bluuebunny/crossref_metadata_2025 huggingface dataset:
Type II odontoid fracture from frontal impact
Authors: Yoganandan Narayan , Baisden Jamie L. , Maiman Dennis J. , Pintar Frank A.
Published: May 2009

✓ The authors report a case of Type II odontoid fracture from a frontal impact sustained in the crash of a late-model motor vehicle. They discuss the biomechanical mechanisms of injury after considering patient demographic data, type and use of restraint systems including seatbelt and airbags, crash characteristics, and laboratory-based experimental studies. Multiple factors contributed to the Type II odontoid fracture: the patient's tall stature and intoxicated state; lack of manual three-point seat belt use; obliqueness of the frontal impact; and the most likely preflexed position of the head—neck complex at the time of impact, which led to contact of the parietal region with the A-pillar roof-rail area of the vehicle and resulted in the transfer of the dynamic compressive force associated with lateral bending. Odontoid fractures still occur in individuals involved in late-model motor vehicle frontal crashes, and because this injury occurs secondary to head impact, airbags may not play a major role in mitigating this type of trauma to an unrestrained occupant. It may be more important to use seat belts than to depend on the airbag alone for protection from injury.
Postangiographic thrombosis of a spinal arteriovenous malformation
Authors: Gupta Vipul , Rizvi Tanvir , Garg Ajay , Gaikwad Shailesh B. , Mishra N. K.
Published: May 2009

✓ The authors report the case of a 30-year-old man who presented with progressive neurological deficits due to a spinal arteriovenous malformation (AVM). There was sudden increase in his neurological deficits after diagnostic angiography was performed. Repeated magnetic resonance imaging and angiography revealed complete thrombosis of the malformation. Stenosis in the draining vein was the most probable cause of this postangiographic occlusion of the AVM. Contrast injection during angiography may have precipitated the thrombosis.
Asymptomatic spherocytosis presenting with spinal cord compression
Authors: Jalbert Florian , Chaynes Patrick , Lagarrigue Jacques
Published: May 2009

✓ Extramedullary hematopoiesis (EMH) is a compensatory mechanism occurring in patients with chronic anemia, which occurs most frequently with thalassemia. The authors report the case of a 57-year-old man, with no history of clinical or hematological disease, presenting with spinal cord compression. Magnetic resonance (MR) imaging demonstrated a homogeneous posterior epidural mass extending from T-3 to T-6. Following decompressive surgery, the patient's symptoms improved. Histological analysis showed features consistent with a diagnosis of EMH. Subsequent workup was remarkable for an asymptomatic spherocytosis without anemia. There was no family history of anemia. An EMH-related presentation of mild spherocytosis has been described in the literature, but its epidural location led to spinal cord compression. The MR imaging features were suggestive of EMH, but in the presence of spinal cord compression and in the absence of a history of chronic anemia, the authors did not believe that nonsurgical management would have been reasonable.
Ligamentum flavum hematoma in the rigid thoracic spinal segments
Authors: Miyakoshi Naohisa , Shimada Yoichi , Okada Kyoji , Hongo Michio , Kasukawa Yuji , Itoi Eiji
Published: May 2009

✓ Ligamentum flavum hematoma, a rare cause of spinal nerve root and canal compression, typically occurs in the mobile lumbar spine segments. A thoracic ligamentum flavum hematoma is extremely rare—only one such case of a thoracolumbar (T11–12) lesion has been reported. The thoracolumbar region with its floating ribs, however, is structurally and biomechanically similar to the lumbar spine and its mobility is greater than the higher thoracic levels. To the best of their knowledge, the authors report the first case of a ligamentum flavum hematoma in the region of the rigid thoracic spinal segments with the contiguous rib cage. A symptomatic T9–10 ligamentum flavum hematoma is described in the case of a 66-year-old woman with compensatory thoracic lordosis secondary to the lumbar degenerative kyphosis. The hematoma was removed and the diagnosis was histologically confirmed. The authors speculate that thoracic lordosis might have contributed to the development of the hematoma because the ligamentum flavum and the facet joint were subjected to greater axial stress than in individuals with normal spinal alignment.
Use of percutaneous endoscopy to place syringopleural or cystoperitoneal cerebrospinal fluid shunts
Authors: Guest James D. , Silbert Lisa , Casas Carlos E.
Published: May 2009

✓ The authors describe a technique for percutaneous endoscopic shunt placement to treat clinically symptomatic spinal cysts. Seven patients underwent the procedure—five with syringomyelia, one with a symptomatic perineurial cyst, and one with a large arachnoid cyst. In all patients the shunt was successfully placed, and clinical improvement occurred in six. In four patients the entire procedure was performed endoscopically, whereas in three conversion to an open surgical exposure was required for safe access of a syrinx cavity. Overall, however, the pleural or peritoneal catheter was successfully placed endoscopically in all seven patients. There were two cases of postoperative positional headaches of which one required valve revision. In one case the catheter migrated and required repositioning. Percutaneous endoscopic shunt placement appears feasible in appropriately selected patients.
Usefulness of neurological examination for diagnosis of the affected level in patients with cervical compressive myelopathy: prospective comparative study with radiological evaluation
Authors: Matsumoto Morio , Ishikawa Masayuki , Ishii Ken , Nishizawa Takashi , Maruiwa Hirofumi , Nakamura Masaya , Chiba Kazuhiro , Toyama Yoshiaki
Published: May 2009

Object. Although neurological examination is the key step to reaching a correct diagnosis of cervical compressive myelopathy (CCM), the accuracy of diagnosis of the affected spinal level for CCM has not yet been tested.

