Sacroiliac stabilization for sacral metastasis: A case series.

BACKGROUND: The sacrum is a rare location for spinal metastasis. These lesions are typically large and destructive by the time of diagnosis, making treatment difficult. When indicated, surgical stabilization offers pain relief and preserves independence in patients with impending and acute pathological sacral fractures. CASE DESCRIPTION: Three consecutive patients presented with sacral metastases. After either failing radiation therapy or presenting with acute fracture and instability, the patients underwent intralesional excision, bilateral L4 to ilium fusion with instrumentation, and sacroiliac (SI) screw fixation. Pain improved after surgery, and there were no wound healing complications. Two patients could continue walking without any assistive device, while one patient required a walker. CONCLUSION: Stabilization with combined modified Galveston fixation and SI screw fixation relieves pain and allows maintenance of independence in patients with sacral metastasis.

Biomechanical Analysis of Intervertebral Cement Extravasation in Vertebral Motion Segments.

Kyphoplasty is a therapeutic option for pain relief in the setting of compression fractures. Cement extravasation into adjacent disks is a common occurrence. The biomechanical and clinical consequences of cement in the disks currently are unknown. This study investigated the biomechanical effects of cement extravasation into the intervertebral disk in a human cadaveric model. Seven thoracolumbar and lumbar embalmed human cadaveric motion segments were evaluated in axial rotation, right and left lateral bending, and flexion and extension. Stiffness was calculated at baseline and following injection of 1 mL of cement into the intervertebral disk. There was a 13.4% (P=.041) increase in stiffness in axial rotation compared with preinjection motion segments. No significant difference was observed in lateral bending or flexion and extension. In this model, cement extravasation into the disk space increased stiffness in axial rotation. [Orthopedics. 2017; 40(2):e300-e304.].

Fat Thickness as a Risk Factor for Infection in Lumbar Spine Surgery.

Body mass index does not account for body mass distribution. This study tested the hypothesis that subcutaneous fat thickness is a better indicator than body mass index of the risk of surgical site infection in lumbar spine procedures performed through a midline posterior approach. Charts were reviewed for previously identified risk factors for surgical site infection (age, diabetes, smoking, obesity, albumin level, multilevel procedures, previous surgery, and operative time) in 149 adult patients who underwent lumbar spine procedures through a midline posterior approach. Subcutaneous fat thickness was measured with a novel automated technique. Regression analysis was used to determine associations between risk factors and fat thickness with surgical site infection. In the study group, 15 surgical site infections occurred (10.1%). Bivariate analysis showed a significant association between surgical site infection and body mass index (P=.01), obesity (P=.02), and fat thickness (P=.002). With multivariate analysis, body mass index and obesity did not show significance, but fat thickness remained significant (P=.026). For every 1-mm thickness of subcutaneous fat there was a 6% (odds ratio, 1.06; 95% confidence interval, 1.02-1.10) increase in the odds of surgical site infection, and patients with fat thickness of greater than 50 mm had a 4-fold increase in the odds of surgical site infection compared with those with fat thickness of less than 50 mm. Body mass index and fat thickness were moderately correlated (r2=0.44). These results confirm the hypothesis that local subcutaneous fat thickness is a better indicator than body mass index of the risk of surgical site infection in lumbar spine procedures. [Orthopedics. 2016; 39(6):e1124-e1128.].

Delayed presentation of pharyngeal erosion after anterior cervical discectomy and fusion.

Dysphagia after anterior cervical discectomy and fusion (ACDF) is common, with a prevalence ranging between 28% and 57% of cases. However, nearly all cases resolve spontaneously within 2 years, thus identifying patients who require more detailed or invasive work-up is a challenging task for clinicians. A review of literature reveals a paucity of case reports detailing work-up and successful management options. The authors performed a clinical and radiographic review of a case of a 47-year-old female who presented with persistent dysphagia 3 years following anterior cervical spine surgery and was found to have an erosive pharyngeal defect with exposed spinal hardware. The diagnosis was made with direct laryngoscopy and treatment consisted of plate removal and pharyngeal repair, followed by revision fusion with deformity correction. This case and the accompanying pertinent review of the literature highlight the importance of a thorough evaluation of dysphagia, especially in the mid- and late-term postoperative period following ACDF, when most cases of dysphagia should have been resolved. Correctly identifying the underlying etiology of dysphagia may lead to improved revision of ACDF outcomes. Unresolved dysphagia should be a red flag for surgeons as it may be the presentation of erosive esophageal/pharyngeal damage, a rare but serious complication following ACDF.

