Fracture and Bilateral Facet Dislocation after Anterior Cervical Fusion in a Patient with a Distraction-Flexion Injury at the Lower Cervical Level / 대한정형외과학회잡지

A bilateral facet dislocation after anterior cervical fusion with a plate in distraction-flexion injury without significant instability in plain radiography is very rare. This paper reports a case with a confirmed injury status (C6–7 and C7–T1) by magnetic resonance imaging and computed tomography with no visible fractures or displacement on plain radiography. Anterior cervical fusion (C6–T1) was performed with a cage and plate. On the other hand, three days later, C6–7 bilateral facet dislocation developed with severe neck and radiating pain, and posterior decompression and fusion were performed.

Efficacy of Dynamic Radiographs in Routine Evaluations for Degenerative Cervical Spine Disease

Objectives@#To analyze the usefulness of flexion-extension radiographs in the diagnosis of degenerative cervical disease.Summary of Literature ReviewThere is little information about the efficacy of flexion-extension radiographs in the diagnosis of degenerative cervical disease. @*Methods@#and MaterialsWe analyzed 1,062 patients with cervical degenerative disease who underwent flexion-extension radiographs and computed tomography (CT) or magnetic resonance imaging (MRI). The range of motion of the cervical joints was measured. Segmental instability was evaluated using the sagittal translation (≥3.5 mm) between C2 and T1, the sagittal angulation (≥3.5°), the vertebral slip angle (≥ 10°), and the dynamic spinal canal stenosis (≤12 mm). The relationship between canal compromise on CT or MRI and radiological instability was also evaluated. @*Results@#Cervical range of motion was 36.45°±17.63° (range, 2.1°–106.6°). Segmental instability was observed in 484 patients (nine cases of sagittal translation, 79 cases of sagittal plane rotation, 415 cases of a vertical slip angle, and 21 cases of dynamic spinal stenosis). Segmental instability was related with pathology in 218 patients with available CT or MRI (42%, including five cases of sagittal translation, 32 cases of sagittal plane rotation, 171 cases of vertical slip angle, and 10 cases of dynamic spinal stenosis. @*Conclusions@#Flexion-extension radiographs of the cervical spine were useful in diagnosing and evaluating subaxial segmental instability.

Efficacy of Dynamic Radiographs in Routine Evaluations for Degenerative Cervical Spine Disease

Objectives@#To analyze the usefulness of flexion-extension radiographs in the diagnosis of degenerative cervical disease.Summary of Literature ReviewThere is little information about the efficacy of flexion-extension radiographs in the diagnosis of degenerative cervical disease. @*Methods@#and MaterialsWe analyzed 1,062 patients with cervical degenerative disease who underwent flexion-extension radiographs and computed tomography (CT) or magnetic resonance imaging (MRI). The range of motion of the cervical joints was measured. Segmental instability was evaluated using the sagittal translation (≥3.5 mm) between C2 and T1, the sagittal angulation (≥3.5°), the vertebral slip angle (≥ 10°), and the dynamic spinal canal stenosis (≤12 mm). The relationship between canal compromise on CT or MRI and radiological instability was also evaluated. @*Results@#Cervical range of motion was 36.45°±17.63° (range, 2.1°–106.6°). Segmental instability was observed in 484 patients (nine cases of sagittal translation, 79 cases of sagittal plane rotation, 415 cases of a vertical slip angle, and 21 cases of dynamic spinal stenosis). Segmental instability was related with pathology in 218 patients with available CT or MRI (42%, including five cases of sagittal translation, 32 cases of sagittal plane rotation, 171 cases of vertical slip angle, and 10 cases of dynamic spinal stenosis. @*Conclusions@#Flexion-extension radiographs of the cervical spine were useful in diagnosing and evaluating subaxial segmental instability.

