic or "relative" hypotension, adjustment of operative position, release of distraction, and cessation of manipulation. Continuous intraoperative somatosensory-evoked potential monitoring also was a practical tool in monitoring cervical surgery.

Spinal stenosis and disc herniation in a 14-year-old male. A case report.

Spinal stenosis should be considered in the differential diagnosis of disc disease when evaluating an adolescent presenting with unrelenting back and leg pain. Although they typically exhibit mechanical signs alone without neurological findings, they nevertheless may prove more vulnerable to rapidly progressive neurological changes. If motor deficits occur, protracted courses of conservative care should be avoided, and proper surgical management considered. Our recent experience with a 14-year-old boy with disc disease and stenosis indicated that aggressive surgical management facilitates a rapid return to an asymptomatic existence.

Advantages of topical marcaine during spinal surgery. Technical note.

Marcaine applied to irritated nerve roots during extradural spinal surgery may attenuate sympathetically mediated and somatosensory (pain)-related hypertensive and tachycardic crises.

Far lateral lumbar disc herniations and associated structural abnormalities. An evaluation in 60 patients of the comparative value of CT, MRI, and myelo-CT in diagnosis and management.

The management of 60 patients with far lateral lumbar disc herniations operated on over a 5-year period are presented. These lesions were located superiorly within the neural foramens beneath or distal to the facet joints. The type of surgery performed in 43 of 60 (72%) of these patients was significantly altered by the presence of diffuse and lateral recess stenosis. This was better appreciated on the myelogram and myelo-CT (M-CT) studies than with the noncontrast CT and MRI examinations alone. Myelo-CT findings were particularly valuable in assessing patients who had previous surgical procedures.

Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.

Herniated disks in children and adolescents can be extremely disabling and difficult to diagnose because of the paucity of neurologic abnormalities and the consequent suspicions of hysteria. The Laségue sign is often the only consistent positive finding, and when persisting without remission, justifies early diagnostic studies such as CT scanning, and electromyography. Myelography may be avoided if these studies are definitively diagnostic. The almost uniformly good results that follow diskectomy do not justify prolonged conservative care. Management is facilitated by awareness of often unrecognized structural abnormalities found in these patients. These include spinal stenosis, lateral recess narrowing, and transitional vertebra. Spinal fusion, while rarely indicated, should be considered where motion segment instability contributes to persistent backache. The management of 25 patients is recorded. Twenty-one of these presented with an anomaly worthy of record requiring modifications in surgical technique to provide proper decompression and lasting relief of symptoms.