Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project.

INTRODUCTION AND PURPOSE: Little information exists on surgical characteristics, complications and outcomes with corrective surgery for rigid cervical kyphosis (CK). To collate the experience of international experts, the CSRS-Europe initiated an international multi-centre retrospective study. METHODS: Included were patients at all ages with rigid CK. Surgical and patient specific characteristics, complications and outcomes were studied. Radiographic assessment included global and regional sagittal parameters. Cervical sagittal balance was stratified according to the CSRS-Europe classification of sagittal cervical balance (types A-D). RESULTS: Eighty-eight patients with average age of 58 years were included. CK etiology was ankylosing spondlitis (n = 34), iatrogenic (n = 25), degenerative (n = 9), syndromatic (n = 6), neuromuscular (n = 4), traumatic (n = 5), and RA (n = 5). Blood loss averaged 957 ml and the osteotomy grade 4.CK-correction and blood loss increased with osteotomy grade (r = 0.4/0.6, p < .01). Patients with different preop sagittal balance types had different approaches, preop deformity parameters and postop alignment changes (e.g. C7-slope, C2-7 SVA, translation). Correction of the regional kyphosis angle (RKA) was average 34° (p < .01). CK-correction was increased in patients with osteoporosis and osteoporotic vertebrae (POV, p = .006). 22% of patients experienced a major long-term complication and 14% needed revision surgery. Patients with complications had larger preop RKA (p = .01), RKA-change (p = .005), and postop increase in distal junctional kyphosis angle (p = .02). The POV-Group more often experienced postop complications (p < .0001) and revision surgery (p = .02). Patients with revision surgery had a larger RKA-change (p = .003) and postop translation (p = .04). 21% of patients had a postop segmental motor deficit and the risk was elevated in the POV-Group (p = .001). CONCLUSIONS: Preop patient specific, radiographic and surgical variables had a significant bearing on alignment changes, outcomes and complication occurrence in the treatment of rigid CK.

Anaplastic extramedullary cervical ependymoma with leptomeningeal metastasis.

We present a rare extramedullary ependymoma with diffuse spinal metastatic disease, and review the previous reports of extramedullary spinal ependymomas. Ependymomas are the most common intramedullary spinal cord tumor in adults. These tumors rarely present as extramedullary masses. We treated a 23-year-old man with a history of progressive neck, shoulder and arm pain, with sensory and motor symptoms in the C7 dermatome. MRI of the cervical spine demonstrated a ventral contrast-enhancing lesion with evidence of enhancement along the dura and spinal cord of the upper cervical spine, thoracic spine, and cauda equina. He underwent a tumor debulking procedure without complications. Following surgery, he received craniospinal radiation to treat the remaining tumor and diffuse leptomeningeal disease. The final pathology of the tumor revealed that is was a World Health Organization Grade III anaplastic ependymoma. At the 1 year follow-up, the patient had stable imaging and had returned to his preoperative functional status. Of the 19 reported patients with primary intradural, extramedullary spinal ependymomas, two had extradural components and seven had anaplastic grades. Only one tumor with an anaplastic grade resulted in metastatic disease, but without spinal recurrence. To our knowledge, this is the first report of an intradural, extramedullary spinal ependymoma with an anaplastic grade, presenting with concomitant diffuse, nodular leptomeningeal metastasis involving the upper cervical spine, thoracic spine, conus medullaris, and cauda equina. Similar to the treatment of intramedullary ependymomas with metastasis, this patient underwent an aggressive debulking procedure followed by radiation therapy to the entire neuroaxis.

Classification of civilian craniocerebral gunshot wounds: a multivariate analysis predictive of mortality.

