Fusion Revision Surgery With Reamer-Irrigator-Aspirator to Harvest Autograft After Spinal Pseudarthrosis.

Background and purpose Spinal pseudarthrosis (SPA) is a common complication after attempted cervical or lumbosacral spinal fusion surgery. Revision surgeries usually necessitate bone graft implementation as an adjunct to hardware revision. Iliac crest bone graft is the gold standard but availability can be limited and usage often leads to persistent postoperative pain at the donor site. There is scant literature regarding the use of reamer-irrigator-aspirator (RIA)-harvested bone graft in lumbar spinal fusion. This is a collaborative study between orthopedic surgery and neurosurgery departments to utilize femur intramedullary autograft harvested using the RIA system as an adjunct graft in SPA revision surgeries. Materials and methods A retrospective review was conducted at a single center between August 2014 and December 2017 of patients aged ≥ 18 years and diagnosed with cervical, thoracic, or lumbar SPA who underwent revision fusion surgery using femur intramedullary autograft harvested using the RIA system. Plain radiographs and CT scans were utilized to confirm successful fusion. Results Eleven patients underwent 12 SPA revision surgeries using the RIA system as a source for bone graft in addition to bone morphogenetic protein 2 (BMP-2) and allograft. The mean amount of graft harvested was 51.3 mL (range: 20-70 mL). Nine patients achieved successful fusion (81.8%). The average time to fusion was 9.1 months. Four patients (36.4%) had postoperative knee pain. Regarding patient position and approach for harvesting, 66.7% (n = 8) of cases were positioned prone and a retrograde approach was utilized in 91.7% (n = 11) of cases. Interpretation This is the first case series in known literature to report the RIA system as a reliably considerable source of autologous bone graft for SPA revision surgeries. It provides a useful adjunct to the known types of bone grafts. Patient positioning and the approach choice for graft harvesting can be adjusted according to the fusion approach and the surgeon's preference.

Surgical management of two- versus three-column injuries of the cervicothoracic junction: biomechanical comparison of translaminar screw and pedicle screw fixation using a cadaveric model.

STUDY DESIGN: An in vitro cadaveric biomechanical study. OBJECTIVE: To determine the stability of translaminar screws compared to pedicle screws at T1-T2 for constructs bridging the cervicothoracic junction. SUMMARY OF BACKGROUND DATA: Instrumented fixation of the cervicothoracic junction is challenging both biomechanically, due to the transition from the mobile cervical to the rigid thoracic spine, and technically, due to the anatomic constraints of the T1-T2 pedicles. For these reasons, an alternate fixation technique at T1-T2 that combines ease of screw insertion and a favorable safety profile with biomechanical stability would be clinically beneficial. METHODS: A 6-degree of freedom spine simulator was used to test multidirectional flexibility in 8 human cadaveric specimens. Flexion, extension, lateral bending, and axial rotation were tested in the intact condition, followed by destabilization via a simulated 2-column injury at C7-T1. Specimens were reconstructed using C5-C6 lateral mass screws and either translaminar or pedicle screws placed at T1, followed by caudal extension to T2. A 3-column injury at C7-T1 was then performed and specimens were tested using a posterior only approach with either translaminar or pedicle screws placed at T1 and T1-T2. Finally, anterior fixation at C7-T1 was added and multidirectional flexibility testing performed as previously described. RESULTS: Following a 2-column injury at C7-T1, there were no significant differences in segmental flexibility at C7-T1 between translaminar and pedicle screw fixation when placed at T1-T2 (P>0.05). For a 3-column injury treated posteriorly, translaminar screws at T1-T2 provided increased flexibility compared to pedicle screws in flexion/extension (P<0.05). There were no differences in segmental flexibility at C7-T1 between the 2 techniques following the addition of anterior fixation (P>0.05). CONCLUSION: Translaminar screws in the upper thoracic spine offer similar stability to pedicle screw fixation for constructs bridging the cervicothoracic junction. Small differences in range of motion must be weighed clinically against the potential benefits of translaminar screw insertion at T1-T2.

Thoracic kyphotic deformity reduction with a distractible titanium cage via an entirely posterior approach.

