Mind the gap: paramedian approach for coccygectomy.

BACKGROUND CONTEXT: Coccydynia is pain in the coccyx that typically occurs idiopathically or from trauma. Most forms are self-limiting. However, if symptoms persist, nonsurgical treatment options can include offloading, NSAIDs, physical therapy, and steroid injections. If all treatment options fail, a growing body of evidence supports a coccygectomy for symptomatic relief. The standard approach for a coccygectomy involves a midline incision cephalad to the anus along the gluteal cleft. Historically, this method has had high rates of infection. PURPOSE: To improve healing and decrease infection rate, we propose the paramedian approach to a coccygectomy. This approach has the benefit of distancing the surgical site from the anus, diminishing the crevice effect of the incision, and increasing the dermal and subdermal thickness for improved surgical closure. STUDY DESIGN/SETTING: We present a case series study of 41 patients who underwent the paramedian approach coccygectomy using a 4 to 6 cm incision, approximately 0.5 to 1.5 cm lateral to the midline, for coccyx removal. These patients were evaluated postoperatively to determine infection rate and various outcome measures. PATIENT SAMPLE: Forty-one patients suffering from refractory coccydynia had a coccygectomy via the paramedian approach between 2011 and 2022 by the senior author. OUTCOME MEASURES: Outcome measures included self-reported measures (Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) pain scale and satisfaction with procedure), physiologic measures (presence of infection and treatment provided) and functional measures (return to vocation/avocation). METHODS: Data was compiled and transferred to Microsoft Excel and analyzed. Two-tailed T-tests were used to compare the patient improvement in VAS and ODI as appropriate for statistical analysis. RESULTS: The patients' average age was 45.8 years. Patients' average body mass index was 27.9, with 71% of patients overweight or obese. A total of 68% of patients were female. Trauma was the most common precipitating factor (75.6%). Five patients presented with postoperative complications (12.1%), one requiring an incision and drainage, and four others were treated with antibiotics for wound erythema. Postoperative evaluations showed continual improvement, with the most significant improvement reported greater than 1-year postoperatively. The Visual Analogue Scale for pain dropped from 7.5 to 2.3 (p<.001), and the Oswestry Disability Index improved from 30.1 to 9.6 (p<.001). A total of 86.7% of patients reported either a good or excellent result. CONCLUSION: Coccygectomies via the midline approach have a variable infection rate, likely due to proximity of the incision to the anus and due to the crevice effect of the gluteal cleft in terms of aeration. These contributing factors are overcome in the paramedian approach, making it an effective option for treating refractory coccydynia that is nonresponsive to conservative management.

Bilateral Upper-Extremity Acute Exertional Compartment Syndrome: A Case Report.

Introduction: Acute exertional compartment syndrome (AECS) is a condition with the potential for devastating outcomes if not promptly treated. Physicians must maintain a high index of suspicion when evaluating patients presenting with pain, swelling, decreased range of motion, and numbness within a muscle compartment. However, AECS is frequently misdiagnosed due to a multitude of factors, leading to a delay in treatment. In this case report, we would like to shed light on a rare case of bilateral upper-extremity AECS and suggest the treatment paradigm we believe will help prevent negative outcomes. Case Report: A previously healthy 33-year-old male presented with bilateral weakness, tingling, tenderness, swelling, and pain upon movement in the trapezius and deltoid muscles. The symptoms started after he performed "burpees" for 18 h following a 12-h forest-fire firefighting shift. The patient's rapidly developing clinical presentation warranted compartmental pressure checks for suspicion of AECS. Being able to quickly determine the elevated trapezius, deltoid, and supraspinatus compartmental pressures allowed us to perform immediate bilateral fasciotomies with delayed primary closure to relieve compartment pressure. Conclusion: The delay in treatment for patients presenting with AECS is multifactorial and may lead to devastating outcomes if not promptly addressed. The lack of literature regarding bilateral upper-extremity AECS makes the treatment for this condition even more difficult. For our patient, having a proper criterion for performing compartmental pressure checks played a vital role in ensuring an accurate diagnosis and timely medical intervention.

Posterior Reversible Encephalopathy Syndrome with Postoperative Hematoma After C4-C6 Spinal Fusion: A Case Report.

CASE: A 71-year-old woman with a 2-year history of spondylosis and radiculopathy presented with progressively worsening cervical spine pain and neurological dysfunction for 2 years. The patient developed posterior reversible encephalopathy syndrome (PRES) after postoperative hematoma in the retroesophageal and retropharyngeal areas. This occurred status post anterior cervical diskectomy and fusion (ACDF) of C4-C6. One year postoperatively, the patient recovered with full ambulation, neurological improvement, and resolution of all PRES signs and symptoms. CONCLUSION: We present a case of a previously undescribed outcome of PRES as a complication of ACDF likely related to postoperative hypertension and fragile blood vessels.

ACDF and posterior spinal fusion revision for posterior nonunion with deformity, myelopathy, and osteoporosis in an 87-year-old: A case report and literature review.