Management of cerebral gunshot injuries has changed considerably since Cushing's (1916) and Matson's (1948) classification schemes, developed during World War I and World War II, respectively. These military injuries are characterized by either very high mass, low-velocity shrapnel wounds or by high muzzle velocity missiles causing extensive destruction of tissue. The preponderance of low muzzle velocity weapons seen in clinical practice and the availability of computed tomographic (CT) evaluation within minutes after presentation has altered the range of prognostic indicators available to the neurosurgeon and the amount of relative importance placed on each factor. Raimondi and Samuelson (1970) noted this difference in wound ballistics and offered a classification scheme based on initial neurologic assessment. No well-defined classification system for civilian craniocerebral gunshot wounds has been proposed that evaluates and integrates clinical, laboratory, and neuroradiologic data. A retrospective study was performed on all 62 civilians with gunshot wounds to the head admitted to the University of Virginia Hospital between December, 1984, and November, 1990. The patient population consists of 86% males and 14% females, with an age range of 10-72 years; 60% self-inflicted wounds and 32% patients who died en route or immediately upon arrival at the hospital. The overall mortality rate was 55% at 1 week postinjury. Although we have demonstrated an association between some previously defined factors and prognosis in civilian injury, such as admission Glasgow Coma Scale (GCS) (p = 0.001) and initial pupillary response (p less than 0.001), we have also defined other significant predictors of outcome including abnormal coagulation states on admission (p less than 0.001) and the neuroradiologic examination.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgeon's foot: a report of sural nerve palsy.

Although compression neuropathies are encountered frequently in neurosurgical practice, involvement of the sural nerve is described rarely. We report a case of bilateral compression neuropathy of the sural nerve with an unusual mechanism of injury. The case is discussed, and the pertinent literature is reviewed.

Neurosurgical applications of fibrin glue: augmentation of dural closure in 134 patients.

In a wide variety of neurosurgical procedures performed on 134 patients over a 3-year period, fibrin glue has been applied as an adjunct to dural closure. Overall success at preventing cerebrospinal fluid (CSF) leakage was 90% (121 of 134, 90% effective). In patients considered to be at high risk for CSF leakage intraoperatively but without pre-established fistulae (Group 1), the success rate was higher (111 of 119, 93% effective). In patients with pre-established CSF fistulae (Group 2), the success rate was lower (10 of 15, 67% effective). As single donor sources of concentrated fibrinogen are now available with reduced risks of blood-borne disease transmission, fibrin glue may be a valuable clinical tool for the neurosurgeon.

Multilevel thoracic pedicle aplasia causing congenital thoracic kyphosis: case report.

OBJECTIVE AND IMPORTANCE: Congenital thoracic kyphosis is a rare cause of treatable myelopathy. Multilevel thoracic pedicle aplasia as a cause of this deformity has not been previously reported in the literature. We report a case and describe the surgical management and outcome. CLINICAL PRESENTATION: A 14-year-old boy presented to us with a 4-month history of back pain and slowly progressive spastic paraparesis. Radiographic studies revealed thoracic kyphosis and bilateral aplasia of the pedicles of T4-T8. INTERVENTION: The patient underwent surgical treatment via a posterior approach for decompression of T4-T8, followed by arthrodesis from T2 to T12, using a hook claw construct with multiple points of fixation and autologous bone grafting. CONCLUSION: Congenital vertebral anomalies may be clinically occult, and delayed presentation may occur in adolescence or adulthood. Aplasia of multiple thoracic pedicles can produce kyphotic deformities with neurological compromise. A posterior approach with multiple points of segmental instrumentation can be effective in treating kyphotic deformities that are flexible and of moderate severity (<75 degrees).

Tumoral calcium pyrophosphate dihydrate deposition disease mimicking a cervical spine neoplasm: case report.

A case of tumoral calcium pyrophosphate dihydrate crystal deposition disease involving the upper cervical spine is reported. It presented clinically, radiographically, and by preliminary intraoperative pathological evaluation as a possible malignant soft tissue tumor. An aggressive resection of the lesion was performed. This case differs from previous reports of calcium pyrophosphate dihydrate crystal deposition disease of the cervical spine by the size, location, and radiographic appearance of the lesion. We suggest that radical surgical procedures should not be performed without consideration of this diagnosis in lesions with similar presentations. A brief review of spinal and tumoral calcium pyrophosphate dihydrate crystal deposition is presented.

