Cervical endplate and facet arthrosis: an anatomic study of cadaveric specimens.

STUDY DESIGN: An anatomic, epidemiologic study of cervical endplate and facet arthrosis in cadaveric spines. OBJECTIVE: To determine the prevalence of cervical endplate and facet arthrosis and the relationship between these 2 entities in a large population sample. SUMMARY OF BACKGROUND DATA: Cervical endplate and facet arthrosis are common radiographic findings, which have both been linked to pain. However, the prevalence and relationship between cervical endplate and facet arthrosis has not been clearly defined. METHODS: The cervical vertebrae from 234 cadaveric spines were examined by a single investigator for evidence of endplate and facet arthrosis. Arthrosis at each endplate and facet was graded on a continuum from 0 to IV. Race, age at death, and sex of each specimen were also recorded. Stepwise multiple linear regression was used to analyze any association between race, age, sex, endplate arthrosis, and facet arthrosis. Factors with P values <0.05 remained in the analysis. Two-tailed t tests for matched samples were used to analyze any difference between mean endplate and facet arthrosis severity scores among patients within the same decades of life. RESULTS: Concurrent cervical endplate and facet arthrosis was present in 77% of the study population. Stepwise multiple linear regression revealed significant (P<0.01) associations between endplate and facet arthrosis and between age and facet arthrosis. Race and sex did not correlate with facet arthrosis. In addition, patients in age groups 30 to 39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, and 80 to 89 demonstrated more severe (P<0.01) endplate arthrosis in comparison with facet arthrosis. CONCLUSIONS: Concurrent cervical endplate and facet arthrosis is a common condition. Cervical endplate arthrosis and advancing age are associated with cervical facet arthrosis independent of race and sex. Cervical endplate arthrosis precedes facet arthrosis.

Wound infections after surgery for neuromuscular scoliosis: risk factors and treatment outcomes.

STUDY DESIGN: Retrospective, case-control study. OBJECTIVE: Determine risk factors for postoperative wound infections after surgery for neuromuscular scoliosis as well as the causative organisms and the results of treatment. SUMMARY OF BACKGROUND DATA: Wound infection after surgery for neuromuscular scoliosis is more common than that for idiopathic scoliosis. A variety of potential risk factors have been identified, but few have demonstrated statistical significance. METHODS: The Pediatric Orthopedic Spine Database identified 151 patients with neuromuscular scoliosis who underwent surgery and had a follow-up of minimum of 2 years. A total of eight patients (5.3% prevalence) developed a postoperative wound infection. Nine patients without an infection were matched by year and type of surgery, for each patient with an infection and selected as controls (n = 72). Preoperative, intraoperative, and postoperative factors were analyzed for an association with wound infection by using stepwise logistic regression. In addition, causative organisms as well as the methods and results of treatment were recorded for each patient. RESULTS.: The control group consisted of 32 males and 40 females with a mean age of 13.3 years (range, 7-21 years) and a mean follow-up of 4.6 years (range, 2.0-20.9 years) at surgery. The infection group (n = 8) consisted of four males and four females with a mean age of 12.5 years (range, 11-14 years) and a mean follow-up of 5.1 year (range, 2.0-12.3 years) at surgery. There were five early and three late wound infections. The presence of a ventriculoperitoneal shunt before surgery was the only factor statistically associated with an increased risk for wound infection (P < 0.01). In addition, infection was associated with pseudarthrosis (P < 0.01) and an increased length of hospitalization (P < 0.01). The most common causative species was staphylococcus and the majority (88%) of infections required surgical intervention with a mean of 2.1 debridements (range, 1-4 debridements). CONCLUSIONS: The presence of a ventriculoperitoneal shunt is a statistically significant risk factor for wound infection after corrective surgery for neuromuscular scoliosis. Wound infection is associated with pseudarthrosis and prolonged hospitalization. LEVEL OF EVIDENCE: III.

Risk factors for major complications after surgery for neuromuscular scoliosis.

STUDY DESIGN: Retrospective, case series. OBJECTIVE: To determine the prevalence of major complications and to identify factors that increase the risk of complications in patients undergoing surgery for neuromuscular scoliosis. SUMMARY OF BACKGROUND DATA: Complications after surgery for neuromuscular scoliosis are more prevalent than in idiopathic scoliosis. However, the associated risk factors have not been statistically significant. METHODS: Our computerized Pediatric Orthopedic Spine Database identified 131 consecutive patients with neuromuscular scoliosis, excluding those with myelodysplasia, who underwent surgery and had a minimum of 2 years of follow-up. Preoperative, intraoperative, and postoperative factors were analyzed for any association with major complications and length of stay using stepwise logistic and multiple regression analyses. Odds ratios were calculated for significant dichotomous variables, and receiver operator characteristic curves were created for significant continuous variables. RESULTS: There were 81 male and 50 female patients with a mean age at surgery of 13.4 years (range, 6-21 years). The majority of patients (n = 75) had cerebral palsy. Eighty-eight patients (67%) underwent posterior spinal fusion and segmental spinal instrumentation (only), whereas 43 patients (33%) underwent an anterior spinal fusion followed by a posterior spinal fusion with segmental spinal instrumentation. Seventy-seven patients (59%) were fused to the pelvis using the Galveston technique. The mean follow-up was 3.9 years (range, 2-16.9 years). There were 46 major complications in 37 patients (28% prevalence), including 2 deaths.Nonambulatory status (P < 0.05) and preoperative curve magnitude (P < 0.01) were associated with an increased prevalence of major complications. Nonambulatory patients (n = 94) were almost 4 times more likely to have a major complication (odds ratio of 3.8, P < 0.05) in comparison with ambulatory patients. A preoperative major curve magnitude of ≥ 60° (P < 0.01) was the most accurate indicator for an increased risk for a major complication. CONCLUSION: Nonambulatory status and a preoperative curve magnitude (≥ 60°) are directly associated with an increased risk for major complications and indirectly associated with increased length of stay. As such, we recommend operative intervention in neuromuscular scoliosis before curve progression to ≥ 60°. Level of Evidence. Level III.

