Cervical spine fractures in ankylosing spondylitis patients: an analysis of the presentation and clinical results of 110 surgically managed patients in two spine centers.

PURPOSE: In this work, a two-center study was performed to study the clinical presentation of cervical spine fractures in ankylosing spondylitis (AS) patients and assess the surgical management of these fractures. METHODS: A retrospective analysis of prospectively collected data in two level-1 spine surgery centers was performed. Both spine centers have a standard database for all admitted patients. Inclusion criteria were surgically treated AS with cervical spine fracture diagnosis (from C1 to Th3) and postoperative follow-up minimum of 12 months. RESULTS: One hundred ten patients (105 male/5 female) were included. The mean age was 62 ± 10 years. The mean time between trauma and surgery was 49 ± 42 days. There was a history of mild trauma in 72 patients (65.4%). The clinical presentation was a pain in all patients. Twenty-seven (24.6%) had a neurological deficit at admission. The most common fracture level was C6/7 in 63 patients (57.23%). The VAS was 7 ± 1, and NDI was 34 ± 8 in the preoperative assessment. The mean preoperative kyphosis angle was 48 ± 26° between C2 and C7. Positioning and preparing of the patients on the operation table took a mean of 57 ± 28 min. The surgical approach was dorsal in 59 patients (53.6%), combined in 45 patients (40.9%), and ventral in 6 patients (6,5%). The mean number of the fixed levels was 6 ± 2 levels. Intraoperative complications occurred in 9 patients (8.2%). Postoperative Cobb angle improved to a mean of 17 ± 9 degrees. Neurological improvement occurred in 20/27 patients. In 12 patients, the recovery was complete. The mean postoperative follow-up was 46 ± 18 months. VAS improved to 3 ± 1, and NDI improved to 14 ± 6 at the last postoperative visit. The improvement was clinically significant (p = 0.01 and 0.00, respectively). CONCLUSION: High suspicion of cervical spine fractures is necessary for patients with AS. CT and MRI images are necessary to rule out cervical spine fractures in AS patients, especially to detect occult fractures. Surgical treatment is safe, and the posterior approach with long-segment fusion is the approach of choice in this group of patients.

Incidence and local risk factors of infection after anterior sub-axial cervical spine surgery: retrospective database analysis of 4897 consecutive procedures.

INTRODUCTION: The anterior cervical spine approach is safe and effective in many cervical spine pathologies. It is considered one of the most common approaches in spine surgery. Postoperative infections after anterior cervical surgery are rare but serious. MATERIALS AND METHODS: This study is a retrospective database analysis. In this study, the incidence, and the local risk factors of postoperative infection after anterior-only sub-axial cervical spine surgery in a high-volume spine center were analyzed. The data of patients operated in a teaching hospital is electronically stored in a comprehensive medical database program. Postoperative infection after anterior cervical surgery from C2 to C7 was calculated and analyzed. In the study period, 4897 patients were operated. Twenty-four infections after a primary aseptic operation were detected. Independent local risk factors were estimated. RESULTS: Postoperative infection occurred in 24/4897 patients (0.49%). The incidence of infection after cervical trauma was 3% (7/229), after spinal cord injury 4.3% (2/46), with myelopathy 1.98% (11/556), and after revision surgery 1.25% (7/560). The incidence showed a significant increase (p = 0.00, 0.01, 0.02). In 14 of the postoperatively infected patients (58.3%) an oesophageal injury was diagnosed. Odds ratios (OR) with a confidence interval (CI) of 95% was calculated. Independent risk factors for the postoperative infections were: Cervical trauma (OR 8.59, 95% CI 3.52-20.93), revision surgery (OR 3.22, 95% CI 1.33-7.82), The presence of cervical myelopathy (OR 6.71, 95% CI 2.99-15.06), and spinal cord injury (OR 9.33, 95% CI 2.13-40.83). CONCLUSIONS: Postoperative infection after anterior cervical surgery is low (0.49%). In addition to the general risk factor for infection, the local risk factors are trauma, myelopathy, spinal cord injury, and revision surgeries. In the case of postoperative infection, an oesophageal injury should be excluded.

Cement discoplasty for managing lumbar spine pseudarthrosis in elderly patients: a less invasive alternative approach for failed posterior lumbar spine interbody fusion.

