Minimally invasive treatment of a painful osteolytic lumbar lesion secondary to epithelioid hemangioendothelioma.

Study Design Case report. Objective Multifocal epithelioid hemangioendothelioma (EHE) of the spine is a rare disorder. We describe a novel, multimodal treatment of a painful osteolytic lumbar lesion secondary to EHE. The minimally invasive treatment results in an excellent patient outcome with decreased morbidity compared to traditional techniques. Methods A previously healthy young adult presented with a painful osteolytic lesion at the L2 vertebrae. Imaging revealed multifocal spinal lesions consistent with a history of EHE. Core needle biopsy confirmed the diagnosis. Preoperative cryoablation of L2 was followed by a staged surgery, which included a partial L2 corpectomy, tumor resection, bone grafting, and vertebral reconstruction using a minimally invasive technique. This treatment was followed by prolonged therapy with interferon and bisphosphonate. Results At 3.5 years' follow-up, the patient has maintained his vertebral body height, has not required a fusion, and has had no recurrence of disease. Conclusion Multimodal treatment consisting of tumor cryoablation, partial corpectomy, allograft reconstruction of the vertebrae, and adjuvant interferon and bisphosphonate can result in good outcomes for well-contained EHE tumors of the spine.

Treatment of a thoracic dural-pleural fistula with a vascularized omental flap: a case report.

STUDY DESIGN: Case report. OBJECTIVE: To report an unusual case of pseudomeningocele with dural-pleural fistula formation and spinal cord herniation after anterior thoracic decompression, as well as a unique surgical method for treating this complication. SUMMARY OF BACKGROUND DATA: Thoracic pseudomeningocele with fistula formation is a rare but serious complication of spinal surgery. The negative pressure environment created in the pleural space can complicate management and result in dural-plural fistula formation. We report on the use of a vascularized omental flap to treat this complication after failure of more traditional techniques. METHODS: A 76-year-old man presented with complaints of myeloradiculopathy, including weakness of lower extremities, with gait and bowel and bladder dysfunction after 2 previous decompressions at the T6-T7 level. Revision surgery was complicated by a dural-plural fistula and spinal cord herniation with neurological deterioration requiring reoperation. RESULTS: Treatment with vascularized omental flap successfully treated the fistula, and the patient had resolution of all symptoms with the exception of some lower extremity neuropathic pain. Postoperative imaging showed excellent decompression of the spinal canal and a small, stable pseudomeningocele without evidence of cerebrospinal fluid hypotension or active dural-pleural fistula. CONCLUSION: Treatment of thoracic psuedomeningoceles and fistulas can be difficult due to the unique negative intrathoracic pressure environment that complicates closure using traditional methods. Alternative treatment options may be necessary when more traditional techniques fail. Our report highlights one such option, a vascularized omental flap, which was used to successfully treat the patient.

Donor-site complications of autogenous nonvascularized fibula strut graft harvest for anterior cervical corpectomy and fusion surgery: experience with 163 consecutive cases.

BACKGROUND CONTEXT: The fibula is a source of bone graft for reconstruction of the appendicular and axial skeleton. PURPOSE: The aim of this study is to determine donor-site complications and morbidity in a large series of patients who underwent autogenous fibula harvesting for anterior cervical corpectomy and fusion (ACCF) surgery. STUDY DESIGN/SETTING: Retrospective review (Level III). PATIENT SAMPLE: One hundred sixty-three patients over an eight-year period who underwent ACCF with autogenous fibula. OUTCOME MEASURES: Donor site complications (such as infection, cellulitis, pain, damage to the superficial peroneal nerve, ankle instability, tibial stress fracture, and so forth), treatment, and final outcome were determined from patient records. METHODS: Retrospective study of patients who underwent ACCF with autogenous nonvascularized fibula strut graft over an eight-year period (from 1995 to 2002) was conducted. Donor site complications (such as infection, cellulitis, pain, damage to the superficial peroneal nerve, ankle instability, tibial stress fracture, and so forth), treatment, and final outcome were determined from patient records. RESULTS: One hundred sixty-three patients underwent ACCF with autogenous fibula graft during the study period. The most common short-term complication (lasting <3 months) was incisional pain, present in 86 of 163 patients (53%). Incisional pain lasted longer than 3 months in 25 of 163 patients (15%) but resolved in all but two patients by 24 months. Two patients (1.2%) developed superficial peroneal neuromas. Five patients (3%) developed tibial stress fractures. Two patients (1.2%) developed ankle instability. Fifteen (9%) patients developed cellulitis that resolved in all patients after a short course of oral antibiotics, with one additional patient developing a deep infection requiring surgical debridement and intravenous antibiotics. CONCLUSIONS: Although autogenous fibula is an excellent graft for multilevel ACCF reconstruction, surgeons should carefully consider the associated morbidity of fibular harvest before surgery. In this series, most complications were of short duration. However, nine patients with long-term complications required five additional surgical procedures. Therefore, patients who are scheduled to undergo autogenous fibula harvest should be advised about these potential complications.

