Surgical Management of Primary Thoracic Epidural Melanoma.

In this study, we reported one of the first cases where a rare robotic-assisted platform with neuronavigation technology and carbon-fiber-polyetheretherketone (CF/PEEK) screws is employed to surgically treat multilevel thoracic primary spinal epidural melanoma. A 67-year-old male presented with left upper thoracic pain. His magnetic resonance imaging (MRI) of the thoracic spine revealed a dumbbell-shaped left epidural mass at the T2-3 level. Partial resection was performed due to tumor growth into the vertebral bodies and patient discretion for minimal surgery. The patient's neurological conditions improved postoperatively, with reduced reported symptoms of pain and numbness. Postoperative imaging showed evidence of appropriate spinal stabilization. Patient underwent stereotactic body radiation therapy (SBRT), and no adverse events were reported. This case reflects one of the first examples of treating thoracic epidural melanoma with the use of robotic-assisted navigation. Further prospective studies are needed to determine the efficacy of robot-assisted navigation for patients with primary spinal malignant melanoma which may open the possibility of surgery to once presumed non-operative patients.

Pseudoendocrine sarcoma: clinicopathologic, molecular, and epigenetic features of one case.

Pseudoendocrine sarcoma (PES) is a recently described neoplasm typically arising in paravertebral soft tissues. Histologically, PES resembles well-differentiated neuroendocrine tumors but lacks expression of epithelial/neuroendocrine markers, and most show aberrant nuclear ß-catenin positivity. We describe the clinicopathological and molecular features and DNA methylation profile of one PES. A resected paraspinal soft tissue mass in a 52-year-old man showed a neuroendocrine-like neoplasm, negative for keratin, and synaptophysin and showing diffuse nuclear ß-catenin expression. Targeted NGS confirmed a CTNNB1 (p.S37C) mutation. Whole genome methylation analysis showed no match to any methylation class in the central nervous system tumor (versions 11b6 and 12b6) or sarcoma classifier (calibrated scores of ≤0.3), but clustered together with a recently reported PES in which methylation analysis was also performed. He remained disease-free for 18 months after surgery, followed by chemoradiation. As more cases are examined, our findings suggest that PES may have a unique methylation profiling signature.

2-Level Anterior Cervical Arthrodesis With Integrated Spacer and Plate vs Traditional Anterior Spacer and Plate System.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is a common surgery to treat cervical degenerative disc disease. Use of an anterior spacer and plate system (ASPS) results in increased disc height, higher fusion rate, lower subsidence rate, and lower complication rate than a spacer alone.1,2 However, anterior cervical plating is associated with complications, such as dysphagia, plate-screw dislodgment, soft tissue injury, neural injury, and esophageal perforation.3-9 To potentially reduce these drawbacks, integrated spacer and plate (ISP) systems have gained popularity. METHODS: From November 2009 to October 2013, a total of 84 consecutive patients who underwent 2-level ACDF using ISP or ASPS were reviewed for clinical and radiographic outcomes. Patient-reported visual analog scale (VAS) and Neck Disability Index (NDI) scores, fusion rates, and hardware failure were determined at 1, 3, 6, 12, and 24 months after surgery. RESULTS: Forty-three patients received ISP and 41 patients received ASPS. There were no significant differences in patient demographics between the 2 groups. Perioperative characteristics were similar, except for operative time. Postoperatively, no significant differences in VAS or NDI scores or fusion status were found. At the proximal surgical level only, there was a trend toward an earlier observed radiographic fusion rate in ASPS vs ISP, but this finding was not statistically significant (P = 0.092). One case of long-term dysphagia was reported in each group. Neither group had implant failures up to 2 years. CONCLUSIONS: The ISP system for 2-level ACDF compared to traditional ASPS has comparable clinical and radiographic outcomes up to 2 years postoperatively. There may be a trend toward an earlier observed radiographic fusion in the ASPS group, but there was no difference in long-term dysphagia rate. CLINICAL RELAVANCE: Integrated spacer and traditional anterior spacer for 2-level ACDF has similar clinical and radiographical outcome.

