Outcomes of 2-Level Versus 3- or 4-Level Anterior Cervical Discectomy and Fusion Using a Biomimetic Surface Titanium Cage: Multicenter Experience.

OBJECTIVE: Interbody cages for spinal fusions are primarily constructed from polyetheretherketone or titanium compositions. However, these crude macroscopic materials pose limitations for improving the rates of bony fusions. The authors aimed to compare the fusion rates and postoperative complications in patients who underwent 2-level or 3-or 4-level anterior cervical discectomy and fusion (ACDF) performed with the use of a novel biomimetic surface titanium cage. METHODS: A retrospective multicenter study was conducted that included all patients who underwent multilevel ACDF with this cage between January 2017 and April 2021. Patient demographics and procedure-related, radiographic, and postoperative complication data were collected. RESULTS: A total of 124 patients were identified; 69 (55.6%) had a 3-or 4-level fusion and 55 (44.4%) had a 2-level fusion. The demographics of the 2 groups differed significantly only in terms of age (P = 0.01). At 3 months, a significantly higher solid fusion rate was found for 2-level fusions than 3-or 4-level fusions (83.7% vs. 56.3%, P = 0.004); however, significance was lost at 6-months (98.2% vs. 88.4%, respectively; P = 0.08). No patients required posterior supplemental fixation. Transient dysphagia was the only postoperative complication that was significantly increased in the 3-or 4-level fusion group compared to the 2-level group (27.5% vs. 9.1%, P = 0.02). CONCLUSIONS: Radiographic and clinical outcomes were equivalent in 3-or 4-level and 2-level ACDFs in which these biomimetic surface titanium cages were used. Furthermore, the use of this technology led to high fusion rates with no requirement for posterior supplemental fusions.

Reducing Surgical Complications in Spine Patients Through a Medication Management Support Program.

STUDY DESIGN: A hospital-wide medication management program was implemented to ensure that high-risk patients would systematically pause antiplatelet and anticoagulant medications. We analyzed complications before and during the implementation of this program. OBJECTIVE: The goal of the study was to determine if a medication management support program was effective for reducing perioperative complications, including hemorrhage, myocardial infarction, stroke, pulmonary embolism, and deep vein thrombosis. DATA AND METHODS: Using data from the National Surgical Quality Improvement Program database, we examined the presence of 5 complications before and during the implementation of a medication management support program. There were 9732 patients in the clinic population who underwent elective spine surgery between 2011 and 2020 and were included in this analysis. Of those 9732 patients, 7205 had surgery before the introduction of the program, whereas 2527 had surgery at some point after the program was introduced. We conducted a series of Pearson's χ 2 tests to determine the relative frequencies of the complications before and during the program. RESULTS: Results showed that during the implementation of the program, patients were relatively less likely to experience hemorrhage (3.16% vs. 1.11%; P <0.001). The reductions in thrombotic complications were clinically significant: myocardial infarction (0.12% vs. 0.00%), stroke (0.10% vs. 0.04%), pulmonary embolism (0.33% vs. 0.28%), and deep vein thrombosis (0.36% vs. 0.28%). These P values ranged from P =0.08 for myocardial infarction to P =0.67 for pulmonary embolism. CONCLUSIONS: The use of this medication management support program appears effective for reducing the need for blood transfusions and thrombotic complications. While promising, the results should be interpreted with caution as we do not know whether this type of program will be effective for other hospital systems.

Pain Provocation and the Energy Cost of Walking: A Matched Comparison Study of Older Adults With and Without Chronic Low Back Pain With Radiculopathy.