PURPOSE: A retrospective cohort study was performed to evaluate pseudoarthrosis treatment results by injection of cement in disc space of failed fusion in posterior lumbar interbody fusion in patients above 65 years. METHODS: Forty-five patients above 65 years with symptomatic pseudarthrosis after lumbar spine fusion were treated by cement injection in the affected disc space. RESULTS: There were 30 females and 15 males. The mean age at the operation was 74 ± 6.5 years (range 65-89). Discoplasty was performed after the primary fusion operations after a mean of 14 ± 1.3 months (range 12-24). The mean preoperative VAS was 7.5 (range 6-9), and ODI was 36 (range 30-45). Cement injection was done at one level in most of the cases (35 patients). In seven cases, two injection levels were done, and in three cases, three levels. Twenty-three patients had discoplasty only, while 22 had discoplasty and screws change, including 14 cases of extension of the instrumentation. The mean postoperative follow-up was 32 ± 6.5 months. The VAS improved to 3.5 (range 2-5) (p = 0.02) and ODI to 12.3 (range 5-35) (p = 0.001). Reoperation was indicated in two (4%) patients by screws loosening. Asymptomatic cement leakage occurred in the paravertebral space in seven cases (15.5%). CONCLUSION: Cement discoplasty offers a less invasive reliable surgical solution in elderly patients with symptomatic lumbar pseudarthrosis in the elderly patients. In cases with screw loosening, discoplasty should be combined with screw revision.

Extra-laminar microscopic-assisted percutaneous nucleotomy (EL-MAPN) for the treatment of foraminal lumbar disc prolapse, a modified minimally invasive approach.

PURPOSE: In this work, a modification of the percutaneous surgical approach for removing the lumbar foraminal disc prolapse is introduced. MATERIAL AND METHODS: A prospective study was performed. The indication for surgery was foraminal disc prolapse presenting with acute motor or persistent sensory radiculopathy. MRI and X-ray of the lumbar spine were performed. VAS and ODI were recorded. The operation was done under general anesthesia. A needle was inserted for level-localization using C-arm. A 1.5 cm para-median skin incision was performed. A gradual dilatation using trocars was followed by the insertion of a tubular system. Under direct vision using the operative microscope, the lateral edge of the lamina was identified. A small, hooked probe was inserted in the foramen, and its position was documented fluoroscopically. With the help of the microscope, the triad consisting of Pedicle, Nerve root, and Prolapse "PNP" was identified. The nerve root was mobilized, and the prolapsed disc was removed. RESULTS: The study included 50 patients, 26 females, and 24 males. The mean follow-up was 18 months. The mean operative time was 65 min. The mean blood loss was 105 ml. The mean VAS improved from 7.8 ± 2.3 preoperatively to 0.8 ± 0.3 after one year (p = 0.001). Mean ODI improved from 28 ± 10.4 to 4 ± 2.3 after one year (p = 0.02). A recurrent disc occurred in 2 patients and was revised in the same technique. CONCLUSION: EL-MAPN represents a minimally invasive approach for foraminal disc prolapse removal under direct visual control avoiding injury to the facet joint or pars interarticularis.

Results of Four-Level Anterior Cervical Discectomy and Fusion Using Stand-Alone Interbody Titanium Cages.

STUDY DESIGN: This is a retrospective study with a minimum follow-up of 2 years. PURPOSE: The aim of this study is to assess the long-term outcomes after performing the four-level anterior cervical discectomy and fusion (ACDF) in the treatment of degenerative cervical spine disease using stand-alone titanium cages. OVERVIEW OF LITERATURE: Over the last decades, a rapid increase in the use of stand-alone cages for ACDF has been observed. However, research on their application in the treatment of four-level diseases is insufficient. METHODS: In this study, 130 patients presenting with symptomatic cervical spondylosis who underwent four-level ACDF using standalone cages in our institution between 2008 and 2016 were assessed. Fifty-two patients were women and 78 men with a mean age of 60.5 years. Their clinical and radiological outcomes were assessed. The results of the Neck Disability Index (NDI) and Visual Analog Scale as well as bony fusion were evaluated, and the revisions were analyzed. All of the patients underwent the four-level microscopic ACDF using the same titanium rectangular cage. RESULTS: The mean follow-up was 47±11.4 months. A fusion of all four levels was achieved in 80.72% of the patients. In 25 patients (19.23%), an incomplete bony bridging was observed in at least one fusion level at the final follow-up. However, only two patients (1.5%) were symptomatic and underwent revision. The mean NDI improved significantly from 39.4±9.3 at presentation to 8.3±6.6 at the final follow-up. Cervical lordosis improved significantly from a mean of 5.5° preoperatively to a mean of 15° postoperatively. Cage sinking and loss of segment height during healing had a mean of 3 mm. CONCLUSIONS: Overall, the application of four-level ACDF using titanium cages in a stand-alone technique has been proven to be a safe and effective treatment method for degenerative disease. In a large cohort, a high rate of good long-term clinical and radiological results was achieved.