Assessment of Surgical Procedural Time, Pedicle Screw Accuracy, and Clinician Radiation Exposure of a Novel Robotic Navigation System Compared With Conventional Open and Percutaneous Freehand Techniques: A Cadaveric Investigation.

STUDY DESIGN: Cadaveric study. OBJECTIVE: To evaluate accuracy, radiation exposure, and surgical time of a new robotic-assisted navigation (RAN) platform compared with freehand techniques in conventional open and percutaneous procedures. METHODS: Ten board-certified surgeons inserted 16 pedicle screws at T10-L5 (n = 40 per technique) in 10 human cadaveric torsos. Pedicle screws were inserted with (1) conventional MIS technique (L2-L5, patient left pedicles), (2) MIS RAN (L2-L5, patient right pedicles), (3) conventional open technique (T10-L1, patient left pedicles), and (4) open RAN (T10-L1, patient right pedicles). Output included (1) operative time, (2) number of fluoroscopic images, and (3) screw accuracy. RESULTS: In the MIS group, compared with the freehand technique, RAN allowed for use of larger screws (diameter: 6.6 ± 0.6 mm vs 6.3 ± 0.5 mm; length: 50.3 ± 4.1 mm vs 46.9 ± 3.5 mm), decreased the number of breaches >2 mm (0 vs 7), fewer fluoroscopic images (0 ± 0 vs 108.3 ± 30.9), and surgical procedure time per screw (3.6 ± 0.4 minutes vs 7.6 ± 2.0 minutes) (all P < .05). Similarly, in the open group, RAN allowed for use of longer screws (46.1 ± 4.1 mm vs 44.0 ± 3.8 mm), decreased the number of breaches >2 mm (0 vs 13), fewer fluoroscopic images (0 ± 0 vs 24.1 ± 25.8) (all P < .05), but increased total surgical procedure time (41.4 ± 8.8 minutes vs 24.7 ± 7.0 minutes, P = .000) while maintaining screw insertion time (3.31.4 minutes vs 3.1 ± 1.0 minutes, P = .650). CONCLUSION: RAN significantly improved accuracy and decreased radiation exposure in comparison to freehand techniques in both conventional open and percutaneous surgical procedures in cadavers. RAN significantly increased setup time compared with both conventional procedures.

Modified expansive laminoplasty and fusion compared with anterior cervical surgeries in treating four-level cervical spondylotic myelopathy.

OBJECTIVE: To compare modified expansive laminoplasty and fusion (MELF) with anterior cervical corpectomy and fusion (ACCF), and anterior cervical discectomy and fusion (ACDF), in treating four-level cervical spondylotic myelopathy (CSM). METHODS: This retrospective study included patients with four-level CSM who had undergone surgery at the Affiliated Hospital of Qingdao University between January 2013 and May 2015. D-values, Cobb's angle, Japanese Orthopaedic Association (JOA) score and quality of life (SF-36 scores) were compared between patients treated with ACCF/ACDF versus MELF. RESULTS: Twenty-six patients who underwent ACCF/ACDF and 26 who underwent MELF were included, and all showed bone fusion following treatment. The most common complications were dysphasia (12/26) in the ACCF/ACDF group and axial neck pain (7/26) in the MELF group. C5 nerve root palsy was not observed in either group. D value and Cobb's angle changes showed that ACDF/ACCF was more effective in curve correction than MELF. Postoperative improvements in JOA and SF-36 scores were noted in both groups, with no statistically significant between-group differences. CONCLUSION: Anterior and posterior approaches may produce similar clinical outcomes in the surgical management of four-level CSM. MELF may avoid known complications of the posterior approach.

Surgical management of symptomatic Tarlov cysts: cyst fenestration and nerve root imbrication-a single institutional experience.