BACKGROUND AND PURPOSE: Chronic low back pain with radiculopathy (CLBPR) is common among older adults and can lead to walking difficulty. Energy cost of walking strongly predicts changes in walking speed, which is predictive of mortality in older adults. The purposes of this study were to examine (1) the impact of pain provocation on the energy cost of walking and (2) the relationship between pain intensity and change in energy cost of walking. METHODS: Older adults (60-85 years) with (n = 20) and without (n = 20) CLBPR were matched on age, sex, and diabetes presence/absence. Energy cost of walking was measured with a portable metabolic gas analyzer, as participants walked for 20 minutes or less. Energy cost and pain measurements occurred during early and late stages of walking. Percent change in energy cost was calculated. Participants were grouped by their pain response during walking: increased pain (n = 13); consistent pain (n = 7); no pain, matched to individuals with increased pain (n = 13); and no pain, matched to individuals with consistent pain (n = 7). We examined the within-groups change in energy cost for all groups, as well as the relationship between late-stage pain intensity and percent change of energy cost for individuals whose pain increased. RESULTS AND DISCUSSION: Within the increased pain group, energy cost of walking significantly increased from early to late stages (median change = 0.003 mL/kg/m, P = .006), and late-stage pain intensity explained 41.2% (p = 0.040) of the variance in percent change. Since pain appears to be linked to energy cost, effective pain management with walking may be an important factor in preventing mobility decline. CONCLUSIONS: Among older adults with CLBPR, pain provocation drives increases in the energy cost of walking. Because high energy cost of walking is predictive of mobility decline, clinicians may focus on effective pain management strategies during walking, which may potentially decrease the risk of mobility decline.

Energy Impairments in Older Adults With Low Back Pain and Radiculopathy: A Matched Case-Control Study.

OBJECTIVES: To investigate the impact that the presence of chronic low back pain with radiculopathy (CLBPR) may have on (1) energy efficiency and (2) energy capacity among community-dwelling older adults. DESIGN: Matched case-control study. SETTING: Clinical research laboratory. PARTICIPANTS: Included in the analysis were community-dwelling older adults (N=38, 60-85 years) with and without CLBPR. Participants were matched between-groups on age (±5 years), sex, and diabetic status. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Energy cost of walking at self-selected speed (ie, energy efficiency) and peak volume of oxygen consumed (ie, energy capacity). RESULTS: Older adults with CLBPR had a higher energy cost of walking at self-selected speed (P=.009) and lower peak volume of oxygen consumed while walking (P=.050), compared to those without pain. CONCLUSIONS: Older adults with CLBPR may benefit from specific rehabilitative interventions that target these potentially modifiable energetic outcomes, thereby reducing the risk of mobility decline. Future studies should identify which mechanisms specifically contribute to diminished energy efficiency and capacity among older adults with CLBPR.

Bow Hunter's Syndrome in a Patient with a Right Hypoplastic Vertebral Artery and a Dynamically Compressible Left Vertebral Artery.

This is a case report of a 48-year-old man with multiple transient ischemic attacks and a known hypoplastic right vertebral artery (VA) who presented after a syncopal event while turning his head to the left. The objective of this study is to demonstrate the necessity of proper diagnosis and management of cerebrovascular pathology including imaging and surgical intervention in patients with known anatomical anomalies. This study was conducted at Massachusetts, United States of America. Our patient's history was significant for a hypoplastic right VA and a stenotic segment of the right VA at the C3-C4 junction. There was also degeneration of the C3-C4 facet on the left, with osteophyte formation compressing the VA, and a fusion of the C2-C3 segment. Imaging demonstrated obliteration of the left VA flow with head rotation to the left and subsequent reconstitution of flow in the neutral position. After consultation, the patient decided to proceed with surgical management with an anterior cervical discectomy and fusion at the level of C3-C4. Symptoms of vertebrobasilar insufficiency including syncopal episodes resolved after treatment. VA anomalies, although uncommon, are important to understand. Our patient presented with an anomalous right VA, as well as severe degenerative changes to the C2/C3 vertebrae that contributed to the development of Bow Hunter's syndrome. It is essential that proper monitoring and follow-up has to be carried out in patients with abnormal cerebral vasculature to minimize the occurrence of Bow Hunter's syndrome.