Minimally Invasive Short-Segment Anteroposterior Surgery for Thoracolumbar Osteoporotic Fractures with Canal Compromise: A Prospective Study with a Minimum 2-Year Follow-up.

STUDY DESIGN: A prospective study with a minimum follow-up of 24 months. PURPOSE: This study aimed to evaluate the results of minimally invasive anteroposterior surgery for osteoporotic vertebral fractures (OVFs) associated with bony spinal canal compromise in elderly patients. OVERVIEW OF LITERATURE: There is a recent increase in the incidence of osteoporosis with OVFs, causing an increasing burden on medical systems. METHODS: The study included 47 patients, of whom 45 completed a minimum of 24-month follow-up. The inclusion criteria were OVF types 3 and 4 according to the osteoporotic fracture classification in patients aged ≥65 years with bony stenosis. The surgical management consisted of anterior corpectomy and decompression using a thoracoscopic or mini-laparotomy approach, together with posterior percutaneous cement-augmented short-segment fixation. Self-reported outcome measures included Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) in the preoperative phase and regular follow-up at a minimum of 24 months. Radiological measures included segmental lordosis, dual-energy X-ray absorptiometry for osteoporosis assessment, and radiological fracture healing. RESULTS: There were 33 patients with lumbar fracture and 12 patients with thoracic fracture. Thirteen patients had preoperative neurological deficits. The mean age was 77.4±8.3 years. The mean preoperative VAS score was 8.12±1.5, and the mean ODI score was 24.4±8.2. The mean preoperative sagittal Cobb angle was 6.3°±4.2° kyphosis. The mean operative time was 220.3±55.5 minutes, with a mean blood loss of 360.75±200.6 mL. After a mean follow-up of 32.6±6.4 months, the mean VAS significantly improved to 2.3, and the ODI to 12. Only three patients still had a partial neurological deficit. The mean final sagittal Cobb angle was significantly better, with 12.5°±4.3° of lordosis. CONCLUSIONS: Short-segment percutaneous fixation with cement augmentation combined with minimally invasive anterior decompression and corpectomy is a less invasive and safe approach in elderly patients with OVF and canal compromise.

Symptomatic Intracranial Hemorrhage after Dural Tear in Spinal Surgery-A Series of 10 Cases and Review of the Literature.

OBJECTIVE: Intracranial hemorrhage (IH) after spinal surgery is a rare but potentially life-threatening complication. Knowledge of predisposing factors and typical clinical signs is essential for early recognition, helping to prevent an unfavorable outcome. METHODS: A retrospective analysis was performed of patients with IH after spinal surgery treated in our institution between 2012 and 2018. The literature dealing with IH complicating spinal surgery was reviewed. RESULTS: Our investigation found 10 patients with IH (6 female and 4 male). To the best of our knowledge, this is the largest series reported so far. The assumable incidence of IH after spinal surgery in our population was 0.0657%. Durotomy was noticed in 6 patients, all of whom were treated according to a local standard protocol. In 4 patients, the dural tear was occult. Hemorrhage occurred mostly in the cerebellar compartment. Eight of 10 patients had long-standing arterial hypertension, which seems to be a risk factor (hazard ratio, 1.58). Five patients were treated conservatively, whereas 3 required a cerebrospinal fluid (CSF) diversion procedure. In 2 patients, revision surgery with duraplasty was necessary. Seven patients were discharged with little to no neurologic symptoms, and 3 had significant deterioration. One patient died because of brainstem herniation. Review of the literature identified 54 articles with 72 patients with IH complicating spinal surgery. CONCLUSIONS: Patients with intraoperative CSF loss should be kept under close supervision postoperatively. After opening of the dura, a watertight closure should be attempted. The use of subfascial suction drainage in cases of a dural tear as well as preexistent arterial hypertension seems to be a risk factor for the development of IH. Intracranial bleeding must be considered in every patient with unexplained neurologic deterioration after spinal surgery and should be ruled out by cranial imaging. To ensure early recognition and prevent an unfavorable outcome, a high index of suspicion is required, especially in revision spinal surgery. The treatment is specific to the extent and location of the IH, thus dictating the outcome. In most patients, conservative treatment led to a good outcome. CSF diversion measures may be necessary in patients with compression or obstruction of the fourth ventricle. Large hematomas with mass effect may require decompressive surgery.

Management of Symptomatic Cervical Spine Pseudarthrosis: A Suggested Algorithm for Surgical Planning.

