Does intraoperative neurophysiological monitoring have predictive value for functional recovery following spinal cord injury? A case report.

To present a case report of a patient with an ASIA B spinal cord injury with partially intact baseline IONM who made a complete functional recovery postoperatively. A thirty-three year old male presented after a motor vehicle accident. Imaging studies revealed a C4-C5 bilateral facet dislocation. On presentation the patient had 4/5 strength in bilateral biceps and wrist extensors, 3/5 strength in bilateral triceps, and 0/5 strength in the finger flexors, intrinsics and all lower extremity muscles. Motor level was C7. Sensation was grossly intact to light touch throughout all extremities, intact to pinprick from C2 to T7, and absent to pinprick caudal to T7. Rectal tone and contraction were absent. After attempts at closed reduction failed the patient underwent an open reduction and posterior C4-C5 fusion. Intraoperative neurophysiologic monitoring (IONM) revealed the presence of baseline responses to the posterior tibial nerve using somatosensory evoked potentials and to the right abductor hallucis using transcranial motor evoked potentials. At the 6 weeks postoperative visit the patient had full 5/5 motor strength to all muscles except the left deltoid that was 4/5 due to a rotator cuff injury. This case illustrates a potential prognostic value of IONM. Despite lack of clinical motor function at the time of surgery, IONM was able to illicit a motor response in the right lower extremity. Further prospective studies are needed for further investigation.

Comparison of vertebroplasty and balloon kyphoplasty for treatment of vertebral compression fractures: a meta-analysis of the literature.

BACKGROUND CONTEXT: Previous investigators have reported on benefits and risks associated with vertebroplasty and kyphoplasty, but there are limited comparison data available. Additionally, much of the data is from retrospective studies and case series. PURPOSE: The purpose of this study is to review the literature and perform a meta-analysis of pain relief and risk of complications associated with vertebroplasty versus kyphoplasty. STUDY DESIGN: A meta-analysis of the literature on effectiveness of pain control and risk of complications after vertebroplasty versus balloon kyphoplasty. Outcomes measures include visual analog scale and complications. METHODS: A comprehensive review of the literature was performed. All studies providing information on pain relief and complications were included. Preoperative, postoperative, and change in visual analog scale (VAS) scores were tabulated. Data were analyzed to identify if a significant improvement in the VAS score occurred. Changes in the VAS scores were compared for vertebroplasty and kyphoplasty to determine if there was a significant difference. RESULTS: A total of 1,036 abstracts were identified. Of these, 168 studies met the inclusion criteria. Mean pre- and postoperative VAS scores for vertebroplasty were 8.36 and 2.68, respectively, with a mean change of 5.68 (p<.001). The mean pre- and postoperative VAS scores for kyphoplasty were 8.06 and 3.46, respectively, with a mean change of 4.60 (p<.001). There was statistically greater improvement found with vertebroplasty versus kyphoplasty (p<.001). The risk of new fracture was 17.9% with vertebroplasty versus 14.1% with kyphoplasty (p<.01). The risk of cement leak was 19.7% with vertebroplasty versus 7.0% with kyphoplasty (p<.001). CONCLUSIONS: Both vertebroplasty and kyphoplasty provided significant improvement in VAS pain scores. Vertebroplasty had a significantly greater improvement in pain scores but also had statistically greater risk of cement leakage and new fracture.

Fixation strength of unicortical versus bicortical C1-C2 transarticular screws.

BACKGROUND CONTEXT: The internal carotid artery and hypoglossal nerve lie over the anterior aspect of the lateral mass of the atlas and are at risk from bicortical C1-C2 transarticular screws. This has led to the recommendation for unicortical screws if the neurovascular structures are in close proximity to the proposed exit point. No data are available on strength of unicortical versus bicortical C1-C2 transarticular screws. PURPOSE: To compare the biomechanical pullout strength of unicortical versus bicortical C1-C2 transarticular screws in a cadaveric model. STUDY DESIGN: Biomechanical study. METHODS: Fifteen cervical spine specimens underwent axial pullout testing. A unicortical C1-C2 transarticular screw was placed on one side with a contralateral bicortical screw. Data were analyzed to reveal any significant differences in strength. RESULTS: Mean pullout strength for the bicortical C1-C2 transarticular screws was 1,048.8 (+/-360.1) N versus 939.2 (+/-360.6) for unicortical screws (p=.22). There was no significant difference in the pullout strength of unicortical and bicortical screws. CONCLUSIONS: In cases with satisfactory bone quality, it appears reasonable to use unicortical screws to avoid the risk of neurovascular injury from penetrating the anterior cortex of C1.

Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management.

Degenerative changes in the cervical spinal column are ubiquitous in the adult population, but infrequently symptomatic. The evaluation of patients with symptoms is facilitated by classifying the resulting clinical syndromes into axial neck pain, cervical radiculopathy, cervical myelopathy, or a combination of these conditions. Although most patients with axial neck pain, cervical radiculopathy, or mild cervical myelopathy respond well to initial nonsurgical treatment, those who continue to have symptoms or patients with clinically evident myelopathy are candidates for surgical intervention.

Delayed presentation of metastatic melanoma of the cervical spine.

A 54-year-old woman presented with neck pain and bilateral shoulder pain. The pain was of varying intensity and was present with activity as well as at night and at rest. She had weakness of her triceps and finger intrinsic muscles. Her past medical history included stage IV melanoma for which she underwent an excision from the right flank area 25 years ago. She was cleared from any disease 5 years after the excision. Magnetic resonance imaging of the cervical spine revealed increased signal intensity in the C7 vertebral body with soft tissue extension into the epidural space. Two weeks after initial presentation the patient underwent a C7 corpectomy and fusion. The C7 vertebral body was grossly pathologic and tissue samples revealed metastatic malignant melanoma. During the 2 weeks following the fusion the patient developed increasing pain and generalized weakness. Repeat MRI of the cervical spine revealed a large soft tissue intensity extending in the spinal canal from C6 to T2. Several days later the patient developed an acute onset of lower extremity weakness as well as urinary incontinence. The patient opted to pursue hospice care, and she died 3 weeks later, 8 weeks after the initial presentation.

Minimally invasive lumbar spinal fusion.

Minimally invasive techniques for lumbar spine fusion have been developed in an attempt to decrease the complications related to traditional open exposures (eg, infection, wound healing problems). Anterior minimally invasive procedures include laparoscopic and mini-open anterior lumbar interbody fusion as well as the lateral transpsoas and percutaneous presacral approaches. Posterior techniques typically use a tubular retractor system that avoids the muscle stripping associated with open procedures. These techniques can be applied to both posterior and transforaminal lumbar interbody fusion procedures. Many initial reports have shown similar clinical results in terms of spinal fusion rates for both traditional open and minimally invasive posterior approaches. However, the anterior minimally invasive procedures are often associated with significantly greater incidence of complications and technical difficulty than their associated open approaches. There is a steep learning curve associated with minimally invasive techniques, and surgeons should not expect to master them in the first several cases.

Effect of lower two-level anterior cervical fusion on the superior adjacent level.

OBJECT: Symptomatic multisegment disease is most common at the C5-6 and C6-7 levels, and two-level anterior cervical discectomy and fusion (ACDF) is performed most often at these levels. Therefore, it may be clinically important to know whether a C5-7 fusion affects the superior C4-5 segment. A biomechanical study was carried out using cadaveric cervical spine specimens to determine the effect of lower two-level anterior cervical fusion on intradiscal pressure and segmental motion at the superior adjacent vertebral level. METHODS: Five cadaveric cervical spine specimens were used in this study. The specimens were stabilized at T-1 and loaded at C-3 to 15 degrees flexion, 10 degrees extension, and 10 degrees lateral bending before and after simulated two-level ACDF with plate placement at C5-7. Intradiscal pressure was recorded at the C4-5 level, and segmental motion was recorded from C-4 through C-7. Differences in mean intradiscal pressures were calculated and analyzed using a paired Student t-test. When the maximum calibrated intradiscal pressures were exceeded ("overshot") during measurements, data from the specimens involved were analyzed using the motion data with a Student t-test. Values for pressure and motion obtained before and after simulated ACDF were compared. RESULTS: During flexion, the mean intradiscal pressure changes (+/- standard deviations) in the pre- and post-ACDF measurements were 1275 (+/- 225) mm Hg and 2475 (+/- 75) mm Hg, respectively (p < 0.05). When the results of pre-ACDF testing were compared with post-ACDF results, no significant difference was found in the mean changes in the intradiscal pressure during extension and lateral bending. The maximum calibrated intradiscal pressures were exceeded during the post-ACDF testing in four specimens in extension, three in flexion, and two in lateral bending. Comparison of pre- and post-ACDF data for all five specimens revealed significant differences in motion and intradiscal pressure (p < 0.05) during flexion, significant differences in motion (p < 0.05) but not in intradiscal pressure during extension, and significant differences in intradiscal pressure changes (p < 0.05) but not in motion during lateral bending. CONCLUSIONS: Simulated C5-7 ACDF caused a significant increase in intradiscal pressure and segmental motion in the superior adjacent C4-5 level during physiological motion. The increased pressure and hypermobility might accelerate normal degenerative changes in the vertebral levels adjacent to the anterior cervical fusion.