Spinal Metastases from a Primary Fallopian Tube Serous Adenocarcinoma: A Case Report.

Study Design Case report. Objective This case exemplifies the importance of a high index of suspicion when dealing with intractable pain and neurologic symptoms in patients with a history of cancer. Fallopian tube cancer is relatively uncommon, accounting for less than 0.2% of all female malignancies. Because of a low index of suspicion, it is often detected at an advanced stage. From an orthopedic perspective, osseous metastasis from primary fallopian tube malignancies is rare with only a few documented cases in the medical literature. Methods This case report documents a 68-year-old woman who developed back pain and leg weakness after undergoing surgical resection with adjuvant therapy of a primary fallopian tube adenocarcinoma. Her hospital course and follow-up are documented. Results Imaging revealed a compression fracture in the L1 vertebral body that when a biopsy confirmed a soft tissue diagnosis of a high-grade serous papillary adenocarcinoma of fallopian tube origin. The patient underwent a surgical decompression, posterior stabilization, and tumor debulking with postoperative resolution of her symptoms. Conclusions This is the first reported case of a spine metastasis from a fallopian tube serous carcinoma in a living patient. This case documents the diagnosis of a pathologic vertebral fracture due to metastasis of an atypical cancer.

Vertebral artery injuries in cervical spine surgery.

BACKGROUND CONTEXT: Vertebral artery injuries (VAIs) are rare but serious complications of cervical spine surgery, with the potential to cause catastrophic bleeding, permanent neurologic impairment, and even death. The present literature regarding incidence of this complication largely comprises a single surgeon or small multicenter case series. PURPOSE: We sought to gather a large sample of high-volume surgeons to adequately characterize the incidence and risk factors for VAI, management strategies used, and patient outcomes after VAI. STUDY DESIGN: The study was constructed as a cross-sectional study comprising all cervical spine patients operated on by the members of the international Cervical Spine Research Society (CSRS). PATIENT SAMPLE: All patients who have undergone cervical spine surgery by a current member of CSRS as of the spring of 2012. OUTCOME MEASURES: For each surgeon surveyed, we collected self-reported measures to include the number of cervical cases performed in the surgeon's career, the number of VAIs encountered, the stage of the case during which the injury occurred, the management strategies used, and the overall patient outcome after injury. METHODS: An anonymous 10-question web-based survey was distributed to the members of the CSRS. Statistical analysis was performed using Student t tests for numerical outcomes and chi-squared analysis for categorical variables. RESULTS: One hundred forty-one CSRS members (of 195 total, 72%) responded to the survey, accounting for a total of 163,324 cervical spine surgeries performed. The overall incidence of VAI was 0.07% (111/163,324). Posterior instrumentation of the upper cervical spine (32.4%), anterior corpectomy (23.4%), and posterior exposure of the cervical spine (11.7%) were the most common stages of the case to result in an injury to the vertebral artery. Discectomy (9%) and anterior exposure of the spine (7.2%) were also common time points for an arterial injury. One-fifth (22/111) of all VAI involved an anomalous course of the vertebral artery. The most common management of VAI was by direct tamponade. The outcomes of VAIs included no permanent sequelae in 90% of patients, permanent neurologic sequelae in 5.5%, and death in 4.5%. Surgeons at academic and private centers had nearly identical rates of VAIs. However, surgeons who had performed 300 or fewer cervical spine surgeries in their career had a VAI incidence of 0.33% compared with 0.06% in those with greater than 300 lifetime cases (p=.028). CONCLUSIONS: The overall incidence of VAI during cervical spine surgery reported from this survey was 0.07%. Less experienced surgeons had a higher rate of VAI compared with their more experienced peers. The results of VAI are highly variable, resulting in no permanent harm most of the time; however, permanent neurologic injury or death occur in 10% of cases.

Control of the vertebral artery from a posterior approach: a technical report.