BACKGROUND: Tarlov cyst disease is a collection of cerebrospinal fluid between the endoneurium and perineurium of spinal, usually sacral, nerve roots. These cysts can become symptomatic in 20% of patients, causing lower back pain, radiculopathy, bladder and bowel dysfunction necessitating medical or surgical intervention. Different surgical and non-surgical modalities have been described for the treatment of symptomatic Tarlov cysts. However, there has been no published study that examined types of surgical techniques side by side. Our study presents a preliminary experience in the surgical management of symptomatic Tarlov cysts using two surgical techniques: cyst fenestration and nerve root imbrication. METHODS: Retrospective chart review and analysis was done for all patients who underwent surgical intervention for symptomatic Tarlov cyst(s) in the period 2007-2013. Operative reports, preoperative and postoperative clinic visit reports were reviewed. The surgical techniques of cyst fenestration and nerve root imbrication were each described in terms of intraoperative parameters, hospital course and outcome. Modified MacNab criteria were used for evaluation of the final clinical outcome. RESULTS: Thirty-six surgical patients were identified. Three had repeat surgery (total of 39 operations). The median age was 51 years (range, 26-84 years). Eighty-six percent were females. The presenting symptoms were low back pain (94%), sensory radiculopathy (69%), bladder and bowel dysfunction (61%), sexual dysfunction (17%) and motor dysfunction (8%). Cyst fenestration was performed in 12 patients (31%) and nerve root imbrication was done in 27 (69%). All patients in the fenestration group but only 67% in the imbrication group had fibrin glue injection into the cyst or around the reconstructed nerve root. The overall surgery-related complication rate was 28%. The complication rate was 5/12 (42%) in the fenestration group and 6/27 (22%) in the imbrication group. At the time of the last clinic visit, improved clinical outcome was noted in 9/11 (82%) and 20/25 (80%) in the fenestration and the imbrication group, respectively. CONCLUSIONS: Cyst fenestration and nerve root imbrication are both surgical techniques to treat symptomatic Tarlov cyst(s), and both can result in clinical improvement.

Adult Thoracic Intradural Exophytic Mature Teratoma: Case Report and Literature Review.

Mature thoracic intraspinal teratomas are rare tumors in adults. In this case study, we present a case of intradural, extramedullary teratoma, which was surgically resected. A 50 year old man presented with progressive bilateral leg pain, severe myelopathy and weakness. Magnetic Resonance Imaging (MRI) revealed a cystic mass lesion in the T11-12 region region. Microsurgical resection of the tumor using CO2 laser with neuromonitoring was performed. Postoperatively, the patient had a remarkable clinical improvement. Mature spinal teratomas are rare, slow growing spinal tumors. Surgical resection provides excellent recovery, and recurrence rates are low.

Unique Complications of Percutaneous Endoscopic Lumbar Discectomy and Percutaneous Endoscopic Interlaminar Discectomy.

BACKGROUND: Percutaneous endoscopic discectomy (PED) includes 2 main procedures: percutaneous endoscopic lumbar discectomy (PELD) and percutaneous endoscopic interlaminar discectomy (PEID), both of which are minimally invasive surgical procedures that effectively deal with lumbar degenerative disorders. Because of the challenging learning curve for the surgeon and the individual characteristics of each patient, preventing and avoiding complications is difficult. The most common complications, such as nucleus pulposus omission, nerve root injury, dural tear, visceral injury, nerve root induced hyperalgesia or burning-like nerve root pain, postoperative dysesthesia, posterior neck pain, and surgical site infection, are difficult to avoid; however, more focus on these issues perioperatively may be in order. Additionally, unique and unexpected complications can also occur, such as retroperitoneal hematoma (RPH), intraoperative seizures, and thrombophlebitis, among others. OBJECTIVE: We aim to delineate unique complications during PED and accumulate strategies to prevent significant morbidity and improve surgical techniques. STUDY DESIGN: A retrospective cohort study of patients undergoing PEID or PELD from October 2014 to January 2016. SETTING: Affiliated hospitals of Qingdao University. METHODS: Patients with lumbar disc herniation (LDH) who underwent PEID and PELD were retrospectively analyzed. Complications were recorded and analyzed pre and postoperatively. We assessed clinical outcomes using the visual analog scale (VAS) and Oswestry Disability Index (ODI) and classified the results into "excellent," "good," "fair," or "poor" based on the modified MacNab criteria. All of the patients were followed for more than one year to evaluate their recovery from complications. RESULTS: From October 2014 to January 2016, 426 patients with LDH underwent PEID (106 cases) or PELD (320 cases). Common complications and occurrence rates were as follows: the incomplete removal of herniated discs was 1.4% (6/426), recurrence 2.8% (12/426), nerve root injury 1.2% (5/426), dural tear 0.9% (4/426), and nerve root induced hyperalgesia or burning-like nerve root pain 2.3% (10/426); no posterior neck pain or surgical site infection occurred. Unique complications included: passage of the working channel through the spinal canal into the disc space (one case), super-elastic nerve hook caught by exiting nerve root (one case), epidural hematoma (one case), radicular artery injury and massive bleeding (one case) which was revised by micro-endoscopic discectomy, and intraoperative seizure (one case). No serious consequences occurred after active medical intervention, and most patients had good recovery by 3 months postoperatively with physical therapy. LIMITATIONS: The main limitations of this study are the retrospective study design, limited case number, and short follow-up period. CONCLUSIONS: PEDs are effective and minimally invasive methods for the surgical treatment of LDH, causing fewer complications due to the very minimal operational trauma for the muscle-ligament complex and stability of the spine. Nevertheless, because of the difficult learning curve for surgeons, lack of experience with the requisite surgical techniques, and enhanced clinical responsibility, a variety of problems may occur. Especially concerning are the unique complications mentioned here, which potentially lead to severe injury for the patient and require diligent preventive measures. KEY WORDS: Unique complications, epidural, hematoma, interlaminar, transforaminal, PEID, PELD.

