Minimally invasive anterior cervical foraminotomy for unilateral radiculopathy.

Anterior cervical foraminotomy (ACF) is an alternative surgical option for the treatment of refractory unilateral radiculopathy due to disc herniation or spondylosis. The efficacy and adverse event rate in experienced practitioners are comparable to those of anterior cervical discectomy and fusion, total disc arthroplasty, and posterior foraminotomy. However, this technique has not been widely adopted, likely because of the proximity of the working zone and the vertebral artery. The authors present a detailed operative video of a patient successfully treated with an ACF. They also present a review of the ACF literature. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23196.

Noninstrumented Free Fibula Flap for Cervical Osteomyelitis.

BACKGROUND AND IMPORTANCE: Severe cases of cervical vertebral osteomyelitis can pose a challenge regarding reconstruction, stability/alignment, and infection eradication. Here we describe the application of vascularized free fibula (FF) flaps to reconstruct the cervical spine without instrumentation in the setting of severe osteomyelitis. CLINICAL PRESENTATION: Two patients presented with symptomatic multilevel cervical osteomyelitis. Both patients were treated with corpectomy and FF flap without instrumentation using a novel wedging and distraction technique to secure the flap into position. Clinical outcomes were based on neurological recovery and infection management. Computed tomography (CT) and CT angiography with 3-dimensional reconstruction were used to measure fusion status and patency of the anastomoses. CT of the cervical spine completed 8 weeks postoperatively demonstrated robust fusion of the fibula flaps to adjacent cervical vertebrae. In both patients, CT angiography demonstrated patency of the arterial anastomoses. Both flaps maintained persistent deformity correction. Both patients made full neurological recovery. DISCUSSION: This reconstructive approach represents a salvage technique that offers advantages in cases of prior hardware failure or unfavorable host factors with rapid fusion and definitive treatment with a single surgery. CONCLUSION: The use of FF flap without instrumentation seems to be a safe and effective option for cervical spine reconstruction in the setting of severe osteomyelitis.

Are we underestimating the burden of traumatic brain injury? Surveillance of severe traumatic brain injury using centers for disease control International classification of disease, ninth revision, clinical modification, traumatic brain injury codes.

BACKGROUND: The epidemiology of traumatic brain injury (TBI) is often studied through the use of International classification of disease, ninth revision, clinical modification (ICD-9-CM), diagnosis codes from the Centers for Disease Control and Prevention TBI Surveillance System. Recent studies suggest that these codes may underestimate the burden of TBI because of inaccuracies and low sensitivity. OBJECTIVE: To determine the sensitivity and specificity of ICD-9-CM codes in a severe TBI population. METHODS: We retrospectively reviewed medical records of all hospital admissions including computed tomography of the head at a single center to identify severe blunt TBI patients, their injuries, and the neurosurgical procedures performed. We calculated sensitivity and specificity by comparing ICD-9-CM diagnosis and procedure codes assigned by hospital coders with medical records, the gold standard. RESULTS: In 2008, there were 148 qualifying admissions. These codes were 89% sensitive for the presence of any severe TBI. However, one-fifth of these cases were identified only with a code defining a nonspecific head injury. Next, we studied types of TBI by categories defined by the Centers for Disease Control and Prevention (morbidity groups) and by ICD-9-CM codes for types of injury (any skull fracture, intracranial contusion, intracranial hemorrhage, concussion/loss of consciousness) and found widely varying sensitivity and specificity for both. In general, these codes had higher specificity than sensitivity. Both sensitivity and specificity were > 80% for only 2 categories: any skull fracture and intracranial hemorrhage. In contrast, we found high sensitivity and specificity for neurosurgical procedures (97% and 94%). CONCLUSION: ICD-9-CM codes were sensitive for the presence of any severe TBI, but further classification of specific types of TBI was limited by variable sensitivity/specificity. Use of these codes should be supplemented by other methodology.

The AIS-2005 Revision in Severe Traumatic Brain Injury: Mission Accomplished or Problems for Future Research?

The Abbreviated Injury Scale (AIS) is commonly used to score injury severity and describe types of injuries. In 2005, the AIS-Head section was revised to capture more detailed information about head injuries and to better reflect their clinical severity, but the impact of these changes is largely unknown. The purpose of this study was to compare AIS-1998 and AIS-2005 coding of traumatic brain injuries (TBI) using medical records at a single Level I trauma center. We included patients with severe TBI (Glasgow Coma Scale 3-8) after blunt injury, excluding those who were missing medical records. Detailed descriptions of injuries were collected, then manually coded into AIS-1998 and AIS-2005 by the same Certified AIS Specialist. Compared to AIS-1998, AIS-2005 coded the same injuries with lower severity scores [p<0.01] and with decreased mean and maximum AIS-Head scores [p<0.01]. Of the types of traumatic brain injuries, most of the changes occurred among cerebellar and cerebral injuries. Traumatic hypoxic brain injury secondary to systemic dysfunction was captured by AIS-2005 but not by AIS-1998. However, AIS-2005 captured fewer loss of consciousness cases due to changes in criteria for coding concussive injury. In conclusion, changes from AIS-1998 to AIS-2005 result in significant differences in severity scores and types of injuries captured. This may complicate future TBI research by precluding direct comparison to datasets using AIS-1998. TBIs should be coded into the same AIS-version for comparison or evaluation of trends, and specify which AIS-version is used.