BACKGROUND CONTEXT: Vertebral artery (VA) injury is a rare but potentially devastating complication of cervical spinal fusion. The Magerl and Harms techniques are associated with a rate between 0% to 8% and 0% to 5%, respectively. Most of reported VA injuries are related to surgical exposure or screw placement, which in turn is likely due to variability in VA anatomy. PURPOSE: The purpose of this report was to present the case of a 77-year-old woman, with a history of right VA occlusion, who sustained an intraoperative left VA injury during posterior cervical spine fusion and the subsequent intraoperative and postoperative management strategies. STUDY DESIGN: This is a single-patient case report. METHODS: The patient was placed prone and into Mayfield tongs. A midline incision was made, and dissection was carried down to the lamina and facet joints from occiput to T2. During dissection, she sustained a left-sided VA injury, which was subsequently controlled. RESULTS: The patient was doing well at her 1-year postoperative visit without any residual neurologic deficits. Her severe neck pain had resolved. CONCLUSION: A detailed understanding of VA anatomy of each individual patient is paramount. There are four types of anomalies: intraforaminal; extraforaminal; arterial; and anomalies of the surrounding bony and soft-tissue architecture. In the event of a posterior intraoperative VA injury, we outlined an algorithm to deal with this complication: control bleeding temporarily to gain visualization of the arterial injury; remove lateral masses and tissue to adequately visualize the arterial injury; once visualized, control the bleeding and see if there are any neuromonitoring changes as a result of the VA occlusion; and proceed with definitive control of the artery by either repair or ligation.

The association between preoperative spinal cord rotation and postoperative C5 nerve palsy.

BACKGROUND: C5 nerve palsy is a known complication of cervical spine surgery. The development and etiology of this complication are not completely understood. The purpose of the present study was to determine whether rotation of the cervical spinal cord predicts the development of a C5 palsy. METHODS: We performed a retrospective review of prospectively collected spine registry data as well as magnetic resonance images. We reviewed the records for 176 patients with degenerative disorders of the cervical spine who underwent anterior cervical decompression or corpectomy within the C4 to C6 levels. Our measurements included area for the spinal cord, space available for the cord, and rotation of the cord with respect to the vertebral body. RESULTS: There was a 6.8% prevalence of postoperative C5 nerve palsy as defined by deltoid motor strength of ≤ 3 of 5. The average rotation of the spinal cord (and standard deviation) was 2.8° ± 3.0°. A significant association was detected between the degree of rotation (0° to 5° versus 6° to 10° versus ≥ 11°) and palsy (point-biserial correlation = 0.94; p < 0.001). A diagnostic criterion of 6° of rotation could identify patients who had a C5 palsy (sensitivity = 1.00 [95% confidence interval, 0.70 to 1.00], specificity = 0.97 [95% confidence interval, 0.93 to 0.99], positive predictive value = 0.71 [95% confidence interval, 0.44 to 0.89], negative predictive value = 1.00 [95% confidence interval, 0.97 to 1.00]). CONCLUSIONS: Our evidence suggests that spinal cord rotation is a strong and significant predictor of C5 palsy postoperatively. Patients can be classified into three types, with Type 1 representing mild rotation (0° to 5°), Type 2 representing moderate rotation (6° to 10°), and Type 3 representing severe rotation (≥ 11°). The rate of C5 palsy was zero of 159 in the Type-1 group, eight of thirteen in the Type-2 group, and four of four in the Type-3 group. This information may be valuable for surgeons and patients considering anterior surgery in the C4 to C6 levels.

Three-part head-splitting proximal humerus fracture through a unicameral bone cyst.