The surgeon as a consultant for medical device manufacturers: what do our patients think?

STUDY DESIGN: Patient survey. OBJECTIVE: To evaluate patient perspective on surgeons as consultants for industry and medical device manufacturers. SUMMARY OF BACKGROUND DATA: Relationships between surgeons and medical device manufacturers are becoming increasingly common. Little is known, however, about how patients perceive these relationships. METHODS: Patients in the waiting area of an orthopedic surgery clinic were given a simple 1-page, 8-question anonymous questionnaire. Their responses were tabulated and analyzed for 3 variables: gender, age, and education level. RESULTS: A total of 245 patients completed the questionnaire. An overwhelming majority (94.3%) believed that surgeon-industry relationship is beneficial to patients, and a majority (66.5%) of patients thought that physicians should be compensated for this role. Women were more likely than men to want this relationship to be regulated by physicians instead of the government or hospitals. Patients older than 55 years were less likely to be in favor of physicians being compensated than younger patients. The more educated the patient, the less likely he/she was in favor of allowing physicians to regulate physician-industry relationship. CONCLUSION: Patients support surgeons in the role of consultants for industry. Gender, age, and education level influence the way that patients perceive this issue.

Utilization of predonated autologous blood in anterior cervical corpectomy and fusion surgery.

OBJECTIVE: To determine the utilization of predonated autologous blood in patients treated with anterior cervical corpectomy and fusion (ACCF). METHODS: Retrospective chart review of 154 patients who underwent 1, 2, or 3-level ACCF over a 6-year period was performed. Variables collected included patterns of autologous and allogenic blood use, blood loss, and hematocrit at admission and discharge from the hospital. RESULTS: For 1-level ACCF, only 16.7% of the predonated autologous blood was used. As expected, use of predonated autologous blood increased with the number of corpectomy levels: Patients with 2 and 3-level ACCF used 29.0% and 53.4% of the predonated blood, respectively. The use of autologous blood significantly reduced the need for allogenic blood transfusion for 2 and 3-level ACCF. CONCLUSIONS: Autologous blood was used efficiently in 3-level ACCF, and predonation is associated with decreased allogeneic blood transfusion requirement in 2 and 3-level ACCF.

Intraoperative somatosensory evoked potential monitoring during anterior cervical discectomy and fusion in nonmyelopathic patients--a review of 1,039 cases.

BACKGROUND CONTEXT: Intraoperative somatosensory evoked potential (SSEP) monitoring has been shown to reduce the incidence of new postoperative neurological deficits in scoliosis surgery. However, its usefulness during cervical spine surgery remains a subject of debate. PURPOSE: To determine the utility of intraoperative SSEP monitoring in a specific patient population (those with cervical radiculopathy in the absence of myelopathy) who underwent anterior cervical discectomy and fusion (ACDF) surgery. STUDY DESIGN: Retrospective review. PATIENT SAMPLE: A total of 1,039 nonmyelopathic patients who underwent single or multilevel ACDF surgery. The control group (462 patients) did not have intraoperative SSEP monitoring, whereas the monitored group (577 patients) had continuous intraoperative SSEP monitoring performed. OUTCOME MEASURE: A new postoperative neurological deficit. METHODS: SSEP tracings were reviewed for all 577 patients in the monitored group and all significant signal changes were noted. Medical records were reviewed for all 1,039 patients to determine if any new neurological deficits developed in the immediate postoperative period. RESULTS: None of the patients in the control group had any new postoperative neurological deficits. In the monitored group there were six instances of transient SSEP changes (1 due to suspected carotid artery compression; 5 thought to be due to transient hypotension) which resolved with the appropriate intraoperative intervention (repositioning of retractors; raising the arterial blood pressure). Upon waking up from anesthesia, one patient in the monitored group had a new neurological deficit (partial central cord syndrome) despite normal intraoperative SSEP signals. CONCLUSIONS: ACDF appears to be a safe surgical procedure with a low incidence of iatrogenic neurological injury. Transient SSEP signal changes, which improved with intraoperative interventions, were not associated with new postoperative neurological deficits. An intraoperative neurological deficit is possible despite normal SSEP signals.