The Management of Cerebrospinal Fluid Leak After Anterior Cervical Decompression Surgery.

Cerebrospinal fluid (CSF) leak is a rare but potentially troublesome and occasionally catastrophic complication after anterior cervical decompression surgery. There is limited literature describing this complication, and the management of CSF leak varies. The aim of this study was to retrospectively review the treatment of cases with CSF leak and develop a management algorithm. A series of 14 patients with CSF leak from January 2011 to May 2016 were included in this study. Their characteristics, management of CSF leak, and outcomes were documented. There were 5 male and 9 female patients. Mean age at surgery was 57.1±9.9 years (range, 37-76 years). All instances of CSF leak, except 1 noted postoperatively, were indirectly repaired intraoperatively. A closed straight wound drain was placed for all patients. A lumbar subarachnoid drain was placed immediately after surgery in 4 patients and postoperatively in 7 patients. In 1 patient, lumbar drain placement was unsuccessful. In 2 additional patients, the surgeon decided not to place a lumbar drain. One patient developed meningitis and recovered after antibiotic therapy with meropenem and vancomycin. Another patient had a deep wound infection and required a revision surgery. Wound drains and lumbar drains should be immediately considered when CSF leak is identified. Antibiotics also should be considered to prevent intradural infection. [Orthopedics. 2018; 41(2):e283-e288.].

Cervical spine fractures in osteopetrosis: a case report and review of the literature.

While management of appendicular fractures has been well described in the setting of osteopetrosis, there is limited information on managing fractures of the axial spine. Here we present an osteopetrotic patient with multiple traumatic multiple, comminuted, unstable cervical spinal fractures managed with non-operative stabilization, and provide a review of the pathophysiology, genetic characteristics, and special considerations that must be explored when determining operative versus non-operative management of spinal injury in osteopetrosis. A PubMed query was performed for English articles in the literature published up to June 2016, and used the following search terms alone and in combination: "osteopetrosis", "spine", "fractures", "osteoclasts", and "operative management". Within four months after initial injury, treatment with halo vest allowed for adequate healing. The patient was asymptomatic with cervical spine dynamic radiographs confirming stability at four months. On four-year follow up examination, the patient remained without neck pain, and CT scan demonstrated partially sclerotic fracture lines with appropriate anatomical alignment. In conclusion, external halo stabilization may be an effective option for treatment of multiple unstable acute traumatic cervical spine fractures in patients with osteopetrosis. Given the challenge of surgical stabilization in osteopetrosis, further research is necessary to elucidate the optimal form of treatment in this select patient population.

Temporary stabilization of unstable spine fractures.