Unicameral bone cysts are rare in adults and are most often found incidentally on radiographs. However, they can persist from the adolescent period and may be present in locations that predispose to or exacerbate fractures.This article describes a case of a healthy 40-year-old woman who sustained a proximal humerus trauma that involved a large unicameral bone cyst, resulting in a 3-part head-splitting fracture. The epiphyseal location of the cyst contributed to the severity and extent of the fracture that resulted from a simple fall. Given the age of the patient, open reduction and internal fixation with a locking plate and lag screws was performed. The patient chose open reduction and internal fixation to preserve a hemiarthroplasty procedure in case of future revision. Successful humeral head reconstruction was achieved, and the patient fully recovered. One year postoperatively, the patient underwent arthroscopic debridement to alleviate subjective stiffness and decreased range of motion.Multipart head-splitting fractures require complex repair strategies. The gold standard for the treatment of these injuries is hemiarthroplasty. However, the decision process is difficult in a young patient given the average survival of autoplastic prostheses and the added difficulty of later revision. The current case demonstrates the complexity of decision making resulting from a rare injury in a young, healthy patient and shows that open reduction and internal fixation can provide acceptable reconstruction in such situations.

The characteristics of patients with type 1: intraforaminal vertebral artery anomalies?

In a previous study, intraforaminal anomalies were found to occur at a rate of 7.6%. This increases the risk of injury to this vessel if the surgeon is unaware of such abnormalities preoperatively. The aim of our retrospective study was to identify patient factors that may predict anomalous intraforaminal vertebral arteries. Patient records were obtained from a previous study. In that study, the records of each consecutive patient who underwent cervical spine magnetic resonance imaging (MRI) for axial neck pain, radiculopathy, or myelopathy between January 2007 and January 2008 were reviewed. The social and medical histories of each patient were evaluated with respect to the presence or absence of an aberrant vertebral artery. We reviewed the medical records of the 250 patients whose MRIs were reviewed in the previous study. Seven patients were excluded for incomplete records. Chi-square and Fisher's exact tests were performed to compare the normal vertebral artery anatomy patients to the aberrant patients. The medical records of 19 patients with aberrant vertebral arteries and 224 patients with normal vertebral arteries were reviewed. The aberrant group was significantly older than the normal group (P=.00015). The only diagnostic condition that represented a statistically significant difference between the 2 groups was incidence of cancer. A relationship may exist between patient age, cancer, and medialization of the vertebral artery. The mechanism of this possible relationship is unclear. Although aberrant vertebral arteries are rare, a surgeon should have raised suspicion of this possibility in patients with a history of cancer.

Is there a difference between simultaneous or staged decompressions for combined cervical and lumbar stenosis?

STUDY DESIGN: We evaluated 43 patients diagnosed with tandem spinal stenosis (TSS) from 1999 to 2005 in an academic hospital. OBJECTIVE: The purpose of this study is to compare outcomes after simultaneous decompression of the cervical and lumbar spine versus staged operations. SUMMARY OF BACKGROUND DATA: TSS is a rare degenerative disease affecting multiple spinal levels with limited research describing operative management. METHODS: Of our patients, 21 underwent simultaneous decompression of both the cervical and lumbar spine and 22 underwent staged decompression of the cervical spine followed by the lumbar spine at a later date. Medical records were reviewed for patient demographics, type and duration of symptoms, operative time, combined blood loss, cervical myelopathy modified Japan Orthopaedic Association Score, Oswestry Disability Index (ODI), major and minor complications, and average length of follow up. Each category was evaluated by Pearson correlations and unpaired Student t tests. RESULTS: With a mean follow-up of 7 years, both groups improved in JOA and ODI without a significant difference between the 2 operative groups in terms of major or minor complications, JOA, or ODI. Independent of the surgical algorithm, age above 68 years, estimated blood loss ≥400 mL, and operative time ≥150 minutes significantly increased the number of complications. CONCLUSIONS: These results indicate that TSS can be effectively managed by either surgical intervention, simultaneous, or staged decompressions. However, patient age, blood loss, and operative time do significantly impact outcomes. Therefore, operative management should be tailored to the patient's age and the option which will limit blood loss and operative time, whether that is by simultaneous or staged procedures.

Identification of type 1: interforaminal vertebral artery anomalies in cervical spine MRIs.