OBJECTIVE: Surgical correction of thoracic kyphotic deformity is often associated with significant surgical and neurological morbidity and unsatisfactory reduction of kyphosis, especially in patients who cannot tolerate anterior thoracic procedures because of associated comorbidity. We describe a technique in which kyphotic deformity of the thoracic and thoracolumbar spine is corrected, decompressed, and stabilized with a circumferential fixation construct from a lone posterior approach. METHODS: We reviewed the radiographic and clinical outcomes of seven patients undergoing vertebrectomy via a bilateral modified costotransversectomy approach followed by posterior placement of a distractible cage, reduction of the deformity via cage distraction, and supplemental dorsal instrumentation. All patients possessed thoracic/thoracolumbar kyphosis; however, a transthoracic approach was thought to be high risk because of medical comorbidity. RESULTS: Seven patients underwent this procedure for thoracolumbar kyphosis resulting from a spinal tumor, osteomyelitis, and fracture. Vertebrectomies were performed at T2-T3, T4-T5, T5-T6, T12-L1, and L1. The mean preoperative kyphosis was 28.6 degrees, the mean postoperative kyphosis at the time of the final follow-up examination was 12.1 degrees, and the mean change in kyphosis was 53%. The mean long-term follow-up period was approximately 16 months. At the time of the final follow-up examination for all patients, there was no decline in neurological function, and pain management consisted of minimal use of oral narcotics. CONCLUSION: This technique allows for circumferential decompression of the spinal cord via a posterior approach in patients with thoracic kyphotic deformities who cannot tolerate anterior thoracic approaches. In addition, in situ distraction of the expandable cage allows correction of sagittal imbalance and restores height without the potential loss of spinal height associated with osteotomies.

Translaminar screw fixation in the upper thoracic spine.

OBJECT: The use of pedicle screws (PSs) for instrument-assisted fusion in the cervical and thoracic spine has increased in recent years, allowing smaller constructs with improved biomechanical stability and repositioning possibilities. In the smaller pedicles of the upper thoracic spine, the placement of PSs can be challenging and may increase the risk of damage to neural structures. As an alternative to PSs, translaminar screws can provide spinal stability, and they may be used when pedicular anatomy precludes successful placement of PSs. The authors describe the technique of translaminar screw placement in the T-1 and T-2 vertebrae. METHODS: Seven patients underwent cervicothoracic fusion to treat trauma, neoplasm, or degenerative disease. Nineteen translaminar screws were placed, 13 at T-1 and six at T-2. A single asymptomatic T-2 screw violated the ventral laminar cortex and was removed. The mean clinical and radiographic follow up exceeded 14 months, at which time there were no cases of screw pullout, screw fracture, or progressive kyphotic deformity. CONCLUSIONS: Rigid fixation with translaminar screws offers an attractive alternative to PS fixation, allowing the creation of sound spinal constructs and minimizing potential neurological morbidity. Their use requires intact posterior elements, and care should be taken to avoid violation of the ventral laminar wall.

Intracranial aneurysm following radiation therapy during childhood for a brain tumor. Case report and review of the literature.

Ionizing radiation therapy is associated with pathological vascular changes in intracranial vessels, most commonly in the form of vessel thrombosis and occlusion. The development of an intracranial aneurysm following such therapy, however, is far less common. In this report the authors describe a 24-year-old man in whom a distal middle cerebral artery aneurysm developed 15 years after radiotherapy, which was given as adjuvant treatment following resection of a medulloblastoma. The patient underwent a craniotomy for microsurgical trapping of the aneurysm and was discharged without any neurological deficit. This case serves to remind clinicians of the possibility, albeit rare, that intracranial aneurysms may form following cranial radiotherapy.

Preoperative imaging of cervical spine hemangioblastomas using three-dimensional fusion digital subtraction angiography. Report of two cases.

Angiography is often performed to identify the vascular supply of hemangioblastomas prior to resection. Conventional two-dimensional (2D) digital subtraction (DS) angiography and three-dimensional (3D) DS angiography provides high-resolution images of the vascular structures associated with these lesions. However, such 3D DS angiography often does not provide reliable anatomical information about nearby osseous structures, or when it does, resolution of vascular anatomy in the immediate vicinity of bone is sacrificed. A novel angiographic reconstruction algorithm was recently developed at The Johns Hopkins University to overcome these inadequacies. By combining two separate sequences of images of bone and blood vessels in a single 3D representation, 3D fusion DS (FDS) angiography provides precise topographic information about vascular lesions in relation to the osseous environment, without a loss of resolution. In this paper, the authors present the cases of two patients with cervical spine hemangioblastomas who underwent preoperative evaluation with FDS angiography and then successful gross-total resection of their tumors. In both cases, FDS angiography provided high-resolution 3D images of the hemangioblastoma anatomy, including each tumor's topographic relationship with adjacent osseous structures and the location and size of feeding arteries and draining veins. These cases provide evidence that FDS angiography represents a useful adjunct to magnetic resonance imaging and 2D DS angiography in the preoperative evaluation and surgical planning of patients with vascular lesions in an osseous environment, such as hemangioblastomas in the spinal cord.