Epidural Hematoma Presenting with Severe Neck Pain without Neurological Deficit - A Late Complication of Posterior Cervical Spine Surgery: Presentation of Three Unusual Cases.

Postoperative epidural hematoma (EDH) usually present with neurological deficit. Massive EDH presenting with only severe pain without neurological deficit are rare. Atypical presentations of postoperative EDHs may lead to delayed diagnosis and treatment. We present three such cases after posterior cervical spine surgery. Three patients presented with severe neck pain and spasms without motor deficits several days after posterior cervical decompressive procedures. Imaging studies identified compressive EDHs at the surgical site with severe compression of the spinal cord. All were treated with emergent decompression, with resulting improvement of symptoms and pain relief without further neurological sequelae. In conclusion, postoperative EDHs after posterior cervical spine surgery may result in minimal neurological deficit. Our report reminds surgeons to keep this possibility in mind when patients complain of unusually severe neck pain and spasms after posterior cervical spine surgery.

Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3,183 consecutive degenerative lumbar cases.

STUDY DESIGN: Retrospective review. OBJECTIVES: To review the experience of a single institution with degenerative lumbar surgery and to identify cases of incidental dural tears (DTs); and to report on the efficacy of our postoperative management protocol for DT, which relies on early mobilization. SUMMARY OF BACKGROUND DATA: DTs are a common complication of degenerative lumbar spine surgery. However, the management strategies for this complication vary from one surgeon to another. METHODS: A total of 3,183 degenerative lumbar spine cases (decompression and/or fusion) were reviewed. Cases complicated by an incidental DT were identified. Patients who required a return to the operating room for a second procedure were identified and the operative findings were reviewed. RESULTS: The incidence of DT during primary lumbar surgeries was 7.6% (153 of 2,024 cases), which compares to an incidence of 15.9% for revision cases (185 of 1,159 cases). If recognized during the index procedure, all DTs were repaired using a 4-0 silk suture. Six patients (4 primary, 2 revisions) who did not improve despite our postoperative management protocol were taken to the operating room for irrigation and debridement, repair of the defect, and placement of a subfascial drain to closed suction. All 6 patients went on to do well and did not have any further complications. CONCLUSIONS: DTs are common during degenerative lumbar spine surgery. Revision surgery is twice as likely as primary surgery to result in this complication. Our postoperative early mobilization protocol appears to be an effective and safe management strategy for treating this complication (98.2% success rate). Very few patients (6 of 338, or 1.8%) needed a reoperation.

Serum C-reactive protein levels correlate with clinical response in patients treated with antibiotics for wound infections after spinal surgery.