Etiology and Related Factors of Postoperative Delirium in Orthopedic Surgery

BACKGROUND: Delirium is a serious complication for elderly patients after orthopedic surgery. The purpose of this study was to assess the etiology and related factors of delirium after orthopedic surgery in Korea. METHODS: We retrospectively reviewed the medical records of 3,611 patients over 50 years who had orthopedic surgery. The age of patients (50s, 60s, 70s, and > 80s), type of anesthesia (general, spinal, and local), operation time (more than 2 hours vs. less than 2 hours), surgical site (spine, hip, knee, or others), and etiology (trauma or disease) were compared to determine possible risk factors of delirium after orthopedic surgery. RESULTS: Of 3,611 patients, 172 (4.76%) were diagnosed with delirium after orthopedic surgery. Postoperative delirium occurred in 1.18% in their 50s, 3.86% in their 60s, 8.49% in their 70s, and 13.04% in > 80s (p < 0.001). According to anesthesia type, 6.50% of postoperative delirium occurred after general anesthesia, 0.77% after spinal anesthesia, and 0.47% after local anesthesia (p < 0.001). More than 2 hours of operation was associated with higher occurrence of delirium than less than 2 hours was (5.88% vs. 4.13%, p = 0.017). For the etiology, 8.17% were trauma cases and 3.02% were disease (p < 0.001). Postoperative delirium occurred in 22 of 493 patients (4.46%) after spine surgery, 18 of 355 patients (5.07%) after hip surgery, 17 of 394 patients (4.31%) after knee surgery, and 15 of 1,145 patients (1.31%) after surgery at other sites (p < 0.001). CONCLUSIONS: Postoperative delirium was more common in older patients who had surgery under general anesthesia, whose surgery took more than 2 hours, and who were hospitalized through the emergency room.

Esophageal Perforation after Anterior Cervical Spine Surgery

STUDY DESIGN: Retrospective case analyses.PURPOSE: To investigate the causes, diagnosis, and management of esophageal perforation, depending on the time of diagnosis.OVERVIEW OF LITERATURE: To date, few studies have addressed these issues.METHODS: A total of seven patients were included in this study. The patients were classified into three groups based on esophageal perforation diagnosis time: intraoperative (diagnosed during surgery), perioperative (diagnosed within 30 days postoperatively), and delayed (diagnosed >30 days postoperatively) groups.RESULTS: In the intraoperative group (N=2), infectious spondylitis was the main cause of esophageal perforation. Anterior plate and screw removal, followed by posterior instrumentation, was performed. The injured esophagus was managed by omentum flap repair in one patient and primary repair in one patient. In the perioperative group (N=2), revision surgery for infection and metal failure were the main causes of esophageal perforation. In both cases, food residue was drained on the third postoperative day. The injured esophagus was managed conservatively. In the delayed group (N=3), chronic irritation caused by metal failure was the main cause of esophageal perforation. In all patients, there was no associated infection. The anterior instrumentation was removed, and the two patients were treated by primary repair, and one patient was treated using sternocleidomastoid muscle flap. One patient in intraoperative group died of sepsis.CONCLUSIONS: The main cause of intraoperative esophageal perforation was esophageal adhesions because of infectious spondylitis. However, perioperative and delayed esophageal perforations were caused by chronic irritation because of metal failure. Anterior plate and screw removal was necessary, and posterior instrumentation and fusion may be considered, depending on the fusion status.

Analysis of Risk Factors of Adjacent Segment Disease with Lumbar and Lumbosacral Arthrodesis for the Degenerative Lumbar Spinal Disorders / 대한정형외과학회잡지