Fusion with occipital bone for atlantoaxial instability: technical note.

A technique is described of using autologous occipital bone for posterior atlantoaxial fusions. The advantages include the ease of harvest, the lack of postoperative discomfort, and the suitability of occipital bone for the fusion.

Atypical hemifacial microsomia associated with Chiari I malformation and syrinx: further evidence indicating that chiari I malformation is a disorder of the paraaxial mesoderm. Case report and review of the literature.

The authors present the first known reported case of hemifacial microsomia associated with a Chiari I malformation and syrinx. A 14-year-old girl presented with progressive torticollis of 3 years' duration and headaches exacerbated by exercise. Computerized tomography scanning and magnetic resonance imaging revealed extensive craniofacial and vertebral abnormalities, including aplasia of the floor of the left middle fossa and posterior fossa cranium, articulation of the left mandibular condyle with the left temporal lobe, and progressive development of a Chiari I malformation with associated syringomyelia. The patient first underwent posterior fossa decompression, duraplasty, and occipitocervical fusion. This procedure was later followed by reconstruction of the floor of the left middle fossa and temporomandibular joint. The patient's outcome was excellent. In this case report the authors review the complex embryological development of craniofacial and craniovertebral structures, and emphasize the use of a staged approach to treat pathophysiological consequences of this congenital anomaly.

Thoracic duct injury during anterior cervical discectomy: a rare complication. Case report.

Chylous fistula resulting from intraoperative injury to the cervical thoracic duct is well described as a complication of neck dissection. However, injury to the thoracic duct during spinal surgery is rarely reported. The authors present the first case of thoracic duct injury occurring during cervical discectomy and fusion via an anterior approach. The anomalous location of the terminal arch of the thoracic duct in this patient contributed to the complication. The morbidity of chyle leakage is minimized by its early recognition, a thorough understanding of lymphatic system anatomy, and aggressive management of the thoracic duct injury.

Management of complex pediatric and adolescent spinal deformity.

OBJECT: The authors sought to analyze prospectively the outcome of surgery for complex spinal deformity in the pediatric and young adult populations. METHODS: The authors evaluate all pediatric and adolescent patients undergoing operative correction of complex spinal deformity from December 1997 through July 1999. No patient was lost to follow-up review (average 21.1 months). There were 27 consecutive pediatric and adolescent patients (3-20 years of age) who underwent 32 operations. Diagnoses included scoliosis (18 idiopathic, five nonidiopathic) and four severe kyphoscoliosis. Operative correction and arthrodesis were achieved via 21 posterior approaches (Cotrel-Dubousset-Horizon), seven anterior approaches (Isola or Kaneda Scoliosis System), and two combined approaches. Operative time averaged 358 minutes (range 115-620 minutes). Blood loss averaged 807 ml (range 100-2,000 ml). Levels treated averaged 9.1 (range three-16 levels). There was a 54% average Cobb angle correction (range 6-82%). No case was complicated by the patient's neurological deterioration, loss of somatosensory evoked potential monitoring, cardiopulmonary disease, donor-site complication, or wound breakdown. There was one case of hook failure and one progression of deformity beyond the site of surgical instrumentation that required reoperation. There were 10 minor complications that did not significantly affect patient outcome. No patient received undirected banked blood products. There was a significant improvement in cosmesis, and no patient experienced continued pain postoperatively. All patients have been able to return to their preoperative activities. CONCLUSIONS: Compared with other major neurosurgical operations, segmental instrumentation for pediatric and adolescent spinal deformity is a safe procedure with minimal morbidity and there is a low risk of needing to use allogeneic blood products.

Modified open-door laminoplasty for treatment of neurological deficits in younger patients with congenital spinal stenosis: analysis of clinical and radiographic data.