BACKGROUND: The clinical outcome of anterior cervical decompression and fusion (ACDF) correlates with fusion rates. There is a debate about how patients with symptomatic pseudarthrosis should be managed. In this study, a treatment plan is developed based on the surgical results of 95 patients and the recent literature. METHODS: A retrospective study to evaluate the long-term results after surgical treatment of symptomatic pseudarthrosis after ACDF. Between 1994 and 2015, 95 patients underwent surgery due to symptomatic pseudarthrosis after ACDF. The diagnosis was confirmed with dynamic radiographs and computed tomography scans. The approach used was anterior in 62 (65.1%), posterior in 13 (13.7%), and combined anterior and posterior in 20 (21.2%) patients. The operative details and the radiological and clinical results were analyzed. RESULTS: The primary operation was fusion using cages in 70, bone graft and plate in 16, and bone graft only in 9 patients. The revision was performed after a mean of 27 months. After a mean follow-up of 52 months, the mean Visual Analog Scale improved from 7.5 to 2.3 (P = 0.001), and the mean Neck Disability index improved from 26.4 to 8.7 (P = 0.034). Fusion was achieved in all patients after a mean of 7.8 (SD 2.9) months. Reoperation was indicated in 4 patients, all of whom were in the anterior-only group, and was due to retropharyngeal hematoma in 1 patient and cage sinking with kyphosis in 3 patients. CONCLUSIONS: Solid arthrodesis significantly improves the symptoms of cervical pseudarthrosis patients. The presence of adjacent segment disease, implant migration, residual stenosis, and segmental kyphosis plays an important role in decision-making. A treatment recommendation plan has been suggested. LEVEL OF EVIDENCE: 4.

Emergency surgical management of cervical spine fracture-dislocation with acute paraplegia in COVID-19 (Coronavirus disease 2019)-suspected patient: first experience from a German spine centre.

PURPOSE: We present an organized hospital plan for the management of Coronavirus disease (COVID-19) patients requiring emergency surgical interventions. To introduce a multidisciplinary approach for the management of COVID-19-infected patients and to report the first operated patient in the Corona unit. METHODS: A detailed presentation of the hospital plan for a separate Corona unit with its intensive care unit and operating rooms. Description of the management of the first spine surgery case treated in this unit. RESULTS: The Corona unit showed a practical approach for the management of an emergency cervical spine fracture-dislocation with acute paralysis. The patient is 92-year-old female. The mechanism of injury was a simple fall during the stay in the internal medicine department where the patient was treated in the referring hospital. The patient had no other injuries and was awake and oriented. The patient did not have the clinical symptom of COVID-19, and the test result of COVID-19 done in the referring hospital was not available on admission in our emergency room. Education of the medical staff and organization of the operating theatre facilitated the management of the patient without an increased risk of spreading the infection. CONCLUSIONS: The current COVID-19 pandemic requires an extra-ordinary organization of the medical and surgical care of the patients. It is possible to manage an infected or a potentially infected patient surgically, but a multidisciplinary plan is necessary to protect other patients and the medical staff.

Haematogenous Spondylodiscitis in Patients With Liver Cirrhosis: Case Series of 36 Patients.

STUDY DESIGN: A retrospective study of 36 liver cirrhosis patients presenting with spondylodiscitis. OBJECTIVES: The aim of this study was to analyze the characteristics of spondylodiscitis in the presence of liver cirrhosis and furthermore, to evaluate the outcome of surgery in this specific group of patients. SUMMARY OF BACKGROUND DATA: The incidence of haematogenous spondylodiscitis is increasing. The coexistence of liver cirrhosis makes the course of the disease more aggressive. METHODS: A total of 36 liver cirrhosis patients presented with haematogenous spondylodiscitis. The onset of infection, clinical course and outcomes of management were reviewed retrospectively. RESULTS: The associated comorbidities were cardiac in 17 patients, diabetes in 19, renal insufficiency in 16, and another focus for infection in nine cases. Neurological deficits were found in 24 patients (67%) and fever in 15 cases. Nine patients had septic manifestations. The lumbar spine was affected in 25 patients (69%). Noncontiguous spinal infection was found in nine patients (25%) and epidural abscess in 24 individuals. The preoperative C-reactive protein was elevated in all cases. The causative organism was most commonly Staphylococcus aureus (17 patients). A combined anteroposterior approach was necessary in 28 patients and a minimallly invasive surgery was performed in 30 cases. In-hospital mortality was 14% (5 patients). The neurological improvement rate was 82%. The postoperative antibiotic therapy was taken for more than 8 weeks in 22 patients. In 15 patients, a combination of antibiotics was necessary. CONCLUSION: Spinal infection in the presence of liver cirrhosis is challenging. The rate epidural abscess formation is relatively high. Early diagnosis remains the main cornerstone in the management and the indication for surgery should be carefully considered. Minimally invasive techniques should be used when possible to minimize complication rate, and higher amounts of intraoperative blood loss should be expected. LEVEL OF EVIDENCE: 4.