PURPOSE: The objective of this study is to confirm the effects of risk factors on Adjacent Segment Disease (ASD). MATERIALS AND METHODS: The subjects of this study were 793 patients who had degenerative lumbar spine disease and were followed-up for an average period of 7.2 years from January of 1999 to September of 2010 after undergoing spinal fusion. To confirm the risk factors, a study on patient factors, surgical factors and radiologic factors was performed. RESULTS: Of 793 patients, 69 patients (group A, 8.7%) underwent a secondary surgical treatment due to ASD. Age of patient, sex, bone mineral density, history of smoking and occupation were not statistically significant. Preoperative body mass index (BMI) (> or =25 kg/m2) and postoperative increase of BMI were the patient's factor in ASD (p=0.02, p<0.001). Regarding surgical factors, multilevel fusion (more than 3 levels) was higher risk in prevalence of ASD than short level fusion (p=0.01). Degeneration of intervertebral disc (p=0.01) and facet joints (p=0.02), and segmental instability (p=0.001) were also associated with the prevalence of ASD in radiologic factors. CONCLUSION: To prevent the occurrence of ASD after lumbosacral fusion, selection of the proper level of fusion preoperatively and modifying the life style with body weight control and reduction of hypermobility after fusion surgery are essential.

Stress Fracture of the Anterior Atlas Arch Following C1 Posterior Arch Resection for Cervical Myelopathy with Retro-Odontoid Pseudotumor / 대한정형외과학회잡지

Atlas fracture accounts for 1% to 3% of all spinal column injuries and 10% of cervical spine fractures, and is most frequently caused by motor vehicle accidents and falls. Only a few cases involving complications after surgical treatment have been reported. We present a case of anterior atlas arch stress fracture accompanied by worsening neurologic symptoms following atlas posterior arch resection for cervical myelopathy with retro-odontoid pseudotumor.

Prognostic Factors for Postsurgical Recovery of Deltoid Palsy due to Cervical Disc Herniations

STUDY DESIGN: Retrospective multicenter study. PURPOSE: We aimed to investigate prognostic factors affecting postsurgical recovery of deltoid palsy due to cervical disc herniation (CDH). OVERVIEW OF LITERATURE: Little information is available about prognostic factors affecting postsurgical recovery of deltoid palsy due to CDH. METHODS: Sixty-one patients with CDH causing deltoid palsy (less than grade 3) were included in this study: 35 soft discs and 26 hard discs. Average duration of preoperative deltoid palsy was 11.9 weeks. Thirty-two patients underwent single-level surgery, 22 two-level, four three-level, and three four-level. Patients with accompanying myelopathy, shoulder diseases, or peripheral neuropathy were excluded from the study. RESULTS: Deltoid palsy (2.4 grades vs. 4.5 grades, p<0.001) and radiculopathy (6.4 points vs. 2.1 points, p<0.001) significantly improved after surgery. Thirty-six of 61 patients (59%) achieved full recovery (grade 5) of deltoid palsy, with an average time of 8.4 weeks. Longer duration of preoperative deltoid palsy and more severe radiculopathy negatively affected the degree of improvement in deltoid palsy. Age, gender, number of surgery level, and disc type did not affect the degree of improvement of deltoid palsy. Contrary to our expectations, severity of preoperative deltoid palsy did not affect the degree of improvement. Due to the shorter duration of preoperative deltoid palsy, in the context of rapid referral, early surgical decompression resulted in significant recovery of more severe grades (grade 0 or 1) of deltoid palsy compared to grade 2 or 3 deltoid palsy. CONCLUSIONS: Early surgical decompression significantly improved deltoid palsy caused by CDH, irrespective of age, gender, number of surgery level, and disc type. However, longer duration of deltoid palsy and more severe intensity of preoperative radiating pain were associated with less improvement of deltoid palsy postoperatively.

Current Concepts of Anterior Cervical Discectomy and Fusion: A Review of Literature

Anterior cervical discectomy and fusion (ACDF) is a safe and effective procedure for degenerative cervical spinal disease unresponsive to conservative management and its outstanding results have been reported. To increase fusion rates and decrease complications, numerous graft materials, cage, anterior plating and total disc replacement have been developed, and better results were reported from those, but still there are areas that have not been established. Therefore, we are going to analyze the treatment outcome with the various procedure through the literature review and determine the efficacy of ACDF.