Redundant publications in the orthopedic literature.

Rates of redundant publications in the general surgery literature are approximately 14%. This article identifies the rate of redundant publications in the orthopedic literature. All original articles published during the year 2000 in The Journal of Bone and Joint Surgery (American Volume), Journal of Orthopaedic Trauma, Journal of Spinal Disorders, and Spine were searched using PubMed. Redundancy rate was 4 (3.15%) of 127 for The Journal of Bone and Joint Surgery (American volume), zero (0%) of 70 for Journal of Orthopaedic Trauma, 2 (2.90%) of 69 for Journal of Spinal Disorders, and 11 (3.12%) of 353 for Spine.

Transforaminal lumbar interbody fusion: a retrospective study of long-term pain relief and fusion outcomes.

No long-term studies exist on the effectiveness of transforaminal lumbar interbody fusion. This study sought to determine postoperative pain, disability, and fusion status of transforaminal lumbar interbody fusion patients after > or = 4 years to establish long-term outcomes. A retrospective analysis of 42 patients with minimum 4-year follow-up was conducted. Patients completed visual analog pain scale (VAS) and Oswestry functional capacity evaluation pre- and postoperatively. Statistically significant improvement was noted in VAS and Oswestry functional capacity evaluation scores. Transforaminal lumbar interbody fusion is effective in alleviating intractable back pain over an extended time period. Solid radiographic fusion is unnecessary for clinically successful outcomes.

Does Resection of the Posterior Longitudinal Ligament Impact the Incidence of C5 Palsy After Cervical Corpectomy Procedures?: A Review of 459 Consecutive Cases.

STUDY DESIGN: Retrospective review. OBJECTIVE: To evaluate key risk factors for the development of C5 palsy after cervical corpectomy, including resection of the posterior longitudinal ligament (PLL). SUMMARY OF BACKGROUND DATA: Postoperative C5 palsy is a well-known complication after cervical spine surgery. It is unknown whether resection of the PLL affects the incidence of C5 palsy. METHODS: We performed a retrospective review of 459 consecutive patients undergoing anterior cervical corpectomies over a 15-year period. Medical records were reviewed to gather demographic data, operative details, and the incidence of C5 palsy. We performed regression analyses to identify variables that predicted the development of C5 palsy. RESULTS: Our final analysis included 397 patients (females 51.4%, mean age 55.6 ±â€Š11.6 yrs). Anterior corpectomy alone was performed in 255 (64.2%) patients, and combined anterior and posterior fusion was performed in 142 (35.8%) patients. Twenty-four patients (6.0%) developed C5 nerve palsy. Univariable regression demonstrated age greater than 65 (odds ratio, OR 2.7, 95% confidence interval, CI 1.2 to 6.3), corpectomy of three or more levels (OR 6.3, 95% CI 2.1 to 18.9), presence of ossification of the PLL (OR 4.3, 95% CI 1.6 to 11.7), and complete or partial resection of the PLL (OR 2.6, 95% CI 1.0 to 6.7) predicted development of C5 palsy. Multivariable regression demonstrated that the odds of getting C5 palsy with complete or partial resection of the PLL is 4.0 times (95% CI 1.5 to 10.5) higher compared with patients with an intact PLL. There were no significant differences in C5 palsy rates based on surgical approach (anterior vs. anterior plus posterior), sex, smoking status, or diabetes. CONCLUSION: Age greater than 65 years, corpectomy of three or more levels, presence of ossification of the PLL, and complete or partial resection of the PLL significantly predicted the development of C5 palsy. LEVEL OF EVIDENCE: 4.

A comparison of outcomes of anterior cervical discectomy and fusion in patients with and without radicular symptoms.