BACKGROUND CONTEXT: C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been used to diagnose postoperative infections after spinal surgery. However, it has not been demonstrated if resolution of the signs and symptoms of postoperative spinal wound infections in patients who are being treated with intravenous antibiotics correlates with these markers. PURPOSE: The objective of this study was to determine if improvement of the signs and symptoms of postoperative wound infection after spinal surgery correlates with a decrease in serum CRP and ESR while intravenous antibiotics are administered. STUDY DESIGN: Retrospective review. PATIENT SAMPLE: The study consisted of 21 patients (mean age 63.8 years; 13 female, 8 male) with postoperative wound infections after spinal surgery. They were studied for a minimum of 20 weeks. OUTCOME MEASURES: CRP and ESR were measured at the time of diagnosis and at serial time-points. METHODS: All patients received intravenous antibiotic therapy for 6-8 weeks. Patients were monitored for clinical signs and symptoms of infection such as fever, drainage, erythema, or a need for continued wound packing at 4, 7, and 20 weeks after being diagnosed with a wound infection. RESULTS: The average CRP for all 21 patients at time of diagnosis was 11.7+/-9.0 mg/dL (range 1.2 to 37.8 mg/dL). At the 4-week time-point, 16 patients ("early responders") showed clinical improvement with no fevers, no wound drainage, no erythema, and no need for wound packing. The average CRP of this group at the 4-week time-point decreased to 0.3+/-0.5 mg/dL. In contrast, at the 4-week time-point five patients ("late responders") still had signs and symptoms of infection (2 with continuing drainage requiring wound packing; 1 with vertebral osteomyelitis requiring irrigation and debridement; 2 with erythema without fevers). The average CRP for this group was still elevated at the 4-week time-point at 7.3+/-3.5 mg/dL. The CRP value difference was statistically significant between the two groups (p<.05). As treatment continued, at the 20-week time-point the average CRP of the late responders gradually decreased to 0.8+/-0.8 mg/dL, which was not statistically different from that of the early responders (average CRP=0.6+/-1.1 mg/dL). All 21 patients had resolution of infection at the 20-week time-point. The ESR did not correlate well with clinical improvement. At time of diagnosis, the ESR of both early responders (average=57.6+/-27.6 mm/hr) and late responders (average=64.0+/-21.9 mm/hr) was elevated. It remained elevated for both groups from the beginning of the study to the end at all time-points. The final ESR at the 20-week time-point was not different between the early responders and late responders (average=27.6+/-22.3 mm/hr vs. 31.0+/-2.6 mm/hr, respectively; p>.05). CONCLUSIONS: Our data suggest that CRP may be of value in following the treatment response to antibiotics in wound infections after spinal surgery. The ESR can remain elevated in the presence of a normal CRP despite a resolution of clinical signs and symptoms of postoperative wound infection.

Intraoperative somatosensory evoked potential monitoring during cervical spine corpectomy surgery: experience with 508 cases.

STUDY DESIGN: Retrospective review. OBJECTIVES: To review consecutive cases of cervical spine corpectomy surgery performed with intraoperative somatosensory-evoked potential (SSEP) monitoring. SUMMARY OF BACKGROUND DATA: There is controversy about the utility of SSEP monitoring during anterior cervical spine surgery. There is no study in the literature that has specifically evaluated the utility of SSEP monitoring for cervical spine corpectomy surgery. METHODS: Intraoperative SSEP tracings for 508 patients (average age, 55.7 years; 268 male, 240 female) who underwent anterior cervical fusion with single-level or multilevel corpectomies were reviewed. Intraoperative and postoperative records were analyzed to determine if any new neurologic deficits developed when the patients woke up from anesthesia. RESULTS: The overall incidence of a new postoperative neurologic deficit in this series of patients was 2.4% (11 with nerve root injury, 1 with quadriplegia). The incidence of significant SSEP changes was 5.3% (27 of 508 patients). The most common identifiable cause of SSEP changes was hypotension, and the most common neurologic deficit was deltoid (C5) weakness. One patient had irreversible SSEP changes, and he woke up with new-onset quadriplegia. The calculated sensitivity and specificity of intraoperative SSEP monitoring for detecting impending or resultant intraoperative iatrogenic neurologic injury were 77.1% and 100%, respectively. However, if the isolated nerve root injuries are removed from the analysis, then both the calculated sensitivity and the negative predictive values were 100%. CONCLUSIONS: Intraoperative SSEP monitoring can alert the surgeon to adverse iatrogenic intraoperative events with potential for neurologic injury. Most SSEP signal changes are reversible and do not result in a clinical deficit. Isolated nerve root injury appears to be the most common iatrogenic intraoperative injury during cervical spine corpectomy surgery.

Acute quadriparesis caused by calcification of the entire cervical ligamentum flavum in a white female--report of an unusual case and a brief review of the literature: case report.