Effects of Polymethylmethacrylate Cement Viscosity and Bone Porosity on Cement Leakage and New Vertebral Fractures After Percutaneous Vertebroplasty: A Prospective Study.

STUDY DESIGN: A prospective randomized study. OBJECTIVES: To evaluate the effect of bone cement viscosity as well as of bone porosity on cement leakage during vertebroplasty and to analyze the occurrence of new vertebral fractures after the procedure. METHODS: Between April 2012 and December 2013, 60 patients suffering from osteoporotic vertebral fractures underwent vertebroplasty. The patients were randomly assigned into 2 equal groups. High-viscosity cement was used in group A, while low-viscosity cement was used in group B. Patients were followed-up for a minimum of 2 years. RESULTS: Cement leakage occurred in 16 patients in group B (20 vertebral bodies) and in 6 patients in group A (9 vertebral bodies). The difference was statistically significant (χ2 = 2.3, P = .01). Lower T-scores were associated with significantly more cement leakage (t = 3.338, P = .002 in group A, and t = 4.329, P = .000 in group B). Patients with a T-score worse than -1.8 had a significantly higher risk of cement leakage if low-viscosity cement was used (χ2 = 3.25, P = .05). New vertebral fractures occurred in 14 (23%) patients, after a mean of 6.5 ± 5.5 months, 10 patients in group A and 4 in group B. The difference did not reach the statistical significance level (χ2 = 3.354, P = .067). Patients presenting with multiple fractures had a significantly more number of new vertebral fractures (χ2 = 7.464, P = .006). CONCLUSIONS: The clinical outcome of vertebroplasty was not influenced by cement viscosity. However, lower cement viscosity and higher degree of osteoporosis were found to be significant risk factors for cement leakage. Furthermore, the number of vertebral body fractures on presentation was a predictor for the occurrence of new fractures postoperatively.

Reoperation rate after anterior cervical discectomy and fusion using standalone cages in degenerative disease: a study of 2,078 cases.

BACKGROUND CONTEXT: Over the last two decades, there has been a rapid increase in the use of cervical spine interbody fusion cages. Reoperation rate remains an important determinant of procedural efficacy and safety. PURPOSE: To evaluate the rate and reasons for reoperations in cervical spondylosis patients undergoing anterior decompression and fusion using stand-alone cervical interbody fusion cages. STUDY DESIGN: A retrospective study of 2,078 consecutive cases of degenerative cervical spine disease undergoing fusion using stand-alone cages. PATIENT SAMPLE: Between January 2005 and December 2014, 2,078 patients underwent anterior cervical decompression and fusion using stand-alone cages in our institution. OUTCOME MEASURES: The reoperations were analyzed and classified into early (during the first 90 days postoperatively) and late (after 90 days) reoperations. The rate and the causes of reoperation in both groups were reported and the results were compared. METHODS: In 1,558 patients, a short segment fusion (≤2 levels) was performed, while the remaining 520 patients underwent a long segment fusion (≥3 levels). RESULTS: The overall incidence of reoperation was 5.63%. The rate of early reoperations was 2.07%, mostly due to postoperative hematoma, and the rate of late reoperations was 3.56%, mostly due to adjacent segment disease. Revision due to pseudarthrosis was performed in 0.58% of cases. The early reoperation rate was significantly higher in the group with a long segment fusion, while the late reoperation rate was significantly higher in patients undergoing a short segment fusion. CONCLUSION: Following anterior cervical decompression and fusion with a stand-alone cage, the overall incidence of symptomatic pseudarthrosis is low. Patients undergoing long segment fusion should be closely observed in the early postoperative period as they have a higher early complication rate. On the other hand, long segment fusions have a lower incidence of adjacent segment disease over the years.

Surgical treatment of type II odontoid fractures in elderly patients: a comparison of anterior odontoid screw fixation and posterior atlantoaxial fusion using the Magerl-Gallie technique.

