Incidence and treatment of delayed symptoms of CSF leak following lumbar spinal surgery.

PURPOSE: Dural tear (DT) resulting in cerebrospinal fluid (CSF) leak is a common complication of spinal surgery. Most cases of DT are recognised and addressed intraoperatively; however, a small percentage of cases may present at a later stage with delayed symptoms of CSF leak, either due to an unrecognised intraoperative DT or as a result of a de novo delayed DT. Apart from few reports describing delayed symptomatic CSF leaks, most studies tend not to separate intraoperatively recognised DTs from delayed symptomatic CSF leaks. To our knowledge, there are no long-term studies describing specifically the incidence and management of this complication. The aim of this study is to determine the incidence of late presentation of dural tear (LPDT) following lumbar spinal surgery, its treatment, associated complications and clinical outcomes from long-term follow-up in a consecutive series of patients. METHODS: A retrospective review was conducted on 2052 consecutive patients who underwent spinal surgery by two spinal surgeons from 2000 to 2005 and 2007 to 2013 at two institutions. RESULTS: A total of 2052 patient records were reviewed. Seventeen patients (0.83%) were found to have LPDT, unrecognised intraoperatively. Fifteen patients required surgical intervention, one patient was treated with insertion of a subarachnoid drain and only one patient settled with conservative measures. Out of the 15 patients who underwent surgery, two patients required another operation and 2 patients were treated with a subarachnoid drain. At 9 months mean follow-up, there was no significant difference in outcome in cases with LPDT compared to those without. CONCLUSION: A delayed symptomatic presentation of DT unrecognised intraoperatively is a specific complication that needs to be recognised and treated appropriately. A high suspicion and vigilance can help discover and address delayed CSF leaks with no long-term sequelae.

Horner's syndrome secondary to intervertebral disc herniation at the level of T1-2.

A 54-year-old Caucasian woman presented with a 6 week history of periscapular pain and a T1 radiculopathy associated with Horner's syndrome. MRI of her cervicothoracic spine revealed an intervertebral disc herniation at the level of T1-2. During investigation she experienced some improvement in her symptoms and a conservative approach was pursued. At 6 months her pain and radiculopathy had resolved, and there was mild residual ptosis.

Scoliosis in association with infantile hypophosphatasia: a case study in two siblings.

STUDY DESIGN: A case study of scoliosis in two siblings with infantile hypophosphatasia and review of literature are presented. OBJECTIVES: To report the rare occurrence of scoliosis in two siblings with infantile hypophosphatasia and detail problems in the surgical management of scoliosis in this rare disease. SUMMARY OF BACKGROUND DATA: To the authors' knowledge there is only one reported case of scoliosis in infantile hypophosphatasia. However, there is no report describing the nature of the curve, its progression, or the surgical management of scoliosis in infantile hypophosphatasia. METHODS: The first sibling was diagnosed shortly after birth to have scoliosis that progressed rapidly despite brace treatment. At 4 years, he underwent anterior convex arthrodesis and posterior T6-L1 Luque trolley stabilization. Because of further curve progression, he had to undergo corrective anterior and posterior osteotomies, stabilization, and fusion at 11 years of age. The second sibling was diagnosed to have scoliosis at the age of 3 years and underwent anterior thoracoscopic release and posterior Luque trolley stabilization. RESULTS: The first sibling with a mild form of infantile hypophosphatasia had to undergo multiple procedures to attain fusion and arrest of curve progression. The second sibling with a severe variety of infantile hypophosphatasia surprisingly attained a spontaneous fusion of the curve following the initial correction and stabilization with no further progression at 9-year follow-up. CONCLUSIONS: Curve progression and fusion rates following scoliosis correction are not related to the disease severity or biochemical findings. These rapidly progressive curves are amenable to surgical correction despite the unfavorable metabolic nature of the disease. Hypercalcemia and seizures responding to pyridoxine are complications in the postoperative period of which the surgeon should be aware.

La quimionucleolisis en el tratamiento de la hernia discal lumbar resultados clínicos y radiológicos / The chymonucleolysis in the treatment for discal hernia. Clinics and radiolgical results

En este trabajo se intenta demostrar la eficacia o inocuidad de la quimionucleolisis en el tratamiento de la hernia discal como alternativa a la cirugía convencional. Para ello se seleccionó un grupo de 91 pacientes a los cuales se aplica dicha técnica, consistente en la inyección bajo control radiológico y mediante punción intradiscal, del enzima quiomiopapaína en el núcleo pulposo, con el fin de conseguir la disolución química del mismo. Se valora la respuesta clínica al tratamiento, así como radiológica, al mes a los 6 meses del mismo, practicándose radiografía de columna vertebral para valorar las curvas de presión intradiscales. De los 91 pacientes seleccionados, se obtuvieron resultados excelentes en 25 casos (29.41 por ciento), Buenos en 37 casos (43.52 por ciento), aceptables en 11 casos (12.94 por ciento), malos en 5 casos (5.88 por ciento), apreciándose correlación entre la disminución del volumen intradiscal y los resultados clínicos obtenidos.

Flexion osteotomy of the cervical spine: a new technique for correction of iatrogenic extension deformity in ankylosing spondylitis.

