Outcomes and Lessons Learned from the Tribal Veterans Representative Program: A Model for System Engagement.

American Indian and Alaska Native Veterans are more rural than Veterans of any other race or ethnicity and face significant barriers to accessing care. Since 2001, the Tribal Veterans Representative (TVR) Program, a partnership between the U.S. Department of Veterans Affairs (VA) and tribal nations, has trained liaisons from tribal communities to facilitate access to VA benefits and services. We delineate the TVR program model alongside supporting data. We reviewed TVR training materials and program evaluations to identify components of the program essential for increasing access to VA services and benefits. We then report a quantitative assessment of benefits attained in one tribal community. The TVR model is characterized by the exchange of two sets of knowledge and resources-'institutional' and 'community'-during a co-sponsored educational program aiming to train community liaisons about the institution. The institution leads the program's content; the community's traditions inform its process. Following the program, liaisons use support networks comprising trainers, trainees and local organizations to teach other community members to access health care and benefits. In the evaluation community, one liaison has facilitated access for hundreds of Veterans, with financial compensation exceeding $400,000 annually. The TVR program has begun to demonstrate its utility for other rural populations, though further formal evaluation is recommended. Compared with similar models to increase rural populations' access to health care and benefits, the long-term support networks from the TVR model may be most useful when the institution must build trust and engage with the target population.

Rural American Indian and Alaska Native veterans' telemental health: A model of culturally centered care.

American Indian and Alaska Native (AI/AN) veterans living in rural areas have unique health care needs and face numerous barriers to accessing health care services. Among these needs is a disproportionate prevalence of posttraumatic stress disorder and other mental illnesses. Since 2001, 14 rural communities have partnered with the U.S. Department of Veterans Affairs and the Centers for American Indian and Alaska Native Health at the University of Colorado Anschutz Medical Campus to extend telemental health clinics to American Indian veterans. Administrative and, to some extent, clinical considerations of these clinics have been reviewed previously. This paper describes a model of care, evolved over a 14-year period, that weaves together evidence-based Western treatment, traditional Native healing, and rural Native communities into 4 main components: mental health care, technology, care coordination, and cultural facilitation. We delineate improvements to care made by addressing barriers such as system transference, provider-patient trust, and videoconferencing. Similarly, the discussion notes ways that the care model leverages strengths within Native communities, such as social cohesion and spirituality. Future steps include selection of appropriate performance indicators for systematic evaluation. The identification of key constructs of this care model will facilitate comparisons with other models of care in underserved populations with chronic and complex health conditions, and eventually advance the state of care for our warriors. (PsycINFO Database Record

A computational model of cardiac fibroblast signaling predicts context-dependent drivers of myofibroblast differentiation.

Cardiac fibroblasts support heart function, and aberrant fibroblast signaling can lead to fibrosis and cardiac dysfunction. Yet how signaling molecules drive myofibroblast differentiation and fibrosis in the complex signaling environment of cardiac injury remains unclear. We developed a large-scale computational model of cardiac fibroblast signaling in order to identify regulators of fibrosis under diverse signaling contexts. The model network integrates 10 signaling pathways, including 91 nodes and 134 reactions, and it correctly predicted 80% of independent previous experiments. The model predicted key fibrotic signaling regulators (e.g. reactive oxygen species, tissue growth factor ß (TGFß) receptor), whose function varied depending on the extracellular environment. We characterized how network structure relates to function, identified functional modules, and predicted cross-talk between TGFß and mechanical signaling, which was validated experimentally in adult cardiac fibroblasts. This study provides a systems framework for predicting key regulators of fibroblast signaling across diverse signaling contexts.

Tribal Veterans Representative (TVR) training program: the effect of community outreach workers on American Indian and Alaska Native Veterans access to and utilization of the Veterans Health Administration.