PURPOSE OF REVIEW: We will review the recent literature concerning the necessity of supplemental fusion to spinal instrumentation and discuss if temporal spinal fixation is a viable option for the treatment of unstable spine fractures. Advancements in minimally invasive techniques offer an alternative approach to traditional open stabilization for unstable spine fractures. The use of minimally invasive surgery offers many advantages concerning operative morbidly; fusion is not utilized and instrumentation can be removed in a delayed fashion. RECENT FINDINGS: There are limited differences in amount of correction loss over time, and multiple studies report equivocal to superior results in patient's functional outcomes when comparing temporary internal stabilization to long segment instrumentation with fusion. Removal of implants can restore segmental motion. Review of the literature demonstrates that temporary internal stabilization for unstable fractures is a viable option. Close clinical and radiographic follow-up is recommended to avoid delayed spinal deformity.

A Clinical Comparison of Anterior Cervical Plates Versus Stand-Alone Intervertebral Fusion Devices for Single-Level Anterior Cervical Discectomy and Fusion Procedures.

OBJECTIVE: To compare radiologic and clinical outcomes, including rates of dysphagia and dysphonia, using a no-profile stand-alone intervertebral spacer with integrated screw fixation versus an anterior cervical plate and spacer construct for single-level anterior cervical discectomy and fusion (ACDF) procedures. METHODS: This multicenter, randomized, prospective study included 54 patients with degenerative disc disease requiring ACDF at a single level at C3-C7. Twenty-six patients underwent single-level ACDF with stand-alone spacers, and 28 with plate fixation and spacers. Analyses were based on comparison of perioperative outcomes, radiologic and clinical metrics, and incidence of dysphagia and/or dysphonia. RESULTS: Mean patient age was 48.8 ± 10.1years (53.7% female). No significant differences were observed between groups in operative time (101.8 ± 34.4 minutes, 114.4 ± 31.5 minutes), estimated blood loss (44.8 ± 76.5 mL, 82.5 ± 195.1 mL), or length of hospital stay (1.2 ± 0.6 days, 1.3 ± 0.6 days). Mean visual analog scale pain scores and Neck Disability Index scores improved significantly from preoperative to last follow-up (10.8 ± 2.6 months) in both groups (P < 0.05). Mean Voice Handicap Index and Eating Assessment Tool scores improved significantly from discharge to last follow-up in both groups (P < 0.05). From discharge to 6 months, the stand-alone spacers group consistently demonstrated greater improvement in Voice Handicap Index. Preoperative intervertebral disc and neuroforaminal heights increased significantly across treatment groups (P < 0.01), and no cases required surgical revision at index or adjacent levels. CONCLUSIONS: Anterior cervical discectomy and fusion with stand-alone spacers resulted in similar clinical and radiologic outcomes as compared with plate and spacers and may help minimize postoperative dysphonia.

Relief of Cervicogenic Headaches after Single-Level and Multilevel Anterior Cervical Diskectomy: A 5-Year Post Hoc Analysis.

STUDY DESIGN: Prospective study. OBJECTIVE: Because single-level disk arthroplasty or arthrodesis in the lower subaxial spine improves headaches after surgery, we studied whether this effect may be better appreciated after two-level arthroplasty. METHODS: We performed an independent post hoc analysis of two concurrent prospective randomized investigational device exemption trials for cervical spondylosis, one for single-level treatment and the other for two adjacent-level treatments. RESULTS: For the one-level study, baseline mean headache scores significantly improved at 60 months for both the cervical disk arthroplasty (CDA) and anterior cervical diskectomy and fusion (ACDF) groups (p < 0.0001). However, mean improvement in headache scores was not statistically different between the investigational and control groups from 6 months through 60 months. For the two-level study, baseline mean headache scores significantly improved at 60 months for both the CDA and ACDF groups (p < 0.0001). The CDA group demonstrated greater improvement from baseline at all points; this difference was statistically significant at 6, 12, 24, 36, and 48 months but not at 18 and 60 months. CONCLUSION: Both CDA and ACDF at either one or two levels are associated with sustained headache relief from baseline. Patients undergoing two-level arthroplasty had significantly greater improvement in headache at all points except for at 18 and 60 months. This difference in improvement was not observed in patients undergoing single-level arthroplasty. The mechanism of greater headache relief after two-level arthroplasty remains unclear.