PURPOSE: This single-centre retrospective study compared anterior odontoid screw fixation and posterior atlantoaxial fusion in the surgical treatment of type II B odontoid fractures according to Grauer in elderly patients. METHODS: Between 1994 and 2014, 133 consecutive patients above 60 years presenting with type II B odontoid fracture were treated surgically in our department. They were divided retrospectively into two groups. Group A included 47 patients in whom anterior odontoid screw fixation was performed. Group B with 86 patients underwent posterior atlantoaxial fusion. The clinical and radiological data were analysed. Any reoperation during the follow-up was recorded and evaluated. RESULTS: The mean age in group A (74.19 years) was significantly less than in group B (78.16 years). The mean operative time in group A (64.5 min) was significantly shorter than in group B (116 min). Again, the mean amount of blood loss in group A (79 ml) was significantly less than in group B (379 ml). The mean postoperative hospital stay was significantly shorter in group A (17.4 days) than in group B (30 days). The mean follow-up was 29.3 months in group A and 32 months in group B. The rate of pseudoarthrosis was significantly higher in group A (25.5%) than in group B (3.5%). Furthermore, the need for revision surgery was significantly increased in group A (23.4%) than in group B (10.47%). CONCLUSIONS: Odontoid screw fixation is a less invasive surgery for type II B odontoid fractures in elderly patients. However, posterior atlantoaxial fusion provides a superior surgical outcome regarding fracture healing and the need for surgical revisions. These slides can be retrieved under Electronic Supplementary Material.

Early Recurrence of a Solid Variant of Aneurysmal Bone Cyst in a Young Child After Resection: Technique and Literature Review and Two-year Follow-up After Corpectomy.

Aneurysmal bone cysts (ABCs) are considered to be rare benign tumors that may affect long bones or the vertebral column. Their incidence varies and is reported to be 1.4% of all benign skeletal tumors. The solid-variant aneurysmal bone cyst (S-ABC) is even rarer and constitutes 3.5% to 7% of all vertebral ABCs. We report the case of an Enneking stage 3 S-ABC in a 5-year-old boy at C7 that showed rapid local recurrence after primary excision from posterior and dorsal stabilization requiring ventral corpectomy and posterior excision of the right lateral mass and right posterolateral fusion. Histologic examination disclosed an S-ABC. To our knowledge, this is the first case of S-ABC described in the literature that used both anterior and posterior approaches and complete corpectomy. Over a 2-year period, the patient showed no radiologic or clinical signs of local recurrence with excellent neurologic function. Solid-variant aneurysmal bone cysts are difficult to diagnose and treat, and careful clinical and radiologic assessment should be done to tailor an appropriate surgical plan to prevent recurrence and neurologic sequelae. To the best of our knowledge, there are to date no publications that studied the behavior of this subtype.

Percutaneous Posterior Transarticular Atlantoaxial Fixation for the Treatment of Odontoid Fractures in the Elderly: A Prospective Study.

STUDY DESIGN: A prospective study of 20 multimorbid patients older than 65 years undergoing minimally invasive surgical treatment for odontoid fracture. OBJECTIVE: To analyze the results of percutaneous transarticular atlantoaxial screw fixation as a new minimally invasive treatment modality in this high risk group of patients. SUMMARY OF BACKGROUND DATA: Odontoid fractures are a common injury pattern in the elderly. These fractures typically present significant challenges as geriatric patients often have multiple comorbidities that may adversely affect fracture management. Despite numerous publications on this subject, with a trend toward primary operative stabilization, the appropriate treatment for this frequent and potentially life threatening injury remains controversial. METHODS: Between January 2013 and December 2015, 20 consecutive patients underwent posterior percutaneous transarticular atlantoaxial screw fixation for odontoid fracture type II. The two main inclusion criteria were age 65 years or older and ASA score of III or IV. The screws were inserted percutaneously with the help of two fluoroscopy devices. Clinical and radiological examinations were regularly performed for a minimum of 18 months postoperatively. RESULTS: The mean age was 81 years, all of them with multiple comorbidities. Reduction of the fracture and screw insertion was possible in all cases. The mean operative time was 51.75 minutes and mean blood loss was 41.7 mL. Three patients died in the first 3 months after surgery. Healing of the fracture occurred in 15 patients (88.2%). Revision surgery was not necessary in any of the patients. Mean visual analogue scale (VAS) at the final follow-up was 2.4, and mean patient satisfaction score was 7.1. CONCLUSION: Percutaneous transarticular atlantoaxial fixation in elderly patients offers a good minimally invasive operative treatment in this multimorbid group of patients. This new technique with short operative time is well tolerated by the geriatric patients leading to a healing rate up to 88%. LEVEL OF EVIDENCE: 4.

Adjacent Segment Disease After Cervical Spine Fusion: Evaluation of a 70 Patient Long-Term Follow-Up.