American Indians and Alaska Natives serve at the highest rate of any US race or ethnic group, yet are the most underserved population of Veterans and do not take advantage of the Department of Veterans Affairs (VA) benefits and services. Barriers to seeking care include stigma, especially for mental health issues; distance to care; and lack of awareness of benefits and services they are entitled to receive. In response to this underutilization of the VA, an innovative program--the Tribal Veterans Representative (TVR) program--was developed within the VA to work with American Indians and Alaska Natives in rural and remote areas. The TVR goes through extensive training every year; is a volunteer, a Veteran and tribal community member who seeks out unenrolled Native Veterans, provides them with information on VA health care services and benefits, and assists them with enrollment paperwork. Being from the community they serve, these outreach workers are able to develop relationships and build rapport and trust with fellow Veterans. In place for over a decade in Montana, this program has enrolled a countless number of Veterans, benefiting not only the individual, but their family and the community as well. Also resulting from this program, are the implementation of Telemental Health Clinics treating Veterans with PTSD, a transportation program helping Veterans get to and from distant VA facilities, a Veteran Resource Center, and a Veteran Tribal Clinic. This program has successfully trained over 800 TVRs, expanded to other parts of the country and into remote areas of Alaska.

Integrin-mediated interactions with extracellular matrix proteins for nucleus pulposus cells of the human intervertebral disc.

The extracellular matrix (ECM) of the human intervertebral disc is rich in molecules that interact with cells through integrin-mediated attachments. Porcine nucleus pulposus (NP) cells have been shown to interact with laminin (LM) isoforms LM-111 and LM-511 through select integrins that regulate biosynthesis and cell attachment. Since human NP cells lose many phenotypic characteristics with age, attachment and interaction with the ECM may be altered. Expression of LM-binding integrins was quantified for human NP cells using flow cytometry. The cell-ECM attachment mechanism was determined by quantifying cell attachment to LM-111, LM-511, or type II collagen after functionally blocking specific integrin subunits. Human NP cells express integrins ß1, α3, and α5, with over 70% of cells positive for each subunit. Blocking subunit ß1 inhibited NP cell attachment to all substrates. Blocking subunits α1, α2, α3, and α5 simultaneously, but not individually, inhibits NP cell attachment to laminins. While integrin α6ß1 mediated porcine NP cell attachment to LM-111, we found integrins α3, α5, and ß1 instead contributed to human NP cell attachment. These findings identify integrin subunits that may mediate interactions with the ECM for human NP cells and could be used to promote cell attachment, survival, and biosynthesis in cell-based therapeutics.

Altered phenotypic gene expression of 10T1/2 mesenchymal cells in nonuniformly stretched PEGDA hydrogels.

Disease-related phenotype modulation of many cell types has been shown to be closely related to mechanical loading conditions; for example, vascular smooth muscle cell (SMC) phenotype shift from a mature, contractile state to a proliferative, synthetic state contributes to the formation of neointimal tissue during atherosclerosis and restenosis development and is related to SMC mechanical loading in vivo. The majority of past in vitro cell-stretching experiments have employed simplistic (uniform, uniaxial or biaxial) stretching environments to elucidate mechanobiological pathways involved in phenotypic shifts. However, the in vivo mechanics of the vascular wall consists of highly nonuniform stretch. Here we subjected 10T1/2 murine mesenchymal cells (an SMC precursor) to two- and three-dimensional nonuniform stretch environments. After 24 h of stretch, cells on an elastomeric membrane demonstrated varied proliferation [assessed by 5-bromo-2'-deoxyuridine (BrdU) incorporation] depending on location upon the membrane, with maximal proliferation occurring in a region of high, uniaxial stretch. Cells subjected to a nonuniform stretching regimen within three-dimensional polyethylene glycol diacrylate (PEGDA) hydrogel constructs demonstrated marked changes in mRNA expression of several phenotype-related proteins, indicating a sort of "hybrid" phenotype with contractile and synthetic markers being both upregulated and downregulated. Furthermore, expression levels of mRNAs were significantly different between various locations within the stretched gel. With the proliferation results, these data exhibit the capability of nonuniform stretching devices to induce heterogeneous cell responses, potentially indicative of spatial distributions of disease-related behaviors in vivo.

Reaching rural communities with culturally appropriate care: a model for adapting remote monitoring to American Indian veterans with posttraumatic stress disorder.