Concomitant conus medullaris ependymoma and filum terminale lipoma: case report.

OBJECTIVE: Ependymomas of the conus medullaris-cauda equina-filum terminale region are typically solitary lesions. In this report, we describe the clinical presentation, radiographic findings, operative details, and pathological features of a patient with a conus medullaris ependymoma and a filum terminale lipoma. CLINICAL PRESENTATION: A 40-year-old woman presented with increasing low back pain and bowel and bladder dysfunction. Magnetic resonance imaging revealed a partially cystic enhancing lesion at the conus medullaris and a T1-weighted hyperintense mass within the filum terminale. INTERVENTION: An L2-L3 laminotomy/laminoplasty was performed for gross total resection of the mass. Histopathological examination demonstrated a conus medullaris ependymoma and filum terminale lipoma. The patient experienced complete resolution of her preoperative symptoms. CONCLUSION: Spinal cord ependymomas are almost exclusively single lesions and their coexistence with other pathological entities is rare. In this report, we describe a patient with a concomitant conus medullaris ependymoma and filum terminale lipoma.

Frameless stereotaxy in a transmandibular, circumglossal, retropharyngeal cervical decompression in a Klippel-Feil patient: technical note.

Frameless stereotaxy, while most commonly applied to intracranial surgery, has seen an increasing number of applications in spinal surgery. Its use in the spine has been described to a greater degree in posterior rather than anterior surgical approaches, presumably due to the relative paucity of anatomical landmarks appropriate for frameless stereotactic registration in the anterior spine. This technical note illustrates the previously undescribed, successful use of frameless stereotaxy to the transmandibular, circumglossal, retropharyngeal surgical approach in a patient with Klippel-Feil syndrome.

A novel intravertebral tumor model in rabbits.

OBJECTIVE: Although the majority of human epidural spinal metastases originate in the vertebral body, current animal models of spinal epidural tumors are limited to extraosseous tumor placement. We investigated the onset of paraparesis, radiographic changes (magnetic resonance imaging [MRI] and computed tomographic [CT] scans), and histopathological findings after intraosseous injection of VX2 carcinoma cells into the lower thoracic vertebrae of rabbits. METHODS: New Zealand white rabbits (n = 23) were injected with a 15-mul suspension containing 300,000 VX2 carcinoma cells in the lowest thoracic vertebral body. Lower extremity motor function was assessed daily. For the first 3 animals, MRI scans (T2-weighted and T1-weighted +/- gadolinium) were acquired at postoperative day (POD) 14 and at the onset of paraparesis. Noncontrast CT scans were obtained on POD 7 and at the time of paraparesis. At the onset of paraparesis, the animals ware killed and the spines were dissected. After demineralization, hematoxylin and eosin cross sections were obtained. RESULTS: Before the onset of paraparesis, the CT and MRI scans revealed no gross tumor. At the onset of paraparesis, CT scans demonstrated an osteolytic tumor centered at the junction of the left pedicle and vertebral body, and MRI scans demonstrated epidural tumor arising from the body and compressing the spinal cord. Histopathological examination confirmed carcinoma arising from the body and extending into the canal, with widespread osteolytic activity. By POD 28, 72% of the animals had become paraparetic, and by the termination of the experiment on POD 120, 89% had become paraparetic. CONCLUSION: We established a novel intraosseous intravertebral tumor model in rabbits and characterized it with respect to onset of paraparesis, imaging features, and histopathological findings.

Outcome and cost of craniotomy performed to treat tumors in regional academic referral centers.