STUDY DESIGN: This is a prospective study. OBJECTIVE: The aim of our study is to identify whether vertebral arteries (VA), normal or aberrant, are routinely described in cervical spine magnetic resonance imaging (MRI) interpretations. SUMMARY OF BACKGROUND DATA: VA injury is a serious complication of anterior cervical spine surgery. Aberrant VA anatomy is a potential cause of such complications. Therefore, VA anatomy should be evaluated in cervical MRIs. METHODS: Six neuroradiologists were blinded to the study design and were asked to interpret 79 cervical MRIs. Of these, 39 had aberrant VAs, whereas 40 had normal VAs. Initially, the indications for the study included only a description of patient's symptoms. The radiologists were then given the same MRIs with different indications. This time, the indications included the patient's symptoms, a request for annotations on the VA, and a definition of VA anomaly. All of the MRI interpretations were then evaluated for the frequency and accuracy of VA description. RESULTS: When the indications for the study did not specifically request a comment on VAs, the VA was never described (0%). When the indications included the specific request and definition, all 6 commented on the VA (100%). Three of the 6 radiologists were 100% accurate in identifying all 40 normal and 39 aberrant VAs, whereas the other 3 identified all 40 normal and 38 of 39 aberrant VAs. CONCLUSION: This study demonstrates that the VA is not a standard component of cervical spine MRI interpretations. Because of the significant complications related to its injury, VA anatomy, whether normal or variant, needs to be evaluated in cervical MRIs. When ordering a cervical MRI, surgeons should request a description of the VA and any anomalies.

Injection treatment and back pain associated with degenerative lumbar spinal stenosis in older adults.

BACKGROUND: Lower back pain is one of the most common health-related complaints in the adult population. Thirty percent of Americans 65 years and older reported symptoms of lower back pain in 2004 (NCHS, 2006). Injection treatment is a commonly used non-surgical procedure to alleviate lower back pain in older adults. However, the effectiveness of injection treatment, particularly in older adults, has not been well documented. OBJECTIVE: This study quantified the effectiveness of injection treatment on pain relief among adults 60 years and over who were diagnosed with degenerative lumbar spinal stenosis, a common cause of lower back pain in older adults. The variations of the effectiveness were examined by selected patient attributes. STUDY DESIGN: Prospective, non-randomized, observational human study. SETTING: Single institution spine clinic. METHODS: Patients scheduled for lumbar injection treatment between January 1 and July 1, 2008 were prospectively selected from the study spine clinic. Selection criteria included patients age 60 and over, diagnosed with degenerative lumbar spinal stenosis and no previous lumbar injection within 6 months or lumbar surgery within 2 years. The pain sub-score of the SF-36 questionnaire was used to measure pain at baseline and at one and 3 months post injection. Variations in longitudinal changes in pain scores by patient characteristics were analyzed in both unadjusted (univariate) analyses using one-way analysis of variance (ANOVA), and adjusted (multiple regression) analyses using linear mixed effects models. LIMITATIONS: This study is limited by its sample size and observational design. RESULTS: Of 62 patients receiving epidural steroid injections, the mean Pain score at baseline was 27.4 (SD =13.6), 41.7 (SD = 22.0) at one month and 35.8 (SD = 19.0) at 3 months. Mean Pain scores improved significantly from baseline to one month (14.1 points), and from baseline to 3 months (8.3 points). Post injection changes in pain scores varied by body mass index (BMI) and baseline emotional health. Based on a linear mixed effects model analysis, higher baseline emotional health, as measured by the SF-36 Mental Component Score (MCS >/= 50), was associated with greater reduction in pain over 3 months when compared to lower emotional health (MCS), was associated with greater reduction in pain over 3 months when compared to lower emotional health (MCS <50). In patients with higher emotional health, pain scores improved by 14.1 (P < .05: 95% CI 6.9, 21.3). Patients who were obese also showed significant improvement in pain scores over 3 months compared to non-obese patients. In obese patients, pain scores increased by 7.9 (P <.05; 95% CI:1.0, 14.8) points. CONCLUSION: Lower back pain in older adults with degenerative lumbar spinal stenosis might be clinically significantly alleviated after injection treatment. Pain relief varies by a patients personal and clinical characteristics. Healthier emotional status and obesity appears to be associated with more pain relief experienced over 3 months following injection.