OBJECTIVE: Providing specialized healthcare to rural communities can be extremely difficult, and consequently many health organizations are turning to the use of telehealth technologies for care delivery. One such technology, remote monitoring, has been successfully implemented with patients suffering from chronic and other medical conditions. A drawback, however, is that remote monitoring devices are programmed to reach a broad audience, and consequently the content may not be suitable for all patients-especially those who are not a part of the dominant culture. SUBJECTS AND METHODS: This report provides a model for adapting remote monitoring to specific populations who are undergoing care for posttraumatic stress disorder. Adaptation changes focus on (1) information gathering, (2) process and dialogue changes, (3) testing, and (4) patient and administrative feedback. Data for such modifications were gathered through a series of community meetings, patient interviews, and provider feedback. A case example highlights the successful implementation of the adaptation model for a rural American Indian Veteran population. RESULTS: Patients showed high acceptability of both the programmatic and cultural adaptations. Feasibility of the program also appeared positive, with most patients reporting that the readability of the program was appropriate, the dialogue duration was not burdensome, and technical problems were rare. CONCLUSIONS: Remote monitoring provides the ability to be modified for use with certain subpopulations. Procedural recommendations in this report highlight special considerations for working with American Indians living on or near reservation areas, although the model can be broadly adapted to several groups.

Differential orientation of 10T1/2 mesenchymal cells on non-uniform stretch environments.

Non-uniform stress and strain fields are prevalent in many tissues in vivo, and often exacerbated by disease or injury. These mechanical gradients potentially play a role in contributing to pathological conditions, presenting a need for experimental tools to allow investigation of cell behavior within non-uniformly stimulated environments. Herein, we employ two in vitro cell-stretching devices (one previously published; one newly presented) capable of subjecting cells to cyclic, non-uniform stretches upon the surface of either a circular elastomeric membrane or a cylindrical PDMS tube. After 24 hours of cyclic stretch, 10T1/2 cells on both devices showed marked changes in long-axis orientation, with tendencies to align parallel to the direction of minimal deformation. The degree of this response varied depending on location within the stretch gradients. These results demonstrated the feasibility of conducting cell mechanobiology investigations with the two novel devices, while also highlighting the experimental capabilities of non-uniform mechanical environments for these types of studies. Such capabilities include robust data collection for developing mechanobiological dose-response curves, signal threshold identification, and potential spatial targeting for drug delivery.

Review of American Indian veteran telemental health.

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

A western gray whale mitigation and monitoring program for a 3-D seismic survey, Sakhalin Island, Russia.