STUDY DESIGN: Case report. OBJECTIVES: To describe an extremely unusual case of acute quadriparesis in a white female caused by calcification of the ligamentum flavum (LF) from C1 to T2, and to review briefly the pertinent literature. SUMMARY OF BACKGROUND DATA: Diseases characterized by abnormal calcium deposition on the spinal ligaments have an unclear etiology. The overwhelming majority of these cases has been reported in people of Asian descent and has a predilection for the thoracic spine. Multilevel involvement of the cervical LF in white patients is exceptionally rare. To our knowledge, complete calcification of the entire cervical LF has not been previously reported in the literature. METHODS: The history, physical examination, and radiographic studies of a 64-year-old white female with a history of scleroderma are described. The patient presented with neck pain and acute quadriparesis caused by spinal cord impingement by calcified cervical LF from C1 to T2. The patient underwent emergent C3-C7 laminectomy and C2-C7 posterior spinal fusion. RESULTS: Operative intervention resulted in marked neurologic improvement and relief from neck pain. Histopathologic examination of the calcified LF showed that the deposits consisted of hydroxyapatite crystals exclusively with no heterotopic bone. However, kyphosis did develop in the patient after laminectomy. CONCLUSION: To our knowledge, this unusual case of complete calcification of the entire cervical LF has not previously been described. Multilevel laminectomy and fusion can improve neurologic function but may result in kyphosis.

Sacral insufficiency fractures following multilevel instrumented spinal fusion: case report.

STUDY DESIGN: Case series. OBJECTIVE: To report a series of patients in whom sacral insufficiency fractures developed following multilevel spinal fusion with instrumentation. SUMMARY OF BACKGROUND DATA: Rigid spinal fusion with instrumentation results in abnormal distribution of forces in the spine. These forces have the potential to cause failure of adjacent segments, especially in older, osteopenic individuals. Sacral insufficiency fractures following lumbar-sacral fusion may be the result of these abnormal forces. However, this complication is not well described in the literature. METHODS: Three patients who sustained sacral fractures after instrumented lumbar-sacral fusion performed for degenerative disease of the spine are discussed. History, physical examination findings, and radiographic features are presented, along with a brief review of the pertinent literature. RESULTS: All 3 patients in our series started complaining of new-onset buttock pain a few weeks after their operative procedure. Radiographic examination revealed that they had transverse sacral fractures just below the fusion instrumentation. Nonoperative, conservative treatment was performed. At final follow-up, the fractures had healed completely and the patients' complaints had resolved. CONCLUSION: Patients who complain of new-onset buttock pain following multilevel lumbar-sacral fusion with instrumentation should be evaluated for sacral insufficiency fractures, especially if they have been sitting for prolonged periods. Conservative treatment seems to be sufficient.

Repeated exposure of tendon to prostaglandin-E2 leads to localized tendon degeneration.

OBJECTIVE: To determine whether repeated exposure of rabbit patellar tendon to prostaglandin-E(2) leads to degenerative changes in the tendon. SETTING: Laboratory animal study. MAIN OUTCOME MEASURES: Intratendinous changes including cellularity, matrix organization, collagen fibril packing, and diameter. METHODS: Skeletally mature New Zealand White rabbits (n = 10) were transcutaneously injected in the midsubstance of the patellar tendon with prostaglandin-E(2) (PGE(2); 50 ng or 500 ng). The contralateral tendons were used as 3 different controls (no injection, saline injection, and needlestick only). The injection was repeated once a week for 4 weeks, and the rabbits were killed 1 week after the last injection. The patellar tendons were harvested and examined using hematoxylin and eosin staining and transmission electron microscopy. RESULTS: Compared with the control groups, tendons exposed to PGE(2) by injection showed focal areas of hypercellularity, loss of normal tissue architecture, and focal areas of tendon disorganization and degeneration. Tendons injected with PGE(2) exhibited loosely organized collagen fibrils and had thinner collagen fibril diameter compared with control tendons (P < 0.005). Tendons injected with 500 ng PGE(2) appeared to be more disorganized and degenerated than those injected with 50 ng PGE(2). CONCLUSIONS: Repeated exposure of the tendon to PGE(2) leads to degenerative changes within the tendon. CLINICAL RELEVANCE: It is known that human tendon fibroblasts produce PGE(2) in vitro and in vivo in response to repetitive mechanical loading. This study demonstrates that repetitive exposure of the tendon to PGE(2) can result in degenerative changes within the tendon. Therefore, PGE(2) produced by tendon fibroblasts in response to repetitive mechanical loading in vivo might contribute to the development of exercise-induced tendinopathy.