STUDY DESIGN: A new surgical technique of cervical osteotomy to correct an extension deformity of the cervical spine is described, and a case is reported. OBJECTIVES: To emphasize the disparate effect of osteotomy level on sagittal balance and gaze angle in surgical correction of global kyphotic deformity, and to describe a new surgical technique. SUMMARY OF BACKGROUND DATA: Previous reports of cervical osteotomy essentially have described extension osteotomy for correction of severe flexion deformity. To the authors' knowledge, flexion osteotomy to correct extension deformity of the cervical spine has not been described previously. METHODS: A 44-year-old woman with global kyphotic deformity caused by ankylosing spondylitis underwent corrective lumbar osteotomy at another institution. Ten years later, she experienced further development of the kyphosis, predominantly at the thoracic level, with resultant restriction of forward gaze. Thoracic corrective osteotomy was performed, which resulted in an upward deviation of her visual field. A flexion osteotomy was performed at C7-T1, using two separate posterior and anterior approaches, in one-stage, in the lateral decubitus. The use of transparent drapes permitted direct visualization of the chin-brow angle during operation. Anterior plate fixation prevented any translation at the osteotomy site. RESULTS: The osteotomy united; the gaze angle was fully corrected (45 degrees to -30 degrees ). No deterioration was noted at 2-year follow-up. CONCLUSIONS: Osteotomy at a higher level in the spine for correction of global kyphotic deformity may result in a significant overcorrection of the gaze angle upward. The authors believe that the new technique described in this report is a technically demanding but adequate and safe approach for correcting such a rare deformity.

Sledging related spinal injuries and fracture patterns: a report on five cases.

The cases are reported of five patients who presented to The Queens Medical Centre, Nottingham after a sledging accident. All five patients presented consecutively during the first weekend in 1997 having sustained the accident in the same public park. The mechanism and subsequent fracture type is described for each. These injuries are preventable, and increasing public awareness of the risk of sledging in public places may reduce the incidence.

Occipital condyle fracture with peripheral neurological deficit.

A 24-year-old woman sustained a type III Anderson and Montesano fracture in a road traffic accident. Acute respiratory stridor, multiple cranial nerve palsies and right upper limb neurological deficits associated with a C1 to T2 extradural haematoma were unique features of this case. The patient made a full and uncomplicated recovery with conservative management.

Progressive thrombotic occlusion of the left common iliac artery after anterior lumbar interbody fusion.

We report a case of progressive thrombotic occlusion of the left common iliac artery in a 41-year-old woman after anterior interbody fusion, which initially presented only as a sensation of numbness. Diagnosis was delayed until complete arterial occlusion occurred 36 h after surgery. A sensory deficit may be the only early sign of a progressive thrombotic arterial occlusion. In anterior spinal surgery, routine postoperative vascular monitoring of the lower extremities is recommended and mandatory for early diagnosis and treatment of this rare complication.

Anterior vertebral body screw pullout testing. A comparison of Zeilke, Kaneda, Universal Spine System, and Universal Spine System with pullout-resistant nut.

STUDY DESIGN: A biomechanical study of pullout of anteriorly implanted screws in cadaveric vertebral bodies. OBJECTIVES: To investigate and compare the pullout strength of the Zielke, Kaneda, Universal Spine System (USS) pedicle screw, and USS pedicle screw with a new pullout-resistant nut. SUMMARY OF BACKGROUND DATA: A common problem with anterior purchase regardless of the implant system is screw pullout at the proximal and distal ends of multilevel constructs. There is limited information on a solution to this problem. METHODS: The L1 to L4 vertebral bodies from four cadavers had one each of Zielke and Kaneda pedicle screws (Acromed Corp., Cleveland, OH), USS pedicle screw (Synthes Spine, Paoli, PA), and USS pedicle screw with pullout-resistant nut implanted transversely across the center of the vertebral body with bicortical purchase in a similar fashion as would be used clinically. The screws were extracted using a servohydraulic material testing system. The maximum axial forces were recorded. RESULTS: The Zielke and Kaneda screws had no significant difference in mean pullout strength (P = 0.542). The USS screw alone was less strong (P = 0.009). The USS screw and pullout-resistant nut increased the pullout strength by twofold (P = 0.00006). In the screw pullout tests, the mode of failure was at the screw thread's interface. The USS screw and pullout-resistant nut failed by imploding the body around the nut. With the USS screw and pullout-resistant nut, the pullout strength was determined by the compressive strength of the bone. CONCLUSIONS: The addition of a pullout-resistant nut to an anterior vertebral body screw improves the pullout strength by twofold and changes the mode of failure to rely ultimately on the inherent vertebral body strength rather than the screw's characteristics. The addition of a pullout-resistant nut may be applicable to multilevel implant constructs to prevent screw pullout at the top and bottom.

Atlanto-axial dislocation without fracture: case report of an ejection injury.

We describe an unusual injury to the upper cervical spine sustained during ejection from an aircraft. MRI provided an accurate and direct diagnosis of the severe ligamentous injuries.

The short form-36 health survey questionnaire in spine surgery.

The Short Form-36 (SF-36) health questionnaire has been put forward as a general measure of outcome in health care and has been evaluated in several recent studies in the UK. We report its use in three groups of patients after spinal operations and have compared it with the Oswestry and Low Back Pain disability scales. There was a significant correlation between all variables of the SF-36 and the low-back scores. The mental-health items had the weakest correlation. Our study shows that the SF-36 questionnaire is valid and has internal consistency when applied to these patients.

Talar neck fracture with talar head dislocation and intact ankle and subtalar joints: a case report.

The authors describe a rare case of fracture of the neck of the talus associated with talonavicular dislocation but no disruption of the ankle and subtalar joints. The fracture united after open reduction and internal fixation. The head of the talus revealed avascular necrosis but the body did not. A literature review retrieved one previous report of a similar injury, but it was open and became infected. The unique features of this injury pattern and its specific complication, isolated avascular necrosis of the talar head, are discussed.