Vertebral artery anatomy: a review of two hundred fifty magnetic resonance imaging scans.

STUDY DESIGN: The aim of this study is to characterize the anatomy of vertebral arteries using magnetic resonance imaging scans of 250 consecutive patients. OBJECTIVES: To document the prevalence of midline vertebral artery (VA) migration in a subgroup of patients presenting with neck pain, radiculopathy, or myelopathy and to identify the course of the VA through the TFs. SUMMARY OF BACKGROUND DATA: Knowledge of VA anomalies and their respective prevalence may help surgeons decrease the incidence of iatrogenic injury to this artery. METHODS: In this retrospective review of 281 consecutive patients, who had an magnetic resonance imaging for axial neck pain, radiculopathy, or myelopathy, anatomic measurements were obtained from C2 to C7. RESULTS: The observed VA anomalies can be classified into following 3 main groups: (1) intraforaminal anomalies-midline migration, (2) extraforaminal anomalies, and (3) arterial anomalies. Midline migration of the VA was identified in 7.6% (19/250) of patients. The etiology can be degenerative or traumatic. It is important to note that the pattern of medial migration was clockwise rotation from caudal to cephalad and was present in all of our patients with anomalous arteries. Additionally, at C6, only 92% (460/500) of VAs were located within their respective transverse foramens and hypoplastic VAs were identified in 10% (25/250) of patients. CONCLUSION: Anomalies that must be considered before surgery include interforamenal anomalies, extraforamenal anomalies, and arterial anomalies. The intraforaminal anomalies involve midline migration, which places the VA at direct risk during corpectomy. Extraforaminal anomalies are related to VAs entering the transverse foramen at a level other than C6, which can increase the risk of injury during the anterior approach to the cervical spine. Arterial anomalies can be fenestrated, hypoplastic, or absent. These raise concern with the ability to maintain cerebral perfusion in the setting of damage to one of the VAs with the presence of contralateral arterial abnormality.

Revision strategy for posterior extrusion of the CHARITÉ polyethylene core.

STUDY DESIGN: This is a case report of a posterior extrusion of the polyethylene core from a CHARITÉ arthroplasty. This is the first reported case of posterior dislocation of the polyethylene and the revision strategies used to correct this problem. OBJECTIVE: To report a novel failure mechanism and revision strategy for CHARITÉ total disc arthroplasty (TDA). SUMMARY OF BACKGROUND DATA: Case report at a Level 1 tertiary care referral center in the northeastern United States. METHODS: This is a case report and review of the literature of a patient who sustained posterior dislocation of the polyethylene core from a CHARITÉ TDA several months after the index procedure. RESULTS: Core dislocation is a known complication of TDA. However, of the known reported dislocations all have been anterior. This case describes the first known occurrence of posterior core dislocation and the revision strategy for this problem. CONCLUSION: This case report highlights the first known case of a posterior dislocation of a CHARITÉ core. It is likely that altered biomechanical forces generated over time attributed to device failure. An instrumented posterior fusion with removal of the core is what ultimately led to a stable revision construct.

A modified technique for dowel fibular strut graft placement and circumferential fusion in the setting of L5-S1 spondylolisthesis and multilevel degenerative disc disease.