OBJECT: Multilevel anterior cervical decompressive surgery and fusion effectively treats cervical myeloradiculopathy that is caused by severe cervical spinal stenosis, but degenerative changes at adjacent vertebral levels frequently result in long-term morbidity. The authors performed a modified open-door laminoplasty procedure in which allograft bone and titanium miniplates were used to treat cervical myeloradiculopathy in younger patients with congenital canal stenosis while maintaining functional cervical motion segments. Pre- and postoperative magnetic resonance imaging and/or computerized tomography myelography were performed to assess changes in cervical spinal canal dimensions. Pre- and postoperative flexion-extension radiographs were compared to determine the residual motion of the targeted operative segments. METHODS: Twenty younger patients (average age 37.7 years) underwent modified open-door laminoplasty for treatment of myelopathy or myeloradiculopathy related to significant cervical spinal stenosis with or without associated central or lateral disc herniation or foraminal stenosis. These surgeries were performed during a 2-year period and follow-up review remains ongoing (average follow-up period 21.6 months). Reconstructive procedures were performed on an average of 4.1 levels (range three-six). Operative time averaged 186 minutes (range 93-229 minutes). Average blood loss was 305 ml (range 100-650 ml). No cases were complicated by neurological deterioration, infection, wound breakdown, graft displacement, or hardware failure. The patients' Nurick Scale grade improved from a preoperative average of 1.8 to a postoperative average of 0.5. Pre- and postoperative sagittal spinal diameter averaged 11.2 mm (8-14 mm) and 16.6 mm (13-19 mm), respectively. The sagittal compression ratio (sagittal/lateral x 100%) increased from 48% pre- to 72% postoperatively. The spinal canal area increased an average of 55% (range 19-127%). In patients in whom pre- and postoperative flexion-extension radiographs were obtained, 72.7% residual neck motion was maintained. No patient developed increased neck or shoulder pain. Neurological symptoms improved in all patients, with total relief of myelopathy in 50% and partial improvement in 50%. CONCLUSIONS: Modified open-door laminoplasty with allograft bone and titanium miniplates effectively treats neurological deficits in younger patients with congenital and spinal stenosis. Although long-term results are unknown, short-term results are good and there is a low incidence of complications.

Efficacy of the Ghajar Guide revisited: a prospective study.

OBJECT: The goal of this study was to compare the freehand technique of catheter placement using external landmarks with the technique of using the Ghajar Guide for this procedure. The placement of a ventricular catheter can be a lifesaving procedure, and it is commonly performed by all neurosurgeons. Various methods have been described to cannulate the ventricular system, including the modified Friedman tunnel technique in which a soft polymeric tube is inserted through a burr hole. Paramore, et al., have noted that two thirds of noninfectious complications have been related to incorrect positioning of the catheter. METHODS: Forty-nine consecutive patients were randomized between either freehand or Ghajar Guide-assisted catheter placement. The target was the foramen of Monro, and the course was through the anterior horn of the lateral ventricle approximately 10 cm above the nasion, 3 cm from the midline, to a depth of 5.5 cm from the inner table of the skull. In all cases, the number of passes was recorded for successful cannulation, and pre- and postplacement computerized tomography scans were obtained. Calculations were performed to determine the bicaudate index and the distance from the catheter tip to the target point. CONCLUSIONS: Successful cannulation was achieved using either technique; however, the catheters placed using the Ghajar Guide were closer to the target.

Treatment of lumbar spinal stenosis by extensive unilateral decompression and contralateral autologous bone fusion: operative technique and results.