The introduction of anthropogenic sounds into the marine environment can impact some marine mammals. Impacts can be greatly reduced if appropriate mitigation measures and monitoring are implemented. This paper concerns such measures undertaken by Exxon Neftegas Limited, as operator of the Sakhalin-1 Consortium, during the Odoptu 3-D seismic survey conducted during 17 August-9 September 2001. The key environmental issue was protection of the critically endangered western gray whale (Eschrichtius robustus), which feeds in summer and fall primarily in the Piltun feeding area off northeast Sakhalin Island. Existing mitigation and monitoring practices for seismic surveys in other jurisdictions were evaluated to identify best practices for reducing impacts on feeding activity by western gray whales. Two buffer zones were established to protect whales from physical injury or undue disturbance during feeding. A 1 km buffer protected all whales from exposure to levels of sound energy potentially capable of producing physical injury. A 4-5 km buffer was established to avoid displacing western gray whales from feeding areas. Trained Marine Mammal Observers (MMOs) on the seismic ship Nordic Explorer had the authority to shut down the air guns if whales were sighted within these buffers. Additional mitigation measures were also incorporated: Temporal mitigation was provided by rescheduling the program from June-August to August-September to avoid interference with spring arrival of migrating gray whales. The survey area was reduced by 19% to avoid certain waters <20 m deep where feeding whales concentrated and where seismic acquisition was a lower priority. The number of air guns and total volume of the air guns were reduced by about half (from 28 to 14 air guns and from 3,390 in(3) to 1,640 in(3)) relative to initial plans. "Ramp-up" (="soft-start") procedures were implemented. Monitoring activities were conducted as needed to implement some mitigation measures, and to assess residual impacts. Aerial and vessel-based surveys determined the distribution of whales before, during and after the seismic survey. Daily aerial reconnaissance helped verify whale-free areas and select the sequence of seismic lines to be surveyed. A scout vessel with MMOs aboard was positioned 4 km shoreward of the active seismic vessel to provide better visual coverage of the 4-5 km buffer and to help define the inshore edge of the 4-5 km buffer. A second scout vessel remained near the seismic vessel. Shore-based observers determined whale numbers, distribution, and behavior during and after the seismic survey. Acoustic monitoring documented received sound levels near and in the main whale feeding area. Statistical analyses of aerial survey data indicated that about 5-10 gray whales moved away from waters near (inshore of) the seismic survey during seismic operations. They shifted into the core gray whale feeding area farther south, and the proportion of gray whales observed feeding did not change over the study period. Five shutdowns of the air guns were invoked for gray whales seen within or near the buffer. A previously unknown gray whale feeding area (the Offshore feeding area) was discovered south and offshore from the nearshore Piltun feeding area. The Offshore area has subsequently been shown to be used by feeding gray whales during several years when no anthropogenic activity occurred near the Piltun feeding area.Shore-based counts indicated that whales continued to feed inshore of the Odoptu block throughout the seismic survey, with no significant correlation between gray whale abundance and seismic activity. Average values of most behavioral parameters were similar to those without seismic surveys. Univariate analysis showed no correlation between seismic sound levels and any behavioral parameter. Multiple regression analyses indicated that, after allowance for environmental covariates, 5 of 11 behavioral parameters were statistically correlated with estimated seismic survey-related variables; 6 of 11 behavioral parameters were not statistically correlated with seismic survey-related variables. Behavioral parameters that were correlated with seismic variables were transient and within the range of variation attributable to environmental effects. Acoustic monitoring determined that the 4-5 km buffer zone, in conjunction with reduction of the air gun array to 14 guns and 1,640 in(3), was effective in limiting sound exposure. Within the Piltun feeding area, these mitigation measures were designed to insure that western gray whales were not exposed to received levels exceeding the 163 dB re 1 microPa (rms) threshold. This was among the most complex and intensive mitigation programs ever conducted for any marine mammal. It provided valuable new information about underwater sounds and gray whale responses during a nearshore seismic program that will be useful in planning future work. Overall, the efforts in 2001 were successful in reducing impacts to levels tolerable by western gray whales. Research in 2002-2005 suggested no biologically significant or population-level impacts of the 2001 seismic survey.

A biomechanical, radiologic, and clinical comparison of outcome after multilevel cervical laminectomy or laminoplasty in the rabbit.

STUDY DESIGN: A rabbit model was used to compare clinical outcome, radiographic changes, and biomechanical flexibility after cervical laminectomy and open-door laminoplasty. OBJECTIVE: This study tested the hypothesis that radiographic changes and biomechanical flexibility could explain the differences in clinical outcome after cervical laminectomy and laminoplasty. SUMMARY OF BACKGROUND DATA: Although multilevel cervical laminoplasty is thought to have advantages over cervical laminectomy, clinical outcome studies have been contradictory, and no experimental study has examined the possible mechanisms for the differences after healing. METHODS: Twenty-four New Zealand White rabbits were randomized into four groups: normal, sham, C3-C6 wide laminectomy, and C3-C6 open-door laminoplasty. Clinical, radiographic, and biomechanical data were collected and compared up to 3 months after surgery. RESULTS: Laminectomy had a statistically significant poorer clinical outcome when compared with laminoplasty after 3 months of healing. Radiologic analysis showed statistically significant angular deformity in the laminectomy group compared with laminoplasty and control groups at 3 months. In contrast, biomechanical measures of flexibility, neutral zone, and range of motion showed only small differences between any of the groups at any time. CONCLUSIONS: The presence of deformity, and not a change in flexibility, is responsible for the differences in clinical outcome observed after laminectomy compared with laminoplasty in this model.

The "mini brain": plasmacytoma in a vertebral body on MR imaging.

OBJECTIVE: Patients with solitary plasmacytoma in the spine frequently require a biopsy for diagnosis of their condition. We report an appearance of plasmacytoma in the spine, which is sufficiently pathognomonic to obviate biopsy. CONCLUSION: Identification of a "mini brain" in an expansile lesion in the spine is characteristic of plasmacytoma. It is important that radiologists note this characteristic because biopsy can be avoided in patients with this appearance. Although biopsy might still be required at many institutions, at our institution, surgeons find this appearance sufficiently pathognomonic to bypass biopsy and start treatment.

The cervical facet capsule and its role in whiplash injury: a biomechanical investigation.