Current Concepts of Anterior Cervical Discectomy and Fusion: A Review of Literature

Anterior cervical discectomy and fusion (ACDF) is a safe and effective procedure for degenerative cervical spinal disease unresponsive to conservative management and its outstanding results have been reported. To increase fusion rates and decrease complications, numerous graft materials, cage, anterior plating and total disc replacement have been developed, and better results were reported from those, but still there are areas that have not been established. Therefore, we are going to analyze the treatment outcome with the various procedure through the literature review and determine the efficacy of ACDF.

Epidural Abscess Following Epidural Catheterization for Painless Mobilization after Total Knee Arthroplasty / 대한정형외과학회잡지

Epidural analgesia is one of the effective methods for pain management after total knee arthroplasty. Although epidural analgesia has been reported to have very low epidural abscess rates, infection could be serious and life-threatening, if there is no early diagnosis and treatment. We report on a patient who developed an epidural abscess following epidural catheterization after total knee arthroplasty.

Does Preoperative Cervical Sagittal Alignment And Range of Motion Affect Adjacent Segment Degeneration After Anterior Arthrodesis In Degenerative Cervical Spinal Disorders?: Midterm Follow up Study

STUDY DESIGN: Retrospective study. OBJECTIVES: The purpose of this study was to investigate whether preoperative sagittal alignment and range of motion (ROM) affect adjacent segment degeneration (ASD) and disease after anterior arthrodesis in degenerative cervical spinal disorders. Summary of Literature Review:There is no study about the relationship between preoperative ROM and sagittal alignment and the development of ASD yet. MATERIALS AND METHODS: We took a retrospective approach to study 136 patients who underwent an anterior arthodesis for less than 2 segments with PEEK cage and plate construct method for degenerative cervical diseases and who have a minimum of 3 years of follow-up. We analyzed ASD and cervical ROM, such as less than 40degrees(group A) and more than 40degrees(group B) and sagittal alignment, such as lordosis or kyphosis with less than 10degrees(group a), 10degrees~30degrees(group b) and more than 30degrees(group c). Adjacent segment degeneration was graded according to Park's classification and Hillibrand method. RESULTS: There was no statistically significant difference between group A(1.35+/-0.48) and group B (1.44+/-0.50) in the correlation between the cervical ROM and the variation of disc height(p=0.07). Concerning the relationship between the ROM and osteophyte formation on adjacent segment, no statistically significant difference has been found between group A(1.64+/-0.88) and group B(1.43+/-0.67) (p=0.06). The disc height change at the final follow up after cervical sagittal alignment showed no statistically significant difference among the groups: Group A presented with 1.53+/-0.50, group B with 1.30+/-0.46 and group C with 1.40+/-0.50.(p=0.08) Regarding sagittal alignment and osteophyte change, there was no statistically significant difference among the groups as group A showed an average of 1.33+/-0.48, group Ban average of 1.56+/-0.88 and group Can average of 1.60+/-0.82(p=0.07). CONCLUSION: Although the preoperative sagittal alignment and ROM did not significantly affect adjacent segment degeneration and diseases in a mid-term follow-up evaluation after anterior arthrodesis with PEEK cage and plate in degenerative cervical spinal disorders, we think a future study is required with a sufficient number of patients and a long term follow-up because there were borderline statistical significances shown in the present study.

Adjacent Segment Pathology Following Anterior Decompression and Fusion Using Cage and Plate for the Treatment of Degenerative Cervical Spinal Diseases