Anterior cervical discectomy and fusion (ACDF) is commonly performed for degenerative conditions of the cervical spine with good to excellent results. There is controversy over the use of ACDF for patients with axial neck pain alone. A retrospective review of 202 patients from two private practice orthopaedic spine surgeons following ACDF with 39-month mean follow-up was performed. Patients completed pain drawings, pre- and postoperative visual analog pain scales (VAS), Oswestry functional capacity evaluations (OSW), and a postoperative neck disability index. Forty-one patients had axial neck pain alone, and 161 had radicular pain with or without neck pain. There were significant improvements in VAS and OSW scores following surgery for the combined study population as well as the neck pain only and radicular pain groups (p < .01). ACDF can be effectively used for treatment of patients with axial neck pain without radicular symptoms.

Perioperative autotransfusion systems in TKA are not necessary.

Perioperative autotransfusion is believed to reduce postoperative allogenic transfusion. A retrospective review of 128 patients undergoing total knee arthroplasty with preoperative hemoglobin < 14 g/dL was performed. Group 1 received an intraoperative tourniquet and postoperative autotransfusion. Group 2 received a tourniquet and hemovac drain postoperatively. Group 3 had a tourniquet only during cementing with no drain. Nine (17%) patients in group 1, 9 (19%) patients in group 2, and 4 (15%) patients in group 3 required transfusion. Perioperative autotransfusion does not decrease the need for allogenic transfusion when compared to similar patients at risk for transfusion because of preoperative hemoglobin level < 14 g/dL.

Hemorrhagic lumbar synovial facet cyst secondary to anticoagulation therapy.

BACKGROUND CONTEXT: Acute onset of radicular symptoms has been reported following hemorrhage into lumbar synovial cysts after trauma or in cases of spinal instability. No previous cases have been linked to anticoagulation therapy. PURPOSE: To present a case of symptomatic hemorrhagic lumbar synovial cyst occurring after anticoagulation therapy. STUDY DESIGN: A case report and review of the literature. METHODS: A patient presented with low back and radicular pain secondary to a large synovial facet cyst. Magnetic resonance imaging revealed a large facet cyst compressing the thecal sac and L3 exiting nerve root. RESULTS: The synovial cyst was excised during a lumbar decompression and fusion. Gross blood was present in the cyst. CONCLUSIONS: This is the first reported case of symptomatic hemorrhagic lumbar facet cyst associated with anticoagulation therapy.

A treatment and outcomes analysis of patients with coccydynia.

BACKGROUND CONTEXT: Coccydynia is a painful condition of the terminal portion of the spine often resulting from direct trauma, childbirth or unknown etiology. This is a relatively rare condition with no universally accepted treatment protocol. PURPOSE: To more clearly determine the optimal treatment for patients with coccydynia and to assess the outcomes after conservative and surgical therapy. STUDY DESIGN: Retrospective review of outcomes of all patients presenting with symptoms of coccydynia during a 5-year period. PATIENT SAMPLE: Thirty-two patients presented to an orthopedic spine surgeon during a 5-year period with symptoms of coccydynia. OUTCOME MEASURES: Patients completed visual analog pain scales (VAS) and the Oswestry (OSW) functional capacity index. METHODS: Of the 32 patients in the study, 4 (13%) were treated with nonsteroidal anti-inflammatory drugs (NSAIDs) alone, 17 (53%) were treated with NSAIDs followed by local injections and 11 (34%) underwent coccygectomy after failure of NSAIDs and local injections. Patients completed VAS and OSW forms. Pain drawings were also completed. RESULTS: Patients undergoing surgery had significantly greater pretreatment VAS scores (8.3 vs 5.4, p=.002). Surgical patients also had greater OSW scores, but not significantly (36.6 vs 24.2, p=.223). Marked improvement was reported by 9 of 11 (82%) surgical patients. Three of 11 (27%) surgical patients developed wound infections and 1 (9%) wound dehiscence. All infections resolved following irrigation and debridement and a short course of oral antibiotics. CONCLUSIONS: Patients with coccydynia should be managed conservatively when possible. Treatment should include NSAIDs and local steroid injections. Patients will often require repeat injections over time. Surgery can offer reasonable results for patients failing conservative treatment, but they should be warned of the high rate of infection.

Use of electrical bone stimulation in spinal fusion.