A new surgical technique for the treatment of lumbar spinal stenosis features extensive unilateral decompression with undercutting of the spinous process and, to preserve stability, uses contralateral autologous bone fusion of the spinous processes, laminae, and facets. The operation was performed in 29 patients over a 19-month period ending in December of 1991. All individuals had been unresponsive to conservative treatment and presented with low-back pain in addition to signs and symptoms consistent with neurogenic claudication or radiculopathy. Nine had undergone previous lumbar decompressive surgery. The minimum and mean postoperative follow-up times were 2 and 2 1/2 years, respectively. The mean patient age was 64 years; only two patients were younger than 50 years of age. Of the patients with neurogenic claudication, 69% reported complete pain relief at follow-up review. Of those with radicular symptoms, 41% had complete relief and 23% had mild residual pain that was rated 3 or less on a pain-functionality scale of 0 to 10. For the entire sample, this surgery decreased pain from 9.2 to 3.3 (p < 0.0001) on the scale. Sixty-nine percent of patients were satisfied with surgery. Low-back pain was significantly relieved in 62% of all patients (p < 0.0001). Low-back pain relief correlated negatively with number of levels decompressed (p < 0.05). To assess fusion, follow-up flexion/extension radiographs were obtained, and no motion was detected at the surgically treated levels in any patient. The results suggest that this decompression procedure safely and successfully treats not only the radicular symptoms caused by lateral stenosis but also the neurogenic claudication symptoms associated with central stenosis. In addition, the procedure, by using contralateral autologous bone fusion along the laminae and spinous processes, can preserve stability without instrumentation.

Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcomes.

The authors retrospectively studied 49 nonparaplegic patients who sustained acute unstable thoracolumbar burst fractures. All patients underwent surgical treatment and were followed for an average of 27 months. All but one patient achieved solid radiographic fusion. Three treatment groups were studied: the first group of 16 patients underwent anterior decompression and fusion with instrumentation; the second group of 27 patients underwent posterior decompression and fusion; and the third group of six patients had combined anterior-posterior surgery. Prior to surgical intervention, these groups were compared and found to be similar in age, gender, level of injury, percentage of canal compromise, neurological function, and kyphosis. Patients treated with posterior surgery had a statistically significant diminution in operative time and blood loss and number of units transfused. There were no significant intergroup differences when considering postoperative kyphotic correction, neurological function, pain assessment, or the ability to return to work. Posterior surgery was found to be as effective as anterior or anterior-posterior surgery when treating unstable thoracolumbar burst fractures. Posterior surgery, however, takes the least time, causes the least blood loss, and is the least expensive of the three procedures.

Progesterone is neuroprotective after acute experimental spinal cord trauma in rats.

STUDY DESIGN: A standardized rat contusion model was used to test the hypothesis that progesterone significantly improves neurologic recovery after a spinal cord injury that results in incomplete paraplegia. OBJECTIVES: To compare the effect of progesterone versus a variety of control agents to determine its effectiveness in promoting neurologic recovery after an incomplete rat spinal cord injury. SUMMARY OF BACKGROUND DATA: Progesterone is a neurosteroid, possessing a variety of functions in the central nervous system. Exogenous progesterone has been shown to improve neurologic function after focal cerebral ischemia and facilitates cognitive recovery after cortical contusion in rats. METHODS: A standardized rat contusion model of spinal cord injury using the New York University impactor that resulted in rats with incomplete paraplegia was used. Forty mature male Sprague-Dawley rats were randomly assigned to four groups: laminectomy with sham contusion, laminectomy with contusion without pharmacologic treatment, laminectomy with contusion treated with dimethylsulfoxide and dissolved progesterone, and laminectomy with contusion treated with dimethylsulfoxide. Functional status was assessed weekly using the Basso-Beattie-Bresnehan (BBB) locomotor rating scale for 6 weeks, after which the animals were killed for histologic studies. RESULTS: Rats treated with progesterone had better outcomes (P = 0.0017; P = 0.0172) with a BBB score of 15.5, compared with 10.0 in the dimethylsulfoxide control group and 12.0 in the spinal cord contusion without pharmacologic intervention group. This was corroborated in histologic analysis by relative sparing of white matter tissue at the epicenter of the injury in the progesterone-treated group (P < 0.05). CONCLUSIONS: Rats treated with progesterone had a better clinical and histologic outcome compared with the various control groups. These results indicate potential therapeutic properties of progesterone in the management of acute spinal cord injury.

The association of lumbar spondylolisthesis with collagen IX tryptophan alleles.

