Early versus late stabilization of the spine in the polytrauma patient.

STUDY DESIGN: Systematic review. OBJECTIVE: To determine whether early spinal stabilization in the multiple trauma patient is safe and does not increase morbidity or mortality. SUMMARY OF BACKGROUND DATA: There is no consensus regarding the timing of surgical stabilization of the injured spine, especially in patients with multiple trauma. Designing and performing randomized clinical trials to evaluate early versus late surgery is difficult. METHODS: Between January 1990 and July 2009, a computer-aided search using the keywords Spine or Spinal, Trauma, Spinal Cord Injury, and Surgery was done that included MEDLINE, EMBASE, HealthSTAR, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, PsycINFO, and PsychLit. Articles dealing only with neurologic improvement that did not mention other non-neurologic factors that were affected by early surgery were excluded. The authors selected and assessed the studies to be included in the analysis. An unblinded assessment of the quality of the study was done using the Gradeing of Recommendation, Assessment, Development and Evaluation approach to rank each article for its relevance to the topic. RESULTS: Eleven articles directly comparing 2 cohorts that had early or late surgery were identified. All of the studies evaluated consistently demonstrated shorter hospital and intensive care unit length of stays, fewer days on mechanical ventilation, and lower pulmonary complications in patients who are treated with early spine decompression and stabilization. These advantages are more marked in patients with polytrauma. Data regarding morbidity and mortality rates are more variable. CONCLUSION: There is strong evidence within the literature that early surgical stabilization consistently leads to shorter hospital stays, shorter intensive care unit stays, less days on mechanical ventilation, and lower pulmonary complications. This effect is more evident in patients who have more severe injuries as measured by Injury Severity Score. This benefit is seen in both, spinal cord injured and noncord-injured patients. There is also some evidence that early stabilization does not increase the complication rates compared to late surgery.

The effect of an anterior cervical operation for cervical radiculopathy or myelopathy on associated headaches.

BACKGROUND: Headaches related to the cervical spine have been reported by various authors, and modalities of treatment are as varied as their speculated causes. The purpose of this study was to determine if anterior cervical reconstructive surgery (cervical arthrodesis and disc arthroplasty) for the treatment of radiculopathy or myelopathy also helps to alleviate associated headaches. METHODS: We conducted a post hoc analysis of study cohorts combined from prospective studies comparing the results of Prestige and Bryan cervical arthroplasty devices and those of anterior cervical arthrodesis with allograft and anterior instrumentation. A total of 1004 patients (51.6% were male) were evaluated with use of the Neck Disability Index questionnaire preoperatively and at five points postoperatively, with the latest evaluation at twenty-four months, resulting in a follow-up of 803 patients. RESULTS: At the twenty-four-month follow-up, the improvement from baseline with regard to headache was significant in both groups (p < 0.0001), with patients who underwent arthroplasty reporting numerically better pain scores. Most arthroplasty and arthrodesis patients (64% and 58.5%, respectively) had improvement in the pain score of at least one grade. Conversely, the pain scores for 8.4% of those who had an arthroplasty and 13.7% of those who had arthrodesis worsened by at least one grade. For the remainder, the score was unchanged. Overall, the patients who had an arthroplasty had significant improvement more frequently than did the patients who had arthrodesis (p = 0.011). CONCLUSIONS: At two years postoperatively, patients undergoing anterior cervical operations, both those who have an arthroplasty and those who have an arthrodesis, for cervical radiculopathy and myelopathy can be expected to have significant improvement from baseline with regard to headache symptoms.

Comparison of single-level cervical fusion and a metal-on-metal cervical disc replacement device.

Cervical fusion is the common treatment for cervical disc disease but can cause secondary disorders. The Prestige ST cervical disc prosthesis (Medtronic Sofamor Danek, Memphis, TN) was designed to preserve spinal motion to potentially limit the secondary disorders. In this article, we report 2-year results from a single-center study comparing use of this device with use of anterior cervical discectomy and fusion (ACDF). Nineteen patients were prospectively randomized to receive the device or to undergo ACDF. Twenty-four months after surgery, patients who received the device demonstrated improvement in neck pain, arm pain, and neurologic function. In our cohort, patients who underwent arthroplasty demonstrated greater improvement in neurologic function and neck pain than patients who underwent cervical discectomy and fusion.

Anatomic consideration for standard and modified techniques of cervical lateral mass screw placement.

BACKGROUND CONTEXT: Posterior screw placement techniques have been previously described. Each technique differs with respect to starting point, lateral angulation and sagittal orientation. PURPOSE: To examine the potential for injury to critical anatomic structures, such as nerve roots and vertebral arteries, during posterior cervical screw placement and to determine safe screw placement. STUDY DESIGN/SETTING: An anatomic study was conducted to determine the optimal screw angulation for posterior cervical lateral mass screws. SPECIMEN SAMPLE: Ten fresh-frozen human cadaveric cervical spine specimens were used, consisting of four females and six males, ranging in age from 32 to 68 years. OUTCOME MEASURES: Angular measurements and distance from nerve root and vertebral arteries were measured with a single caliper and recorded. One millimeter of proximity to a vital structure was considered a violation of that structure. METHODS: Ten fresh-frozen human cadaveric cervical spine specimens were instrumented from C2 to C7 by a single surgeon. Kirschner wires (2.0 mm) were used to reproduce the Roy-Camille, Anderson and Magerl screw trajectories. The wire was drilled through each lateral mass, simulating overdrill error. Each technique was instrumented according to the original description and with additional modifications. The modification consisted of varying the angle of screw placement in the axial plane of the original description from 0 to 30 degrees. Distances to the closest neurovascular structures were averaged for all assays. RESULTS: The Magerl technique is safe at the standard position and modified positions of 20 degrees and 30 degrees from C3-C6. The Roy-Camille technique frequently violates neurovascular structures below C3, especially the nerve root with more lateral screw angulation. The standard technique is noted to have good bone purchase only at C2 and C3. The Anderson technique is safe at 20 degrees and 30 degrees modified positions from C3-C7. Posterior screw placement at the C7 vertebral level was safe only with a modified Anderson technique of 20 degrees and 30 degrees of lateral screw angulation. CONCLUSIONS: The present study indicates that there are significant differences of potential neurovascular injury, which is dependent on the technique used for screw entry, the level instrumented and the angle of screw trajectory in the parasagittal plane.