STUDY DESIGN: Cervical facet capsular strains were determined during bending and at failure in the human cadaver. OBJECTIVE: To determine the effect of an axial pretorque on facet capsular strains and estimate the risk for subcatastrophic capsular injury during normal bending motions. SUMMARY OF BACKGROUND DATA: Epidemiologic and clinical studies have identified the facet capsule as a potential site of injury and prerotation as a risk factor for whiplash injury. Unfortunately, biomechanical data on the cervical facet capsule and its role in whiplash injury are not available. METHODS: Cervical spine motion segments were tested in a pure-moment test frame and the full-field strains determined throughout the facet capsule. Motion segments were tested with and without a pretorque in pure bending. The isolated facet was then elongated to failure. Maximum principal strains during bending were compared with failure strains, by paired t test. RESULTS: Statistically significant increases in principal capsular strains during flexion-extension loading were observed when a pretorque was applied. All measured strains during bending were significantly less than strains at catastrophic joint failure. The same was true for subcatastrophic ligament failure strains, except in the presence of a pretorque. CONCLUSIONS: Pretorque of the head and neck increases facet capsular strains, supporting its role in the whiplash mechanism. Although the facet capsule does not appear to be at risk for gross injury during normal bending motions, a small portion of the population may be at risk for subcatastrophic injury.

Clinical outcome scales for use in a rabbit model of cervical myelopathy.

This study determined the ability of an upper extremity Tarlov scale, a lower extremity Tarlov scale, and the Durham scale to predict the development of myelopathy and the likelihood of survival in a rabbit model of surgical treatments for cervical spondylotic myelopathy. Forty-eight rabbits were evaluated using the scales after cervical spinal surgery. Logistic regression analysis revealed that all three scales could predict the occurrence of myelopathy. However, only the Durham and lower extremity Tarlov scales also predicted the likelihood of survival. The Durham scale is offered as a useful predictor of myelopathy and survival in an animal model of surgical treatments for cervical spondylotic myelopathy. The lower extremity Tarlov scale is also a useful predictor of outcome; however, the upper extremity Tarlov scale is not recommended.

"Spinolaminar breach": an important sign in cervical spinous process fractures.

OBJECTIVE: To report the sign of "spinolaminar breach" and its likely importance in fractures of the cervical spinous processes. DESIGN: Six cases of spinous process fractures demonstrating disruption of the spinolaminar line or "spinolaminar breach" were analyzed. Lateral and anteroposterior radiographs (n=6), CT scans (n=3) and MRI scans (n=1) were reviewed together by the authors, with consensus being reached as to the radiographic findings. Clinical records were also reviewed. RESULTS: The levels of injury were C6 (n=5) and C5 (n=2). Injuries were associated with delayed anterior subluxation (n=4) and neurological deficit (n=2). Five patients were male and one was female with a mean age of 31 years (range 8-59 years). Injuries resulted from motor vehicle accidents (n=4), a motor cycle accident (n=1) and a fall (n=1). CONCLUSION: "Spinolaminar breach", or disruption of the spinolaminar line, indicates a complex spinous process fracture with extension into the lamina and spinal canal. Spinous process fractures with spinolaminar breach may have associated posterior ligamentous injury with potential for delayed instability and neurological deficit. It is important that radiologists and physicians caring for the trauma patient be aware of this sign in order to avoid misdiagnosis as a "clay shoveler's fracture", which can lead to adverse outcome.

Surgical correction of lumbar kyphotic deformity: posterior reduction "eggshell" osteotomy.