BACKGROUND: Traditional techniques for the treatment of isthmic spondylolisthesis pass a fibular dowel graft across the L5-S1 disc by using the anterior portion of the L5 body. OBJECTIVE: To introduce a technique for the treatment of isthmic spondylolisthesis in the setting of multilevel degenerative disc disease in adults. Our modified technique allows us to traverse the L5-S1 disc via the L4-5 disc space thereby treating the degenerated disc at L4-5 simultaneously. METHODS: A standard anterior discectomy was performed on L4-5. Using biplanar fluoroscopy, a Kirschner wire was placed beginning at the anterior third of the L5 superior endplate and ending at S1. An anterior cruciate ligament reamer was used to make a channel for the fibular allograft. Then, a femoral ring allograft was placed in the disc space at L4-5, and standard anterior lumbar interbody fusions were performed at any additional cephalad level(s). Afterward, posterior instrumented fusion was performed to complement the anterior fusion procedure (except at L5), and wide decompression followed. RESULTS: All patients presented with isthmic spondylolisthesis and all had multilevel fusions. The mean slip angle was 32.6 degrees (37.8 degrees preoperatively), and mean lumbar index was 67%. After the procedure, the average endplate-to-dowel angle was 107.1 degrees compared with 134 degrees. All patients had clinical and radiographic evidence of solid fusion without the need for revisions. CONCLUSION: The proposed advantage of our modified technique is twofold. The graft is placed nearly perpendicular to the L5-S1 interface, as it will behave more efficiently with respect to interfragmental compression. Also, surgeons gain access to fuse L4-5 anteriorly and posteriorly.

Treatment of distal biceps tendon ruptures using a single-incision technique and a Bio-Tenodesis screw.

No consensus exists in the literature on the optimal operative treatment method for distal biceps tendon ruptures. It is our hypothesis that a single-incision technique with a poly-L-lactide Bio-Tenodesis screw (Arthrex, Inc, Naples, Florida) is a safe and effective method for operative management of distal biceps tendon ruptures, with success and complication rates comparable to previous reports in the literature. This article describes a prospective case series of 29 consecutive patients (30 operations) managed by the same surgeon over 34 months. Average follow-up was 19.6 months. Two patients were lost to follow-up. Elbow range of motion (ROM) and strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and SF-12 score were measured at various time points up to 2 years. All patients had full extension and supination. Supination and flexion strength was at least 4/5 in all patients. Mean DASH, SF-12 Physical Component (PCS), and SF-12 Mental Component (MCS) scores were 5.86 (range, 0-16.67), 50.35 (range, 30.4-60.1), and 57.15 (range, 41.7-64.4), respectively. These scores are comparable to normative values reported by the American Academy of Orthopaedic Surgeons. Complication rates were similar to those previously reported in the literature. This type of fixation allowed for early mobilization of the operative arm. Our study demonstrates that use of a tenodesis screw for distal biceps repair results in DASH and SF-12 scores comparable to the norm for the general population with complications similar to those seen in past studies. In addition, biomechanical studies suggest that the repair is strong enough to allow early ROM, and the fixation technique may allow for more anatomic positioning of the distal biceps along the ulnar border of the bicipital tuberosity.

A lateral meniscus tear incarcerated behind the popliteus tendon: a case report.

A 51-year-old male, sustained an injury to his left knee after being pinned between his motorcycle and a road barrier. In the ER, the patient complained of medial knee pain, and had a significant joint effusion. MRI demonstrated an ACL injury, medial meniscal tear, bone bruising and impaction at the lateral femoral condyle and tibial plateau, and a tear of the posterior horn of the lateral meniscus that was displaced behind the popliteus. Unfortunately, the patient also presented with a deep vein thrombosis and thus could not proceed to the operating room for two months. During this time, scar tissue developed around the lateral meniscus. The purpose of this report is to present an unusual variant of a common injury pattern previously unreported where the posterior horn of the lateral meniscus became incarcerated behind the popliteus tendon and was left in place. It is likely that our patient will develop osteoarthritis in the future, but considering the circumstances he received a favorable early clinical outcome. Early recognition and a mobile fragment are essential restoring a patient's original anatomical features and achieving an optimal clinical outcome.