Stereotactic guidance for navigated percutaneous sacroiliac joint fusion.

Arthrodesis of the sacroiliac joint (SIJ) for surgical treatment of SIJ dysfunction has regained interest among spine specialists. Current techniques described in the literature most often utilize intraoperative fluoroscopy to aid in implant placement; however, image guidance for SIJ fusion may allow for minimally invasive percutaneous instrumentation with more precise implant placement. In the following cases, we performed percutaneous stereotactic navigated sacroiliac instrumentation using O-arm® multidimensional surgical imaging with StealthStation® navigation (Medtronic, Inc. Minneapolis, MN). Patients were positioned prone and an image-guidance reference frame was placed contralateral to the surgical site. O-arm® integrated with StealthStation® allowed immediate auto-registration. The skin incision was planned with an image-guidance probe. An image-guided awl, drill and tap were utilized to choose a starting point and trajectory. Threaded titanium cage(s) packed with autograft and/or allograft were then placed. O-arm® image-guidance allowed for implant placement in the SIJ with a small skin incision. However, we could not track the cage depth position with our current system, and in one patient, the SIJ cage had to be revised secondary to the anterior breach of sacrum.

Preliminary fsLIBS study on bone tumors.

The aim of this study is to evaluate the capability of femtosecond Laser Induced Breakdown Spectroscopy (fsLIBS) to discriminate between normal and cancerous bone, with implications to femtosecond laser surgery procedures. The main advantage of using femtosecond lasers for surgery is that the same laser that is being used to ablate can also be used for a feedback system to prevent ablation of certain tissues. For bone tumor removal, this technique has the potential to reduce the number of repeat surgeries that currently must be performed due to incomplete removal of the tumor mass. In this paper, we performed fsLIBS on primary bone tumor, secondary tumor in bone, and normal bone. These tissues were excised from consenting patients and processed through the UC Davis Cancer Center Biorepository. For comparison, each tumor sample had a matched normal bone sample. fsLIBS was performed to characterize the spectral signatures of each tissue type. A minimum of 20 spectra were acquired for each sample. We did not detect significant differences between the fsLIBS spectra of secondary bone tumors and their matched normal bone samples, likely due to the heterogeneous nature of secondary bone tumors, with normal and cancerous tissue intermingling. However, we did observe an increase in the fsLIBS magnesium peak intensity relative to the calcium peak intensity for the primary bone tumor samples compared to the normal bone samples. These results show the potential of using femtosecond lasers for both ablation and a real-time feedback control system for treatment of primary bone tumors.

Dysphagia Secondary to Anterior Osteophytes of the Cervical Spine.

Study Design Retrospective case series. Objective Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier disease involves hyperostosis of the spinal column. Hyperostosis involving the anterior margin of the cervical vertebrae can cause dysphonia, dyspnea, and/or dysphagia. However, the natural history pertaining to the risk factors remain unknown. We present the surgical management of two cases of dysphagia secondary to cervical hyperostosis and discuss the etiology and management of DISH based on the literature review. Methods This is a retrospective review of two patients with DISH and anterior cervical osteophytes. We reviewed the preoperative and postoperative images and clinical history. Results Two patients underwent anterior cervical osteophytectomies due to severe dysphagia. At more than a year follow-up, both patients noted improvement in swallowing as well as their associated pain. Conclusion The surgical removal of cervical osteophytes can be highly successful in treating dysphagia if refractory to prolonged conservative therapy.

Is lateral stabilization enough in thoracolumbar burst fracture reconstruction? A biomechanical investigation.