OBJECT: Progressive kyphotic deformity of the lumbar or thoracolumbar spine may lead to back pain, cosmetic deformity, and risk of neurological compromise. The authors describe a series of patients in whom they performed a single-stage, posterior reduction ("eggshell") osteotomy procedure to improve sagittal contour by creating lordosis within a single vertebral body. METHODS: From 1995 to 1997 the authors performed 12 osteotomy procedures in 11 patients with thoracolumbar or lumbar kyphosis. Seven patients presented with iatrogenic deformity, three with deformity secondary to traumatic injury, and one patient with ankylosing spondylitis. Their mean age at time of surgery was 46.6 years (range 23-78 years). All patients suffered from back pain and were unable to stand upright, but in only one patient were neurological findings demonstrated. The mean preoperative deformity was -26 degrees (range -90 to 0 degrees). At 6-month follow-up examination the mean sagittal contour measured 17.5 degrees (range - 17 to 44 degrees), indicating that the mean surgical correction was 40.1 degrees (range 25 to 58 degrees). All patients reported decreased back pain at follow up, and none required narcotic analgesic medication. Complications included a dense paresis that developed immediately postoperatively in a patient who was found to have residual dural compression, which was corrected by emergency decompressive surgery. One elderly patient suffered a perioperative cerebrovascular accident, and three patients suffered neurapraxia with transient muscle weakness of the quadriceps. There was one case of a dural tear. There were no deaths, and prolonged intensive care stays were not required. CONCLUSIONS: Single-level posterior reduction osteotomy provides excellent sagittal correction of kyphotic deformity in the lumbar region, with a risk of cauda equina and root and plexus compromise due to the extensive neural exposure.

MR imaging of fibrocartilaginous masses arising on the margins of spondylolysis defects.

OBJECTIVE: Spondylolysis is reported in up to 7% of the population. An uncommon process that can accompany a pars interarticularis defect is a fibrocartilaginous mass, which can cause impression on the nerve roots and thecal sac. Recognition is important so that the presence may be addressed at the time of surgery. This report describes the MR imaging appearance and clinical significance of a fibrocartilaginous mass in association with spondylolysis. MATERIALS AND METHODS: We reviewed data regarding 336 patients who had lumbar spine imaging at our institution during a 12-month period. Contiguous axial and sagittal MR imaging using T1-weighted and fast spin-echo T2-weighted sequences was used. Images were evaluated for a mass of tissue surrounding the pars defect with MR characteristics of cartilaginous and fibrous low signal intensity on T1-weighted images and low to intermediate signal intensity on T2-weighted images. The position of the fibrocartilaginous mass and its relation to the thecal sac were noted. Surgical correlation between those patients with a fibrocartilaginous mass and those without was examined. RESULTS: Twenty-nine (8.6%) of 336 patients were identified as having a pars interarticularis defect. A fibrocartilaginous mass was present in 26 (90%) of 29 patients. Six (21%) of the 29 patients had a mass effect on the thecal sac. Of the remaining 23 patients, 20 had a fibrocartilaginous mass external to the thecal sac, and three did not show any fibrocartilaginous mass. Histologic analysis in one patient confirmed the fibrous and cartilaginous nature of the lesion at the pars defect. CONCLUSION: A fibrocartilaginous mass was present in 90% of the patients with spondylolysis. Mass effect on the thecal sac that required surgery was identified in 21% of the patients with spondylolysis. Awareness of this mass and proper imaging protocols will enable the radiologist to preoperatively alert the surgeon to its presence.

Functional outcome of plate fusions for disorders of the occipitocervical junction.

Twenty-eight patients with average followup of 27 months (range, 12-51 months) required occipitocervical fusion with plates. A 1992 to 1996 consecutive case series enrolled patients prospectively from two institutions. Five surgeons participated. Sixteen patients had inflammatory arthritis; four, osteogenesis imperfecta; three, tumors; three, congenital anomalies; one, pseudarthrosis after odontoid fracture; and one, osteoarthritis. Twenty-two of 28 (78.6%) patients had serious comorbid medical conditions. Additional halo immobilization of 6 weeks was used in 16 of 27 patients. Four patients required revision surgery. No patients showed a decline in neurologic status and average neurologic improvement was one Nurick grade. Two-year followup showed 13 (50%) excellent, nine (34.6%) good, two (7.7%) fair, and two (7.7%) poor outcomes based on a functional outcome scale. There were three deaths during the followup period (overall mortality rate of 10.7%). One death was attributable to airway obstruction, one death 14 months postoperatively was attributable to late Methicillin resistant Staphylococcus aureus sepsis at the bone graft donor site, and one death 41 months postoperatively was attributable to a stroke. The overall fusion rate was 85.2% (23 of 27 patients), with a 96.3% (26 of 27 patients) occipitocervical fusion rate. Three patients had a possible asymptomatic end segment pseudarthrosis with screw loosening. Twenty-two of 26 (84.6%) interviewed patients would choose the surgery again if given the choice.