Patient impressions of reimbursement for orthopedic spine surgeons.

The study aim was to understand patient impressions of reimbursement to orthopedic spine surgeons. Our findings revealed that the majority of patients significantly overestimate the amount surgeons are reimbursed per procedure. Despite this, most feel that surgeons are appropriately compensated. Additionally, many patients are unaware of the global billing period.

Functional outcomes and height restoration for patients with multiple myeloma-related osteolytic vertebral compression fractures treated with kyphoplasty.

STUDY DESIGN: A retrospective review of pathologic vertebral fractures related to multiple myeloma. OBJECTIVE: To report the functional status and height restoration of 32 patients treated with kyphoplasty for multiple myeloma-related vertebral compression fractures. SUMMARY OF BACKGROUND DATA: Multiple myeloma can cause significant bony resorption, and vertebral involvement is extremely common. Compression fractures due to myelomatous vertebral metastases result in significant pain and can lead to kyphosis and sagittal imbalance. Nonoperative treatment can result in deformity and continued pain, and large surgical procedures have significant morbidity. Percutaneous cement augmentation (kyphoplasty and vertebroplasty) is a minimally invasive technique that can improve pain in these patients. Kyphoplasty also has the potential to provide mild deformity correction in addition to fracture stabilization. METHODS: Study participants were patients with biopsy-proven multiple myeloma presenting with compression fracture treated with kyphoplasty. Data were compiled from patient charts and preoperative and postoperative radiographs. Patient self-reported functional status were obtained through the use of the Oswestry Disability Index. The degree of vertebral body collapse and deformity was evaluated using the method of Genant and analyzed using paired Student t test. RESULTS: Thirty-two consecutive patients who underwent kyphoplasty at a total of 76 levels for myelomatous vertebral compression fractures were identified. Sixteen fractures were at the thoracolumbar junction. The mean age was 64.3 years. The average Genant grade for the involved levels improved from 1.9 preoperative to 1.53 postoperative, which was statistically significant (P<0.0001). The postoperative Oswestry Disability Index score was obtained at a mean of 24 months, with a mean of 29.6%. Complications occurred in 12 (37.5%) patients, all consisting of minimal intraoperative cement extravasation without clinical sequelae. No changes in the neurological status were observed. The average hospital stay was 1.34 days postprocedure. CONCLUSION: Kyphoplasty for vertebral compression fractures due to multiple myeloma is a safe and effective procedure that can lead to pain relief and vertebral height restoration.

Sternocleidomastoid muscular flap: treatment of persistent cerebrospinal fluid leak after anterior cervical spine surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: To describe a novel application of rotational sternocleidomastoid (SCM) muscle flap in management of ventral cervical durotomy. SUMMARY OF BACKGROUND DATA: Even for the most experienced surgeons, incidental durotomy is a common occurrence in spine surgery. Primary direct suture repair is indicated to avoid possible complications such as pseudomeningocele or spinocutaneous fistula formation. Significant secondary effects of these complications have been described, including airway compromise, radiculopathy, myelopathy, and infection. When primary repair is not feasible, surgeons have used alternative management techniques based on their clinical judgment. In the setting of persistent symptomatic cerebrospinal fluid leak after repair, reoperation is warranted. METHODS: A retrospective review was conducted of clinical records and radiographic data for 2 patients who underwent reoperation for management of ventral cervical durotomy encountered during anterior cervical spine surgery. SCM muscular flap was used to augment durotomy repair. RESULTS: Both patients did not have any persistent cerebrospinal fluid leak after repair with pedicled SCM muscle flap, and did not require any further surgical procedures related to the cervical spine. CONCLUSIONS: The use of a rotational SCM muscular flap may be useful in cases of ventral cervical durotomy refractory to conventional management.

Cervical arterial injury after blunt trauma in children: characterization and advanced imaging.