Complications of mandibular distraction osteogenesis.

BACKGROUND: Mandibular hypoplasia, retrognathia, and micrognathia are commonly encountered problems in pediatric plastic surgery. Mandibular distraction osteogenesis (MDO) is a relatively simple technique that allows for correction of the deformity with minimal morbidity. However, MDO can lead to a wide variety of complications. METHODS: The PubMed database was queried for all articles describing complications of MDO. Each article was then reviewed, and relevant data were extracted and compiled. Finally, several case reports are presented to illustrate poignant examples of complications. RESULTS: Complications of MDO include relapse (64.8% incidence), tooth injury (22.5%), hypertrophic scarring (15.6%), nerve injury (11.4%), infection (9.5%), inappropriate distraction vector (8.8%), device failure (7.9%), fusion error (2.4%), and temporomandibular joint injury (0.7%). CONCLUSIONS: Mandibular distraction osteogenesis can be associated with a wide variety of minor and major complications, but all complications can be avoided with careful planning and technique.

Prevalence of concurrent lumbar and cervical arthrosis: an anatomic study of cadaveric specimens.

STUDY DESIGN: An anatomic, epidemiologic study of lumbar and cervical arthrosis in cadaveric spines. OBJECTIVE: Determine the prevalence of combined lumbar and cervical arthrosis in a large population sample and examine its association with age, sex, and race. SUMMARY OF BACKGROUND DATA: Lumbar and cervical arthrosis are common radiographic findings, which have both been linked to pain. However, the prevalence of and temporal relationship between combined lumbar and cervical arthrosis has not been defined. METHODS: The lumbar and cervical segments from 234 cadaveric spines were examined by a single investigator for evidence of endplate and facet arthrosis. Arthrosis at each endplate and facet was graded on a continuum from 0 to IV. Race, age at death, and sex of each specimen was recorded.Stepwise multiple linear regression was used to analyze any association between race, age, sex, lumbar arthrosis, and cervical arthrosis. Factors with P-values <0.05 remained in the analysis. T tests for matched samples were used to analyze any difference between the mean lumbar and cervical arthrosis severity among patients within the same decades of life. RESULTS: Concurrent lumbar and cervical arthrosis was present in 80% of the study population. Stepwise multiple linear regression revealed significant (P < 0.01) associations between lumbar arthrosis and cervical arthrosis and between age and cervical arthrosis. Race and sex did not correlate with lumbar or cervical arthrosis. In addition, patients in age groups 20 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, and 80 to 89 demonstrated more severe (P < 0.01) lumbar arthrosis in comparison to cervical arthrosis. CONCLUSION: Concurrent lumbar and cervical arthrosis is a common condition. Lumbar arthrosis and advancing age are associated with cervical arthrosis independent of race and sex. Lumbar arthrosis precedes cervical arthrosis. These findings suggest an underlying systemic component for spinal osteoarthritis.

Spinal cord monitoring for scoliosis surgery in Rett syndrome: can these patients be accurately monitored?

STUDY DESIGN: A level III retrospective comparative study. OBJECTIVE: Assess the clinical efficacy of somatosensory-evoked potential (SSEP) spinal cord monitoring (SCM) in Rett syndrome patients undergoing scoliosis surgery. SUMMARY OF BACKGROUND DATA: The role of SCM in neuromuscular scoliosis is less accurate compared with idiopathic scoliosis because of the nature of the neuropathic or myopathic disorder. Currently, there are no studies that have specifically addressed the accuracy of SCM in Rett syndrome. METHODS: A retrospective study to assess the clinical efficacy of SSEP SCM in Rett syndrome patients undergoing scoliosis surgery. Somatosensory-evoked potentials were monitored in 7 patients (8 procedures) with Rett syndrome undergoing scoliosis surgery. Transcranial motor-evoked potentials were not performed because of a concomitant history of seizures. The specific methods of anesthesia and SSEP monitoring were standardized for all patients. RESULTS: Adequate baseline and intraoperative SSEP measurements could be obtained in all patients. There were no false-negative or false-positive results. There were 7 true-negative and 1 true-positive results during surgery. The latter was a signal amplitude decrease that did not immediately resolve with standard interventions. Consequently, a Stagnara wake-up test was performed that showed spontaneous muscle activity in both lower extremities. No intravenous steroids were given, and the procedure was completed. The patient had transient unilateral lower extremity motor weakness postoperatively, but recovered preoperative muscle function within 24 hours. CONCLUSIONS: Patients with Rett syndrome undergoing scoliosis surgery can be successfully monitored with SSEPs. A history of seizures is a relative contraindication to transcranial motor-evoked potentials. Monitoring can accurately alert the surgeon to potential intraoperative spinal cord compromise and, therefore, decrease postoperative morbidity.