STUDY DESIGN: Retrospective study. PURPOSE: To analyze the incidence and prevalence of clinical adjacent segment pathology (CASP) following anterior decompression and fusion with cage and plate augmentation for degenerative cervical diseases. OVERVIEW OF LITERATURE: No long-term data on the use of cage and plate augmentation have been reported. METHODS: The study population consisted of 231 patients who underwent anterior cervical discectomy and fusion (ACDF) with cage and plate for degenerative cervical spinal disease. The incidence and prevalence of CASP was determined by using the Kaplan-Meier survival analysis. To analyze the factors that influence CASP, data on preoperative and postoperative sagittal alignment, spinal canal diameter, the distance between the plate and adjacent disc, extent of fusion level, and the presence or absence of adjacent segment degenerative changes by imaging studies were evaluated. RESULTS: CASP occurred in 15 of the cases, of which 9 required additional surgery. At 8-year follow-up, the average yearly incidence was 1.1%. The rate of disease-free survival based on Kaplan-Meier survival analysis was 93.6% at 5 years and 90.2% at 8 years. No statistically significant differences in CASP incidence based on radiological analysis were observed. Significantly high incidence of CASP was observed in the presence of increased adjacent segment degenerative changes (p<0.001). CONCLUSIONS: ACDF with cage and plate for the treatment of degenerative cervical disease is associated with a lower incidence in CSAP by 1.1% per year, and the extent of preoperative adjacent segment degenerative changes has been shown as a risk factor for CASP.

A Case of Gait Disturbance due to Chronic Bilateral Subdural Hematoma Mimicking Cervical Spondylotic Myelopathy / 대한정형외과학회잡지

Cervical spondylotic myelopathy (CSM) is a spinal cord dysfunction involving compression of the vascular and neural structures due to bony spurring or soft tissue hypertrophy in patients with degenerative cervical disorders. It presents initially as subtle gait disturbance with gradual deterioration. An elderly patient presenting with gait disturbance due to spasticity and motor weakness of both lower extremities without mental change can be easily misdiagnosed as CSM. We report on a case of gait disturbance due to chronic bilateral subdural hematoma mimicking CSM.

Treatment of Irreducible Bilateral Cervical Facet Fracture-Dislocation with a Prolapsed Disc Using a Prefixed Polyetheretherketone Cage and Plate System

When anterior reduction fail in the surgical treatment of cervical bilateral facet fracture-dislocation with concomitant disc extrusion, it is necessary to perform a reduction using a posterior approach and then a third anterior procedure is often necessary to accomplish the anterior reconstruction. This presents difficulties for both patients and surgeons because of the need for frequent position changes (supine-prone-supine). The purpose of this study is to illustrate a modified surgical technique, which is anterior reduction and fixation with a prefixed polyetheretherketone (PEEK) cage to a buttress plate for the treatment of irreducible bilateral cervical facet fracture-dislocation with a prolapsed disc is an enhancing technique for the stability of the interbody graft than a buttress plate alone because the PEEK cage has more fixation power and reduces both the number of position changes and the length of the operation.

Acute Respiratory Distress Due to Delayed Hematoma after Anterior Cervical Discectomy Fusion / 대한정형외과학회잡지

Hematoma resulting in acute respiratory distress associated with anterior cervical spine surgery is rare; however, it is a serious adverse complication and occurs primarily within postoperative three days and is cured in the hospital. Rarely, delayed hematoma occurs after discharge from the hospital, and treatment of respiration is difficult. In this review, we report on a case of acute respiratory distress due to delayed hematoma following anterior cervical discectomy and fusion, which occurred at postoperative five days.

Closed Traction Reduction as an Initial Management for Subaxial Unilateral Facet Dislocation / 대한정형외과학회잡지

PURPOSE: Subaxial unilateral facet dislocation requires immediate reduction; however, cases of failure with reduction have also been reported. We analyzed the factors preventing closed traction reduction and attempted to determine the efficacy and indications of closed traction reduction. MATERIALS AND METHODS: We selected 26 patients, 17 men and nine women. The average age of the patients in selected group was 49 years (20-69 years). Each patient was first treated with Gardner head traction and closed traction reduction. Each patient was checked for the degree of locking of the dislocated segment, intervertebral disc herniation, the degree of contralateral facet joint subluxation, and accompanied fracture. The effect of the location of the injured segment, age, and sex on closed reduction traction was analyzed. RESULTS: A high rate of unsuccessful closed traction reduction was observed for patients with more than 50% locking of the dislocated facet joint (p=0.039). Intervertebral disc herniation, the degree of contralateral facet joint subluxation, facet joint fracture, and pedicle and lamina fracture were unrelated to the success of closed traction reduction. The location of dislocation and sex showed no statistically significant relevance to failure of closed traction reduction. A high rate of failure was observed for patients younger than 40 years. Of the 26 patients, closed traction reduction was successful for 12 and unsuccessful for 14. CONCLUSION: For patients whose degree of locking of the dislocated facet joint is less than 50%, closed traction reduction using skull traction is considered effective, however, for patients younger than 40 years or with more than 50% locking of the dislocated facet, prompt reduction under general anesthesia and subsequent appropriate surgery is considered beneficial.