OBJECTIVE: Improved clinical and economic outcomes for high-risk surgical procedures have been previously cited in support of regionalization. The goal of this study was to examine the effects of regionalization by analyzing the cost and outcome of craniotomy for tumors and to compare the findings in academic medical centers versus community-based hospitals. METHODS: Outcomes and charges were analyzed for all adult patients undergoing craniotomy for tumor in 33 nonfederal acute care hospitals in Maryland using the Maryland Health Service Cost Review Commission database for the years 1990 to 1996. A total of 4723 patients who underwent craniotomy for tumor were selected on the basis of Diagnostic Related Group 1 (craniotomy except for trauma, age 18 or older) and International Classification of Diseases-9th Revision diagnosis code for benign tumor, primary malignant neoplasm, or secondary malignant neoplasm (codes 191, 192, 194, 200, 225, 227, 228, 237, and 239). Hospitals were categorized as high-volume hospitals (>50 craniotomies/yr) or low-volume hospitals (

Decompressive craniectomy for intractable cerebral edema: experience of a single center.

Several case reports and small clinical series have reported benefits of decompressive hemicraniectomy in patients with intractable cerebral edema and early clinical herniation. Specific indications and timing for this intervention remain unclear. We present our experience with this procedure in a subset of 18 patients with massive cerebral edema refractory to medical management, treated with decompressive craniectomy over a 3-year period (1997 to 2000). Computerized tomography (CT) scans were independently analyzed by a neuroradiologist blinded to clinical outcome. Eleven male and seven female patients, ages 20 to 69 years (mean +/- SEM, 46 +/- 14 years), underwent hemicraniectomy for the following diagnoses: 12 hemispheric infarcts, 3 traumatic intracerebral hemorrhages/contusions, 2 nontraumatic intraparenchymal hemorrhages (ICH), and 1 subdural empyema. This population included four patients with aneurysmal subarachnoid hemorrhage (SAH). Patients were followed for a mean of 10 months. Clinical factors including age, side of lesion, preoperative herniation signs, and early surgery (<12 or <24 hours) were not significantly associated with mortality or Glasgow outcome score (GOS). Preoperative CT evidence of transtentorial herniation (present in 5/17 patients) was associated with mortality ( = 0.04), while preoperative uncal herniation (8/17 patients) was associated with poor outcome (GOS > 1) ( = 0.01). Favorable outcome (GOS > 3) occurred in six patients, three with spontaneous or traumatic focal hematomas. Of four patients with SAH, one died while the others were severely disabled (GOS 3). Seven of nine patients with malignant MCA infarctions unrelated to SAH had poor outcomes. The overall mortality was 4/18 (22%). Patients with refractory cerebral swelling secondary to focal hematomas may have better outcomes following decompressive craniectomy. Patients with preexisting SAH seem to have poor outcomes, possibly related to other neurologic comorbidities. Hemicraniectomy requires definition of proper timing. Preoperative CT findings, especially transtentorial and uncal herniation may be useful in defining when decompressive surgery should not be performed.

Ectopic recurrence of craniopharyngioma after an interhemispheric transcallosal approach: case report.

OBJECTIVE AND IMPORTANCE: Ectopic recurrence of a craniopharyngioma is a rare postoperative complication. We present a case of a craniopharyngioma that ectopically recurred along the tract of a previous surgical route. CLINICAL PRESENTATION: A 73-year-old female patient presented 8 years earlier with a suprasellar craniopharyngioma. She underwent a right frontal craniotomy, with an interhemispheric transcallosal approach, for total microsurgical resection of the tumor. No postoperative radiotherapy was administered. Four years after surgery, magnetic resonance imaging studies revealed a well-circumscribed, heterogeneously enhancing, parasagittal mass with significant vasogenic edema in the right frontal lobe. Enlargement of the lesion was noted in subsequent radiological evaluations until 8 years after surgery, when the patient experienced a significant decline in neurocognitive status and the mass was surgically resected. INTERVENTION: Gross total resection of a histologically confirmed craniopharyngioma was achieved. CONCLUSION: To our knowledge, only eight previous case reports described the ectopic recurrence of a craniopharyngioma. Transplantation of tumor cells along the tract of a previous surgical route in six cases and dissemination in cerebrospinal fluid in two cases are presumed to be the primary mechanisms by which these ectopic recurrences occurred. The results of our literature review led us to conclude that total surgical resection, combined with careful inspection and irrigation of the surgical field, is the optimal treatment for preventing ectopic recurrences. Furthermore, it is recommended that, after primary craniopharyngioma resection, patients undergo long-term clinical and radiological follow-up monitoring for the rare development of an ectopically recurring tumor.