STUDY DESIGN: A retrospective study of 70 patients undergoing surgical treatment for adjacent segment disease (ASD) after anterior cervical decompression and fusion (ACDF). OBJECTIVE: To analyze the risk factors for the development of ASD in patients who underwent ACDF. SUMMARY OF BACKGROUND DATA: ACDF has provided a high rate of clinical success for the cervical degenerative disc disease; nevertheless, adjacent segment degeneration has been reported as a complication at the adjacent level secondary to the rigid fixation. METHODS: Between January 2005 and December 2012, 70 consecutive patients underwent surgery for ASD after ACDF in our institution. In all patients thorough clinical and radiological examination was performed preoperatively, postoperatively, and at the final follow-up. The clinical data included the Neck Disability Index (NDI) and the Visual Analogue Scale (VAS). The radiological evaluation included x-rays and magnetic resonance imaging (MRI) for all patients. The duration of follow up after the adjacent segment operation ranged from 3 to 10 years. RESULTS: Surgery for ASD was performed after a mean period of 32 months from the primary ACDF. ASD occurred after single level ACDF in 54% of cases, most commonly after C5/6 fusion (28%). Risk factors for ASD were found to be preexisting radiological signs of degeneration at the primary surgery (74%) and bad sagittal profile after the primary ACDF (90%). CONCLUSION: ASD occurred predominantly in the middle cervical region (C4-6); especially in patients with preexisting evidence of radiological degeneration in the adjacent segment at the time of primary cervical fusion, notably when this surgery failed to restore or maintain the cervical lordosis. LEVEL OF EVIDENCE: 4.

Presentation and management of symptomatic central bone cement embolization.

BACKGROUND CONTEXT: With more cement augmentation procedures done, the occurrence of serious complications is also expected to rise. Symptomatic central cement embolization is a rare but very serious complication. Moreover, the pathophysiology and treatment of intrathoracic cement embolism remain controversial. PURPOSE: In this case series, we are trying to identify various presentations and suggest our emergent management scheme for symptomatic central cement embolization. PATIENT SAMPLE: Retrospective case series of nine patients with symptomatic central cement embolism identified after vertebroplasty with 24 months of follow-up. Level IV. OUTCOME MEASURES: The degree of dyspnea measured by the New York Heart Association (NYHA) score and/or death related to cement embolism induced cardio/respiratory failure at the final follow-up at 24 months. METHODS: The nine patients, eight females, and one male had a mean age of 70.25 years (range 65-78 years) and were operated between January 2004 and December 2014. They had percutaneous vertebroplasty for osteoporotic non-traumatic and malignant vertebral collapse of dorsal and lumbar vertebrae. Post-vertebroplasty dyspnea and stitching chest pain were striking in the nine patients. After exclusion of cardiac ischemia and medical pulmonary causes for dyspnea, we identified radiopaque lesions on the chest X-ray. Further echocardiography and high-resolution chest CT were performed for optimal localization. Emergent heart surgery was performed in two patients: interventional therapy was conducted in one patient, while the remaining six patients were conservatively treated by anticoagulation. The management decision was taken in the setting of an interdisciplinary meeting depending on localization, fragmentation, and clinical status. RESULTS: All patients of this series showed gradual improvement and an uneventful hospital stay. During our 24-month follow-up phase, eight patients showed no subsequent cardiological and/or respiratory symptoms (NYHA I). However, one mortality due to advanced malignancy occurred. Preoperative anemia was the only common intersecting preoperative parameter among these nine patients. CONCLUSIONS: After cement augmentation, close clinical monitoring is mandatory. A chest CT is pivotal in determining the interdisciplinary management approach in view of the availability of necessary expertise, facilities and the location of the cement emboli whether accessible by cardiac or vascular surgical means. The clinical presentation and its timing may vary and the patient may be seen subsequently by other health care providers obligating a wide-spread awareness for this serious entity among health care providers for this age group as spine surgeons, family and emergency room doctors, and institutional or home-care nurses. Most symptomatic central cement emboli may be treated conservatively.

Infection rate after minimally invasive noninstrumented spinal surgery based on 4350 procedures.