Spinal fusion is commonly done to manage deformity, restore stability, and eliminate excessive motion at specific spinal levels. Pseudarthrosis limits the clinical success of spinal fusion. Three types of electrical stimulation, which is used to manage non-union in long bones, recently have been applied in an attempt to enhance the rate of spinal fusion. Direct current electrical stimulation is internal and thus eliminates dependence on patient compliance. Pulsed electromagnetic fields and capacitively coupled electrical stimulation are external techniques that require patient compliance but do not have the increased risk associated with implantable devices. Firm conclusions about efficacy are difficult to establish because of inconsistencies in both determining a reliable, reproducible end point for fusion and in incorporating the effect of patient parameters. Most data indicate a positive effect for use of direct current stimulation, but further studies are necessary to determine its appropriateness as an adjuvant to spinal fusion.

Return to play after lumbar spine conditions and surgeries.

Low back pain in athletes can result from a wide variety of conditions. A detailed history and physical examination supplemented by appropriate imaging studies can lead to an accurate diagnosis. The majority of cases will be self-limiting and resolve within 6 weeks regardless of treatment, but it is important to be able to identify conditions that require specific treatment. The decision of when an athlete can return to active competition is determined by the specific condition, associated symptoms, and treatment provided. Most athletes can return to full unrestricted play after sufficient resolution of pain and restoration of range of motion. Athletes undergoing spinal fusion are typically restricted from full-contact sports.

Dysphagia caused by anterior cervical osteophytes: a case report.

This 79-year-old man had a several-year history of dysphagia. On presentation, he spoke with difficulty but was not short of breath, and hemoptysis was present. A 17-mm osteophyte anterior to C3-C4 encroached on the posterior aspect of the oral pharynx and esophagus. The patient underwent C3-C6 anterior ostectomy; recovery was complete within 4 weeks.

Vertebroplasty: a new treatment strategy for osteoporotic compression fractures.

Vertebroplasty is a procedure in which bone cement is injected into a fractured vertebral body in an attempt to stabilize fractured segments and reduce pain. This procedure was originally used to treat spinal lesions caused by metastases and has recently been used to treat severe bone loss caused by osteoporosis. In this article, we review the current treatment for osteoporosis, introduce vertebroplasty with its associated efficacy and risks, and describe kyphoplasty.

Preliminary experience with a new surgical treatment for dysphagia due to anterior cervical osteophytes.

A technique for surgical treatment of anterior cervical osteophytes is presented. A midline trough is created in the osteophytes using a burr under fluoroscopy down to the anterior cervical line. A rongeur is used to remove the remaining osteophytes while protecting the lateral soft tissues. Two patients presented with symptoms of progressive dysphagia secondary to anterior cervical osteophytes. Each underwent surgical ostectomy without complication after failing conservative treatment. This technique provides a safe, effective method to remove anterior cervical osteophytes.

Survey of Cervical Spine Research Society members on the use of high-dose steroids for acute spinal cord injuries.

STUDY DESIGN: A questionnaire survey. OBJECTIVE: To characterize surgeons' current perspectives on the administration of methylprednisolone for acute spinal cord injury (SCI) and determine how this has changed during the last 7 years. SUMMARY OF BACKGROUND DATA: The determinants of and complications associated with off-label steroid use for acute SCI remain controversial. METHODS: A survey was sent to surgeon members of the Cervical Spine Research Society requesting information regarding their use of steroids for acute SCI. Determinants included surgeons' specialty, trauma center level, number of SCIs treated per year, severity of injury, and location of injury. These results were compared across groups as well as with a historical control. RESULTS: In the case of cervical complete and incomplete SCIs, 47.4% and 56.4% of respondents, respectively, reported using steroids. For complete and incomplete thoracolumbar spine injuries, the usage rate was 46.2% and 55.1%, respectively. There has been a significant (P < 0.0001) decrease in the number of surgeons using high-dose steroids in the treatment of acute SCIs when compared with a previous report in 2006 (56% vs. 89%).More than 80% of respondents reported sepsis, active gastrointestinal bleeding, and SCI occurring earlier than 8 hours as contraindications. Seventy-one percent of respondents reported observing complications from the use of steroids, and 76.3% thought that the complications were severe enough to limit steroid use. Of the surgeons who used steroids for SCI, 26% thought that steroids improved neurological recovery, 19.2% used steroids to adhere to institutional protocol, and 25.6% stated they did not think steroids were beneficial but used them because of medicolegal concerns. CONCLUSION: There has been a significant decrease in the number of surgeons using high-dose steroids for acute SCIs. Sepsis, gastrointestinal bleeding, and an injury occurring more than 8 hours prior to presentation were agreed upon as contraindications to steroid use.