Segmental and global lordosis changes with two-level axial lumbar interbody fusion and posterior instrumentation.

BACKGROUND: Loss of lumbar lordosis has been reported after lumbar interbody fusion surgery and may portend poor clinical and radiographic outcome. The objective of this research was to measure changes in segmental and global lumbar lordosis in patients treated with presacral axial L4-S1 interbody fusion and posterior instrumentation and to determine if these changes influenced patient outcomes. METHODS: We performed a retrospective, multi-center review of prospectively collected data in 58 consecutive patients with disabling lumbar pain and radiculopathy unresponsive to nonsurgical treatment who underwent L4-S1 interbody fusion with the AxiaLIF two-level system (Baxano Surgical, Raleigh NC). Main outcomes included back pain severity, Oswestry Disability Index (ODI), Odom's outcome criteria, and fusion status using flexion and extension radiographs and computed tomography scans. Segmental (L4-S1) and global (L1-S1) lumbar lordosis measurements were made using standing lateral radiographs. All patients were followed for at least 24 months (mean: 29 months, range 24-56 months). RESULTS: There was no bowel injury, vascular injury, deep infection, neurologic complication or implant failure. Mean back pain severity improved from 7.8±1.7 at baseline to 3.3±2.6 at 2 years (p < 0.001). Mean ODI scores improved from 60±15% at baseline to 34±27% at 2 years (p < 0.001). At final follow-up, 83% of patients were rated as good or excellent using Odom's criteria. Interbody fusion was observed in 111 (96%) of 116 treated interspaces. Maintenance of lordosis, defined as a change in Cobb angle ≤ 5°, was identified in 84% of patients at L4-S1 and 81% of patients at L1-S1. Patients with loss or gain in segmental or global lordosis experienced similar 2-year outcomes versus those with less than a 5° change. CONCLUSIONS/CLINICAL RELEVANCE: Two-level axial interbody fusion supplemented with posterior fixation does not alter segmental or global lordosis in most patients. Patients with postoperative change in lordosis greater than 5° have similarly favorable long-term clinical outcomes and fusion rates compared to patients with less than 5° lordosis change.

Conus medullaris syndrome after epidural steroid injection: Case report.

BACKGROUND: Given the risk of paralysis associated with cervical transforaminal injection, is it time to reconsider transforaminal injections of the lumbar spine? Arguments for discontinuing lumbar injections have been discussed in the anesthesia literature, raising concern about the risks of epidural steroid injections (ESIs). METHODS: In a 47-year-old man, paraplegia of the lower extremities developed, specifically conus medullaris syndrome, after he underwent an ESI for recurrent pain. Correct needle placement was verified with epidurography. Immediately after the injection, the patient felt his legs "going dead"; paraplegia of the lower extremities was noted. RESULTS: An initial magnetic resonance imaging study performed after the patient was transferred to the emergency department was unremarkable. However, a later neurosurgical evaluation showed conus medullaris syndrome, and a second magnetic resonance imaging study showed the conus infarct. We conducted a search of the PubMed database of articles from 2002 to 2011 containing the following keywords: complications, lumbar epidural steroid injection(s), cauda equina syndrome, conus medullaris infarction, spinal cord infarction, spinal cord injury, paralysis, paresis, plegia, paresthesia, and anesthesia. CONCLUSIONS: Summarizing this case and 5 similar cases, we weigh the potential benefits and risks of ESI. Although one can safely assume that this severe, devastating complication is rare, we speculate that its true incidence remains unknown, possibly because of medicolegal implications. We believe that the rarity of this complication should not preclude the continued use of transforaminal ESI; rather, it should be emphasized for discussion with patients during the consent process.

Translaminar cervical epidural steroid injection: short-term results and factors influencing outcome.

PURPOSE: To assess the efficacy of translaminar cervical epidural steroid injection (ESI) in the management of localized or radicular neck pain and assess categoric factors that can help predict clinical outcome. MATERIALS AND METHODS: In all patients studied, treatment of neck pain with oral pain medications or physical therapy had failed. A total of 280 translaminar cervical ESIs were performed in 161 patients with an average age of 58 years (range, 26-82 y). The average duration of symptoms until the time the procedure was performed was 18.2 months (range, 0.25-240 months). All patients were assessed by telephone approximately 10 days after the procedure to determine efficacy. RESULTS: Of the 280 total injections, 233 (83%) resulted in pain relief. Patients were more likely to experience pain relief if they presented with multilevel degenerative changes (odds ratio [OR] = 4.13, P = .0055), had radicular symptoms in the hand and/or finger (OR = 2.72, P = .0011), or underwent injection at the C7-T1 level (OR = 2.44, P = .0034). Patients who required narcotics for their symptoms before the procedure showed lower odds of pain relief (OR = 0.80, P = .4367). There were no major complications and the overall minor complication rate was 5.18%. CONCLUSION: Translaminar cervical ESI is a safe procedure. Although repeat injections may be necessary in some patients, excellent short-term clinical results can be achieved.

Management strategy for adult patients with dorsal midbrain gliomas.

OBJECTIVE: Dorsal midbrain gliomas (DMGs) involving the tectum occur more commonly in children than in adults. These lesions are often indolent in nature, and patients require treatment only for obstructive hydrocephalus. Because limited information is available concerning adults with this type of lesion, we describe our experience and management strategy in adults with DMGs. METHODS: We retrospectively reviewed the charts and magnetic resonance imaging scans of five adult patients (four men, one woman; mean age, 51.6 yr; range, 23-69 yr) who were treated from March 1992 to August 2001 for DMGs involving the tectum. The mean follow-up time for these patients was 71.4 months (range, 25-113 mo). We analyzed the data to determine the optimal treatment strategy and outcomes of patients with DMGs. Tumor volume was analyzed objectively with Scion Image software (Scion Corp., Frederick, MD) to document changes in volume and determine whether treatment strategy differed significantly with tumor size. RESULTS: Tumors in two of these patients were found incidentally, and three others presented with obstructive hydrocephalus. Magnetic resonance imaging scans demonstrated an isolated tectal glioma in one patient, tectal and tegmental (periaqueductal) gliomas in three patients, and a tectal glioma with right thalamic extension in one patient. Treatment consisted of routine follow-up for the two asymptomatic patients and cerebrospinal fluid diversion surgery for the three patients with hydrocephalus. Volumetric analysis demonstrated that all asymptomatic patients had tumors smaller than 9.3 cm(3), and symptomatic patients had tumors larger than 28.5 cm(3). All follow-up magnetic resonance imaging scans revealed stable dorsal midbrain lesions, and no patient required tumor-specific therapy. CONCLUSION: Although tumors of the dorsal midbrain occur primarily in the pediatric population, similar tumors may occur in adults. As has been learned from experience with children, these lesions are often clinically and radiographically stable and require only appropriate therapy for obstructive hydrocephalus. We advocate a similar conservative strategy of routine imaging follow-up and treatment for hydrocephalus in adult patients. Surgery and other therapy should be reserved for patients with progressive lesions.