Airway Compression as a Result of Extensive Prevertebral Hematoma Following Extension Injury of Lower Cervical Spine without Fracture/Dislocation / 대한정형외과학회잡지

A 77-year-old man presented with severe dyspnea, neck pain, tingling sensation in both hands, and weakness after an acute prevertebral soft tissue hematoma due to distractive-extension injury. Magnetic resonance images demonstrated an extensive hematoma accumulation, anterior longitudinal ligament and longus colli muscle injuries. We report here a case of dyspnea due to an extensive prevertebral hematoma by soft tissue injury without cervical vertebral fracture and/or dislocation and a review the relevant literature.

Clinical Analysis of Lower Cervical Spine Injury according to Injury Mechanism: Data of 277 Surgical Patients / 대한정형외과학회잡지

PURPOSE: To analyze the incidence and treatment outcomes of lower cervical spine injury since there is no long term, large Korean data available. MATERIALS AND METHODS: We analyzed 277 patients with lower cervical spine injury who underwent surgical treatments between May 1994 and October 2008. The injury types are based on Allen's classification, and neurologic injury was classified as complete, incomplete cord injury, root injury and no neurologic status. We analyzed postoperative complications, neurologic recovery and the relief of pain. RESULTS: Distractive-extension injury occurred most commonly in 140 patients (50.5%). Neurologic injury was detected in 232 cases (83.8%); 46 (16.6%) complete cord injury; 154 (55.6%) incomplete cord injury; and 32 (11.6%) root injury. Incomplete cord injury of distractive extension injury was poorly recovered. Clinical outcomes demonstrated improvement compared with the preoperative values in mean visual analogue scale. Complications were respiratory failure, neurogenic bladder, urinary tract infection and gastritis. CONCLUSION: This study showed the highest incidence of distractive extension injury and neurologic injury contrary to previous studies. This result was caused by the use of plain radiograph to establish Allen's classification in the past. Therefore, we suggest the use of magnetic resonance imaging for evaluating soft tissue injury with Allen's classification to achieve accurate assessment.

Efficacy of Postoperative Radiograph for Evaluating the Prevertebral Soft Tissue Swelling after Anterior Cervical Discectomy and Fusion

BACKGROUND: After surgery for degenerative spinal disease by the anterior approach, the degree of soft tissue swelling can be assessed simply using plain radiographs. However, there are little studies according to the surgical methods or extent of surgery, and no study had addressed the clinical meaning of swelling determined by plain radiography. The purpose of this study was to evaluate the clinical significance of prevertebral soft tissue swelling (PSTS) after anterior cervical fusion with plate fixation for the treatment of degenerative cervical spinal disorders. METHODS: One hundred and thirty-five patients that underwent anterior cervical fusion with plate augmentation for degenerative cervical spondylosis were included in this study. PSTS differences were analyzed with respect to numbers of fusion segments and location of fusion. Cases were divided into two groups based on the amount of PSTS, and incidences of dyspnea, dysphagia, dysphonia were evaluated. RESULTS: PSTS increments were significantly greater in patients that had undergone multi-level or high-level fusion. Complications of dyspnea, dysphagia and dysphonia were found more frequently in patients with marked PSTS group. CONCLUSIONS: Increments of PSTS after anterior cervical fusion for degenerative spinal disorders are greater and incidences of complications are higher in patients that undergo multi-level or high-level fusion. Thus, measurement of PSTS using consecutive cervical lateral radiographs after anterior cervical surgery is clinically meaningful procedure.