BACKGROUND CONTEXT: Traditional reconstruction for burst fractures involves columnar support with posterior fixation at one or two levels cephalad/caudad; however, some surgeons choose to only stabilize the vertebral column. PURPOSE: The aim was to distinguish biomechanical differences in stability between a burst fracture stabilized through a lateral approach using corpectomy spacers of different end plate sizes with and without integrated screws and with and without posterior fixation. STUDY DESIGN/SETTING: This was an in vitro biomechanical study assessing thoracolumbar burst fracture stabilization. METHODS: Six human spines (T11-L3) were tested on a six-degrees-of-freedom simulator enabling unconstrained range of motion (ROM) at ±6 N·m in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) after a simulated burst fracture at L1. Expandable corpectomy spacers with/without integrated screws (Fi/F; FORTIFY Integrated/FORTIFY; Globus Medical, Inc., Audubon, PA, USA) were tested with different end plate sizes (21×23 mm, 22×40-50 mm). Posterior instrumentation (PI) via bilateral pedicle screws and rods was used one level above and one level below the burst fracture. Lateral plate (LP) fixation was tested. Devices were tested in the following order: intact; Fi21×23; Fi21×23+PI; F21×23+PI+LP; F21×23+LP; F22×40-50+LP; F22×40-50+PI+LP; Fi22×40-50+PI; Fi22×40-50. RESULTS: In FE and AR, constructs without PI showed no significant difference (p<.05) in stability compared with intact. In LB, F22×40-50+LP showed a significant increase in stability relative to intact, but no other construct without PI reached significance. In FE and LB, circumferential constructs were significantly more stable than intact. In AR, no construct showed significant differences in motion when compared with the intact condition. CONCLUSIONS: Constructs without posterior fixation were the least stable of all tested constructs. Circumferential fixation provided greater stability in FE and LB than lateral fixation and intact. Axial rotation showed no significant differences in any construct compared with the intact state.

Cervical spinous process reconstruction.

Posterior neck deformity with an unsightly crater-like defect may result after cervicothoracic laminectomies. The authors present a new technique, spinous process reconstruction, to address this problem. A 64-year-old man presented with progressive quadriparesis secondary to cervical spondylotic myelopathy. Previously he had undergone multiple neck surgeries including cervicothoracic decompressive laminectomy. Postoperatively, he developed severe craniocervical spinal deformity and a large painful concave surgical defect in the neck. The authors performed craniocervical decompression and craniocervicothoracic instrumented stabilization. At the same time, cervicothoracic spinous process reconstruction was performed using titanium mesh to address the defect. Cervicothoracic decompressive laminectomy results in varying degrees of neck defect with resulting unsightly and an often painful surgical wound defect despite an appropriate multilayer closure. The presented spinous process reconstruction is a simple technique to address this problem with good clinical outcome.

Effect of pedal pump and thoracic pump techniques on intracranial pressure in patients with traumatic brain injuries.

CONTEXT: Although osteopathic manipulative treatment (OMT) is used to manage myriad conditions, there has been some hesitation regarding the safety of applying OMT to patients with intracranial injuries or elevated intracranial pressure (ICP). OBJECTIVE: To assess the safety of two OMT techniques--pedal pump and thoracic pump--on ICP and cerebral perfusion pressure (CPP) in patients with traumatic brain injuries (Glasgow Coma Scale score < or =8). METHODS: We prospectively enrolled consecutive patients admitted to the intensive care unit (ICU) for traumatic brain injury. Patients between the ages of 18 and 75 years and with abnormal CT scans were included in the present study. Patients with baseline ICP values of 20 mm Hg or lower were assigned to group 1, and those with ICP levels greater than 20 mm Hg, group 2. Patients underwent continuous ICP and CPP monitoring, with ICP measured using a ventricular catheter and fiber optic device. Values of ICP and CPP were recorded at baseline, during application of the OMT techniques, and 5 minutes after the two OMT techniques were completed. Patients received up to three treatment cycles. Ventricular drains remained open (stopcock open) during OMT, allowing continued cerebral spinal fluid drainage, except for brief periodic closures (stopcock closed) every minute to register accurate ICP values. Statistical analysis was performed using a dependent t test with repeated measures. RESULTS: Twenty-four comatose patients, aged 18 to 69 years, received a total of 50 sessions of pedal pump and thoracic pump techniques. In group 1 patients, a slight decrease in ICP values (mean, -0.586 mm Hg) and an increase in CPP values (mean, 1.1613 mm Hg) was noted post-OMT. Patients in group 2 also had decreased mean ICP values (-1.20 mm Hg) and increased mean CPP values (2.2105 mm Hg). Changes were not statistically significant in either group. CONCLUSION: According to the present limited study, pedal pump and thoracic pump techniques may be used safely in patients with severe brain injuries.