STUDY DESIGN: Retrospective review of a prospectively collected database. OBJECTIVE: To assess the rate of postoperative infection associated with minimally invasive noninstrumented spinal surgery. SUMMARY OF BACKGROUND DATA: Infection after spinal surgery results in significant morbidity, extended hospital stay, and significant costs. Minimally invasive spinal techniques require smaller incisions and less dissection, minimizing the risk of postoperative infection. METHODS: Inclusion criteria were patients undergoing posterior spinal surgery using a tubular retractor system with the aid of operative microscope between June 1998 and November 2013. The analysis revealed a total number of 4350 procedures performed in 4037 patients (mean age=53.2 yr). Sixty percent of the patients were male. The majority of procedures were performed in the lumbar spine (98.4%), and the indication was mostly degenerative in nature (96.9%). The databases were then reviewed for any infectious complications. RESULTS: Postoperative infection was recorded in 4 patients (0.09%). All of them occurred in the lumbar region after discectomy. These patients presented with discitis and underwent revision in the form of open debridement and fusion. The time lapse between the index surgery and revision was 56 days. All 4 patients recovered, with a mean follow-up of 7.5 years. CONCLUSION: Infection rate after posterior transtubular microscopic assisted spinal surgery is very low (0.09%). Surgical debridement with fusion was the method of choice in treating such complications. This minimally invasive technique reduces markedly the risk of postoperative infection when compared with other large series published in the literature. LEVEL OF EVIDENCE: 4.

Infection rate after transoral approach for the upper cervical spine.

STUDY DESIGN: A retrospective review of prospectively collected databases of 139 consecutive patients who underwent transoral surgery for lesions of the upper cervical spine. OBJECTIVE: To analyze the incidence and risk factors of local infection after transoral surgery for the craniocervical junction in a single institution and to compare the findings with the literature. SUMMARY OF BACKGROUND DATA: One of the primary risks associated with transoral approach for lesions in the upper cervical spine is postoperative surgical wound infection. METHODS: From April 1994 to December 2012, 139 consecutive transoral surgical procedures were performed at a single referral center. The mean age at presentation was 53.6 years (range: 5-87 yr), and more than half of the patients were males (58.3%). The majority of cases were experiencing rheumatic diseases (43.9%), whereas tumor destruction was the indication for surgery in 23.7% of the cases. A total of 23% had fracture of the upper cervical spine and primary infection was found in 7 patients (5%). The mean follow-up period was 4.5 years. RESULTS: Infection of the pharyngeal wound occurred in 5 patients (3.6%), solely in the rheumatic and tumor groups. The presentation was mostly in the first 4 months. A single patient with cage reconstruction after giant cell tumor C2 presented with a late infection 5 years postoperatively. Debridement and primary closure was possible in 2 patients, whereas flap coverage of the pharyngeal wall was necessary in 3 patients. The presence of implant did not have a statistically significant effect on the occurrence of infection. However, infection in the presence of titanium cage mostly necessitated flap coverage of the pharyngeal wall after removal of the cage. CONCLUSION: The transoral route has proved to be an invaluable method of approaching pathological lesions in the upper cervical spine. The infection rate in this work was 3.6%. Patients with rheumatic diseases and patients presenting with tumors were more susceptible to postoperative surgical wound infection. LEVEL OF EVIDENCE: 4.

ABCD classification system: a novel classification for subaxial cervical spine injuries.

STUDY DESIGN: The classification system was derived through a retrospective analysis of 73 consecutive cases of subaxial cervical spine injury as well as thorough literature review. OBJECTIVE: To define a new classification system for subaxial cervical spine injuries. SUMMARY OF BACKGROUND DATA: There exist several methods to classify subaxial cervical spine injuries but no single system has emerged as clearly superior to the others. METHODS: On the basis of a 2-column anatomical model, the first part of the proposed classification is an anatomical description of the injury. It delivers the information whether the injury is bony, ligamentous, or a combined one. The first 4 alphabetical letters have been used for simplicity. Each column is represented by an alphabetical letter from A to D. Each letter has a radiological meaning (A = Absent injury, B = Bony lesion, C = Combined bony and ligamentous, D = Disc or ligamentous injury).The second part of the classification is represented by 3 modifiers. These are the neurological status of the patient (N), the degree of spinal canal stenosis (S), and the degree of instability (I). For simplicity, each modifier was graded in an ascending pattern of severity from zero to 2. The last part is optional and denotes which radiological examination has been used to define the injury type. RESULTS: The new ABCD classification was applicable for all patients. The most common type was anterior ligamentous and posterior combined injury "DC" (37.9%), followed by "DD" injury in 12% of the cases. CONCLUSION: Through this work a new classification for cervical spine injuries is proposed. The aim is to establish criteria for a common language in description of cervical injuries aiming for simplification, especially for junior residents. Each letter and each sign has a meaning to deliver the largest amount of information. Both the radiological as well as the clinical data are represented in this scheme. However, further evaluation of this classification is needed. LEVEL OF EVIDENCE: 3.