Two collagen type IX gene polymorphisms that introduce a tryptophan residue into the protein's triple-helical domain have been linked to an increased risk of lumbar disc disease. To determine whether a particular subset of symptomatic lumbar disease is specifically associated with these polymorphisms, we performed a prospective case-control study of 107 patients who underwent surgery of the lumbar spine. Patients were assigned to one of five clinical categories (fracture, disc degeneration, disc herniation, spinal stenosis without spondylolisthesis and spinal stenosis with spondylolisthesis) based on history, imaging results, and findings during surgery. Of the 11 tryptophan-positive patients, eight had spinal stenosis with spondylolisthesis and three had disc herniation. The presence of the tryptophan allele was significantly associated with African-American or Asian designation for race (odds ratio 4.61, 95% CI 0.63 to 25.35) and with the diagnosis of spinal stenosis with spondylolisthesis (odds ratio 6.81, 95% CI 1.47 to 41.95). Our findings indicate that tryptophan polymorphisms predispose carriers to the development of symptomatic spinal stenosis associated with spondylolisthesis which requires surgery.

Surgical treatment of thoracolumbar fractures.

Many studies indicate that spinal canal decompression and stabilization lead to improved neurologic recovery in patients with incomplete neurologic deficits. It is recognized that surgical stabilization of unstable thoracolumbar injuries with complete neurologic deficit or without deficit reduces hospital stay, improves spinal alignment, shortens rehabilitation, and results in fewer medical complications. Unfortunately, many aspects of management remain controversial. For many injuries, more than one treatment method has been shown to be efficacious, although certain injuries have improved outcome with specific treatment modalities. This article is an overview of indications for surgery, operative approaches, types of instrumentation, and treatment options for specific thoracolumbar injuries.

Surgical treatment of metopic synostosis.

Metopic synostosis can present with various skull abnormalities for which early surgical treatment can provide significant benefit to the patient. Correction of skull deformities associated with metopic synostosis requires accurate assessment of the full range of craniofacial defects within context of the patient's age. Alteration in the characteristics of cranial bone as the child grows older necessitates modifications in techniques used for bony remodeling. Changes in the rate of brain and cranial vault growth also must be considered for adjustments in fixation methods. Thus, both the patient's age and the severity of aesthetic deformity dictate the surgical techniques used in the correction of metopic synostosis.

Lumbar disc surgery in a fixed compensation population: a model for influence of secondary gain on surgical outcome.

BACKGROUND: Reported outcomes in patients undergoing surgical procedures for lumbar disc herniation are poorer in patients eligible for workers' compensation or with pending litigation. In the civilian community, the amount of compensation for one's disability is variable and thus its influence on surgical outcome is difficult to quantify. In the military, all members are covered by a standardized workers' compensation system, and have generally standardized work requirements, a standard pay scale, and third party evaluation of disability based on the Veterans Affairs rating system. This made the military a good system in which to study the effect of potential compensation on surgical outcome. METHODS: The study population consisted of active duty military members who underwent sequential lumbar microdiscectomies over a 31-month period. Omitted were lumbar fusions, decompressive laminectomies, and far lateral discectomies. Clinical and demographic variables, along with financial data for each patient were derived from these data. A good result was defined as return to active military duty. RESULTS: Three hundred forty-nine lumbar discectomies were performed in 348 active duty military members. Overall, 75.3% (262) of the 348 patients were able to return to full military duty after surgery, and 24.7% (86) received disability compensation. Chi-square univariate analysis showed higher compensation incentive was a significant determinant of poor surgical outcome (p = 0.0021). The influence of compensation incentive was proportional to the amount of anticipated payout, and relative to a military service member's usual income. In mutivariate analysis, lower base pay (0.0005) and female gender (p = 0.038) were predictive of poor outcome. CONCLUSIONS: Secondary gain in the form of disability pay has a proportionally adverse effect on outcome following lumbar disc surgery. Although studying this issue in the military system allowed standardization of secondary gain values, the influence of other factors could not be eliminated entirely. Potential disability pay is proportionally greater in lower ranked service members. Thus, other variables such as income level, education, and job satisfaction may contribute to the poorer results in this subgroup of military members.