BACKGROUND: The incidence of cervical vascular injury (CVI) after blunt cervical trauma in children and adolescents is low. Potential harm from missed injury is high. Screening for CVI has increased with advances in noninvasive angiography, including computed tomographic angiography (CTA) and magnetic resonance angiography (MRA). We attempt to characterize CVI in children and adolescents and evaluate the utility of advanced imaging in CVI screening in this patient population. METHODS: Clinical and radiographic records of consecutive patients aged 4 to 18 years with blunt cervical spine trauma from 1998 to 2008 were reviewed. Patient demographics, injury pattern, neurological findings, and treatment were recorded. RESULTS: Sixty-one patients were identified. Nineteen underwent screening to evaluate for CVI, including 12 males and 7 females, mean age 13.5 years. The most common mechanism of injury was motor vehicle collision (n=11). Seven patients underwent MRA, 7 CTA, 3 had both studies, and 2 had traditional angiography. Seven patients had CVI, with an overall incidence of 11.5%. High-risk criteria (fracture extension to transverse foramina, fracture/dislocations or severe subluxations, or C1-C3 injury) were associated with increased rates of CVI. Neurological injury was found in 12/19 patients screened and 6/7 patients with CVI. Two of 7 patients underwent anticoagulation due to documented CVI. No delayed-onset ischemic neurological events occurred. CONCLUSIONS: After blunt cervical spine trauma, certain fracture patterns increase the risk of CVI. CVI is common, with a minimum incidence of 7/61 or >10% of pediatric patients with blunt cervical spine injury. Over 1/4 of patients studied on the basis of high-risk criteria had injury. Advanced imaging with noninvasive angiography (CTA/MRA) should be strongly considered in pediatric patients with cervical spine trauma. The presence of CVI may prompt a change in management. LEVEL OF EVIDENCE: Level IV-retrospective diagnostic study.

Evaluating the use and utility of noninvasive angiography in diagnosing traumatic blunt cerebrovascular injury.

BACKGROUND: Digital subtraction angiography (DSA) is the gold standard for radiographic diagnosis of blunt cerebrovascular injury (BCVI), but use of computed tomography angiography (CTA) and magnetic resonance angiography (MRA) has increased dramatically in BCVI screening. This study explores the utility, effectiveness, and cost of noninvasive CTA and MRA screening for BCVI. METHODS: Medical records of 2,025 consecutive adults evaluated for acute blunt neck trauma and BCVI were reviewed retrospectively. The incidence of BCVI, level(s) of cervical injury, involvement of foramina transversaria and internal carotid canals, presence of bony dislocation or subluxation, and subsequent treatment received were assessed. Asymptomatic patients were analyzed based on fracture and injury patterns. The cost effectiveness of CTA compared with DSA and the effects of CTA sensitivity and screening yield were determined. RESULTS: Of reviewed patients, 196 received CTA or MRA. Thirty-eight patients (19.4%) were diagnosed with BCVI. Screening yield in patients symptomatic at presentation was 48.8%. Large-vessel internal carotid, vertebral, anterior spinal, and basilar artery occlusion were associated with a positive screen, as were concurrent stroke and spinal cord injury (p < 0.01). Of patients with injuries found with noninvasive imaging, 50.0% of BCVI involved C1-3 fracture, 34.2% involved subluxation, and 65.8% involved foramina transversaria. In both symptomatic and asymptomatic patients, CTA screening was more cost effective than DSA. CONCLUSION: Noninvasive imaging is a safe, accurate, and cost-effective tool for BCVI screening. Symptomatic presentation was the best predictor of BCVI. Significant cost savings were realized using CTA rather than DSA, with similar effectiveness and patient outcomes. LEVEL OF EVIDENCE: Diagnostic study, level III; economic analysis, level IV.

Cervical spine trauma in children and adults: perioperative considerations.

A wide spectrum of cervical spine injuries, including stable and unstable injuries with and without neurologic compromise, account for a large percentage of emergency department visits. Effective treatment of the polytrauma patient with cervical spine injury requires knowledge of cervical spine anatomy and the pathophysiology of spinal cord injury, as well as techniques for cervical spine stabilization, intraoperative positioning, and airway management. The orthopaedic surgeon must oversee patient care and coordinate treatment with emergency department physicians and anesthesia services in both the acute and subacute settings. Children are particularly susceptible to substantial destabilizing cervical injuries and must be treated with a high degree of caution. The surgeon must understand the unique anatomic and biomechanical properties associated with the pediatric cervical spine as well as injury patterns and stabilization techniques specific to this patient population.

Facet violation with the placement of percutaneous pedicle screws.