INTRODUCTION: Cervical spondylotic myelopathy (CSM) is a spinal degenerative disorder that can ultimately lead to compression of the vertebral column with neurological sequelae. Although CSM is the most common spine pathology in the elderly American population, it remains a challenging disorder to treat among older patients. CASE PRESENTATION: We report an 86 year old female patient with CSM with a history of posterior cervical fusion attempt on C3-C6 that progressed to C3-C6 nonunion with loose instrumentation. The patient had severe osteoporosis. With these indications, the patient underwent a combined anterior-posterior decompression and fusion (CAPDF) consisting of anterior cervical discectomy and fusion (ACDF) of the C3-C5, corpectomy of C6 and C7 with off FDA label use of polymethyl methacrylate augmentation (PMMA) fixation of T1 screws anteriorly for C3-T1 plate fixation and second stage instrumented posterior spinal fusion (PSF) of C3-T3. The patient had a successful fusion and reduction of her cervical spine pain with preservation of her neurological status. DISCUSSION: We report this case of multi-stage combined anterior and posterior fusion as a corrective measure for pseudarthrosis of a prior posterior cervical spinal fusion attempt. CONCLUSION: In the event of posterior spinal fusion instrumentation failure in patients with severe osteoporosis, combined multi-stage anterior-posterior fusion is a viable corrective intervention in octogenarians. This case also illustrated the utility of using PMMA for anterior cervical plate and screw stabilization in osteoporotic bone. The authors are not aware of the prior use of PMMA for screw fixation augmentation in the anterior cervical spine.

Traumatic hangman's fracture after cervical disk arthroplasty with device in-tact: A case report and literature review.

BACKGROUND CONTEXT: Cervical disk arthroplasty (CDA) has been demonstrated to be a safe and effective method to treat myelopathy with the added benefit of preserving neck mobility compared to anterior cervical discectomy and fusion (ACDF). Few studies describe complications of trauma after CDA, and to our knowledge this is the only study describing a grossly intact artificial cervical disk (ACD) without extrusion after high energy trauma. Based on our case and a review of literature, we hypothesize that, given adequate osseous integration (OI), CDA may be a safe intervention despite their risk for higher energy trauma. PURPOSE: To present a rare case of high-energy trauma after CDA resulting in a Hangman's fracture and grossly in-tact ACD and to engage a biomechanical discussion of trauma after CDA and ACDF utilizing a literature review. STUDY DESIGN/SETTING: Case-report with literature review and discussion. PATIENT SAMPLE: Electronic medical record data. OUTCOME MEASURES: Computed Tomography, Magnetic Resonance Imaging, and X-Ray physiologic measures. METHODS: We report the case of a 44-year-old woman who received a C5-C6 level CDA with a (Synthes Prodisc-C©, Synthes Spine Company, L.P., West Chester, PA) and was subsequently involved in a high-speed motorcycle accident one-and-a-half years later resulting in a Hangman's fracture. RESULTS: Radiographic evidence after the motorcycle wreck demonstrated a minimally displaced Hangman's fracture at the C2 vertebrae through the pedicles on both sides, partially involving the transverse foramina with approximately 5 mm of displacement. The ACD at C5-C6 was grossly intact and no malalignment was noted. Three years later the patient elected to have an ACDF due to recurrence of facet pain that appeared by way of selective medial branch block injections to originate posteriorly in the facets of C5-6. A literature review revealed reports of trauma induced adjacent disk herniation, metallosis, and implant extrusion after CDA. No accounts of intact hardware, or concomitant Hangman's fracture after CDA were found following high-energy trauma. CONCLUSIONS: Our case reveals the first reported occurrence of a traumatic Hangman's fracture with intact fusion hardware after CDA. We hypothesize that the preserved mobility in the affected spinal level after the CDA exerted a protective effect compared to an ACDF following the high-speed trauma, particularly on the adjacent segments. This case and included literature review, reveal the need for future research efforts to guide decision making in whether ACDF or CDA is superior in younger patients at higher risk for trauma.

Results of repeat meniscal repair.

BACKGROUND: The efficacy of repeat repair of retorn menisci has not been demonstrated. PURPOSE: To document clinical and radiographic results of repeat repair of retorn menisci that had previously undergone primary repair. STUDY DESIGN: Uncontrolled retrospective review. METHODS: Eighteen consecutive repeat meniscal repairs were performed over an 11-year period. RESULTS: Fourteen of 18 patients (13 repeat meniscal repairs and 1 second repeat meniscal repair) had clinically intact menisci and were available for a mean follow-up of 7.33 years (range, 3.25 to 13.75). The average durability of the initial repair was 3.46 years (range, 0.17 to 14.67). Five patients sustained a tear at the site of rerepair; one underwent second repeat repair of the meniscus and the other four patients underwent partial meniscectomy. The mean Lysholm score for the remaining 14 patients was 82.1 (range, 38 to 100), and the mean Tegner score was 5.6 (range, 2 to 8). On the International Knee Documentation Committee rating scale, five knees received an overall rating of normal; six, nearly normal; and three, abnormal. Radiographs revealed grade 0 changes (normal) in five of the involved knee compartments and grade I changes (sclerosis or mild narrowing measuring 1 to 2 mm) in the remaining five. CONCLUSIONS: Repeat repair of retorn menisci had a 72% survival rate with relief of symptoms and return to high levels of function.