STUDY DESIGN: Independent review and classification of therapeutic procedures performed on cadavers by surgeons blinded to purpose of study. OBJECTIVE: The objective of this study is to determine the rate of facet violation with the placement of percutaneous pedicle screws. SUMMARY OF BACKGROUND DATA: Improvements in percutaneous instrumentation and fluoroscopic imaging have led to a resurgence of percutaneous pedicle screw insertion in lumbar spine surgery in an attempt to minimize many of the complications associated with open techniques of pedicle screw placement. Rates of pedicle breech and neurologic injury resulting from percutaneous insertion are reportedly similar to those of open techniques. Postoperative pain because of impingement and instability is believed to result from violation of the facet capsule or facet joint. To the authors' knowledge, however, the rate of facet injury associated with the placement of percutaneous pedicle screws is unreported in the literature. METHODS: Percutaneous pedicle screw placement was performed on 4 cadaveric specimens by 4 certified orthopedic surgeons who had clinical experience in the procedure and who were blinded to the study's purpose. The surgeons were instructed to place pedicle screws from L1-S1 using their preferred clinical techniques and a 5.5-mm screw system with which they were all familiar. All surgeons utilized 1 OEC C-arm for fluoroscopic imaging. After insertion, 2 independent spine surgeons each reviewed and classified the placement of all facet screws. RESULTS: A total of 48 screws were inserted and classified. The placement of 28 screws (58%) resulted in violation of facet articulation, with 8 of these screws being intra-articular. Interobserver reliability of the classification system was 100%. CONCLUSION: Percutaneous pedicle screw placement may result in a high rate of facet violation. Facet injury can be reliability classified and therefore, perhaps, easily prevented.

Mortality and morbidity associated with correction of severe cervical hyperextension.

STUDY DESIGN: Three case reports of patients with treatment of severe cervical hyperextension. OBJECTIVE: Cervical hyperextension is a rare spine deformity that is associated with myopathies. Previous reports of surgical correction have reported no major operative complications. This report outlines our experience with 3 patients who experienced significant complications. SUMMARY OF BACKGROUND DATA: The limited literature on the treatment of cervical hyperextension has good to excellent outcomes. METHODS: Three case reports are presented. RESULTS: Three cases with severe cervical hyperextension with intraoperative correction had associated morbidity and mortality. One case had a failed intubation requiring tracheotomy. This was followed by a successful posterior release with halo traction for 2 weeks and then an instrumented posterior cervical fusion. This patient died at home 2 weeks after surgery. The second and third cases had an intraoperative spinal cord injury during a posterior release for cervical hyperextension. CONCLUSION: Patients with severe cervical hyperextension have high neurologic perioperative risk.

Aneurysmal bone cyst of the second cervical vertebrae causing multilevel upper cervical instability.

OBJECTIVE: Aneurysmal bone cyst (ABC) is a rare expansile osteolytic lesion of bone comprising proliferating vascular tissue lining blood-filled cystic cavities. ABCs occur most frequently in patients under age 20 and are uncommon after 30 years of age. Three to 20% of cases occur in the spine, and upper cervical involvement is rare. Lesions may grow rapidly and attain considerable size. When involving the spine, ABCs may result in instability and neurologic compromise, making prompt diagnosis and treatment imperative. We present a report of a 6-year-old child with an ABC of the second cervical vertebrae causing atlantoaxial and C2-C3 instability, treated successfully with curettage, decompression, and anterior and posterior arthrodesis with posterior instrumentation. METHODS: The patient underwent a staged procedure consisting of posterior instrumentation from occiput to C4 and curettage of the lesion followed by anterior cervical discectomy and fusion of C2-C4. The diagnosis, surgical treatment, and outcome of the case are described and relevant literature reviewed. RESULTS: The patient sustained no lasting neurologic deficits and was disease-free at 3 years of follow-up. CONCLUSIONS: ABC is a rare but potentially devastating cause of upper cervical spine instability. Prompt detection and treatment with curettage, decompression, and fusion can produce a satisfactory result and prevent spinal cord injury.

Posterior instrumentation for thoracolumbar fractures.

Thoracolumbar fractures are relatively common injuries. Numerous classification systems have been developed to characterize these fractures and their prognostic and therapeutic implications. Recent emphasis on short, rigid fixation has influenced surgical management. Most compression and stable burst fractures should be treated nonsurgically. Neurologically intact patients with unstable burst fractures that have >25 degrees of kyphosis, >50% loss of vertebral height, or >40% canal compromise often can be treated with short, rigid posterior fusions. Patients with unstable burst fractures and neurologic deficits require direct or indirect decompression. Posterior stabilization can be effective with Chance fractures and flexion-distraction injuries that have marked kyphosis, and in translational or shear injuries. Advances in understanding both biomechanics and types of fixation have influenced the development of reliable systems that can effectively stabilize these fractures and permit early mobilization.