Methods. The authors conducted a prospective study to elucidate how accurately the affected intervertebral level can be determined and decompressed based on neurological examination. Fifty patients who underwent successful decompressive surgery for cervical myelopathy caused by single-level disc herniation or spondylosis were included in this study (38 men and 12 women, mean age 60 years). Three board-certified spine surgeons participated in establishing the neurological diagnoses. One of the three surgeons made a diagnosis of CCM, and the other two conducted the neurological examination including deep tendon reflex, pinprick response, muscle weakness, and numbness in the hand only, knowing that the patient had CCM, and established the neurological-level diagnosis. A single intervertebral level responsible for patient's symptoms was determined concordantly based on magnetic resonance imaging and myelography findings by two spine surgeons, and this served as the standard. Agreement between neurological and neuroimaging/radiological level diagnoses was determined. The rate of agreement between neurological and neuroimaging diagnosis was 66%. Among the neurological tests, patient-perceived location of numbness in the hands was the most useful for establishing the affected level. For the other three tests the agreement rate was lower than 50% and thus each individual test may not be reliable for diagnosing the affected level.

Conclusions. The results of this study suggested that neurological examination in patients with CCM is moderately accurate and reliable for determining the neurological level of disease.
Spinal tumors in neurofibromatosis Type 2. Is emerging knowledge of genotype predictive of natural history?
Authors: Dow Graham , Biggs Nigel , Evans Gareth , Gillespie Jimmie , Ramsden Richard , King Andrew
Published: May 2009

Object. The authors conducted a study to examine the incidence, classification, and progression of spinal tumors in patients with neurofibromatosis Type 2 (NF2) treated at a single center, and to examine relationships with the known mutational subtypes of NF2.

Methods. They performed a retrospective review of clinical records, neuroimaging studies, and genetic data obtained in 61 patients with NF2.

Forty-one (67%) of 61 patients harbored one or more spinal tumors. Thirty-four patients had undergone serial spinal magnetic resonance imaging during a mean follow-up period of 52 months (range 10–103 months; median 53 months). In 16 patients there were multiple extramedullary tumors smaller than 5 mm, which did not progress. Fourteen patients harbored at least one extramedullary tumor that was greater than 5 mm; of these, radiological progression was demonstrated or spinal tumor excision was performed during the follow-up period in eight cases (57%). Eleven patients harbored intramedullary cord tumors in addition to small and large extramedullary tumors, three (27%) of which exhibited radiological progression. In cases in which genotypes were known, protein-truncating mutations were significantly more likely to be associated with the presence of spinal tumors than in other types (p = 0.03, Fisher exact test). No associations between clinical behavior of spinal tumors and genotype, however, could be demonstrated.

Conclusions. Spinal tumors in cases involving NF2 are heterogeneous in type, distribution, and behavior but larger-size tumors are more likely to progress significantly. Intramedullary tumors usually accompany multiple extramedullary tumors. In the authors' experience subtyping of the NF2 mutation has not yet influenced management. Protein-truncating mutations are associated with an increased prevalence of spinal tumors.
Embolization of spinal dural arteriovenous fistulas: importance of occlusion of the draining vein
Authors: Jellema Korné , Sluzewski Menno , van Rooij Willem Jan , Tijssen Cees C. , Beute Guus N.
Published: May 2009

Object. The aim of this study was to assess whether glue-induced occlusion of the draining vein predicts permanent closure of the fistula following embolization of spinal dural arteriovenous fistulas (SDAVFs).

Methods. Between 1994 and 2004, 36 consecutive patients with an SDAVF were treated at the authors' institution. Twelve patients underwent surgery and 24 glue-based embolization. In 12 of 24 embolization procedures the draining vein was occluded and no recurrence or persistent fistula was seen during the follow-up period. In the other 12 patients the glue had not reached the draining vein and in eight of these the fistula recurred, necessitating additional treatment.

Conclusions. In embolization of SDAVFs penetration of the glue into the draining vein predicts permanent closure of the fistula. When penetration of the glue into the draining vein can be expected, embolization is the preferred treatment option. In other cases surgery should be the treatment of choice.
An anatomical study comparing standard fluoroscopy and virtual fluoroscopy for the placement of C1–2 transarticular screws
Authors: Tannoury Tony , Crowl Adam C. , Battaglia Todd C. , Chan Donald P. K. , Anderson D. Greg
Published: May 2009

Object.The authors sought to compare radiation exposure, surgical time, and accuracy of screw placement when using either standard fluoroscopy or virtual fluoroscopy for the placement of C1–2 transarticular screws.

Methods.Twenty-two C1–2 transarticular screws were placed in 11 cadavers in a randomized and alternating order by using either standard fluoroscopy or virtual fluoroscopy (fluoronavigation). The radiation time, procedure time, and accuracy of screw placement were recorded and statistically compared. A small but statistically significant reduction in fluoroscopy time was noted with the virtual fluoroscopy technique but the surgical times were similar between the two techniques. The incidence of noncritical and critical breaches (those at risk of causing a neurovascular injury) was not significantly different between the two groups. Careful analysis of the C1–2 anatomy in these specimens underscored the importance of placing the screw path in a maximally dorsal and medial portion of the C-2 isthmus to avoid injury to the vertebral artery and to maximize the bone purchase of the C-1 lateral mass.

Conclusions.Although virtual fluoroscopy may represent a useful tool for transarticular screw placement, it does not supplant traditional surgical techniques and does not appear to lower the incidence of bone breaches that can occur when performing this demanding procedure.
Diaphragmatic paralysis caused by cervical spondylosis
Authors: Hayashi Hideki , Kihara Shun-ichi , Hoshimaru Minoru , Hashimoto Nobuo
Published: May 2009

✓ The authors describe a rare case of diaphragmatic paralysis caused by cervical spondylosis. A 64-year-old man presented with dyspnea as well as cervical radicular pain and left-sided upper-extremity motor weakness. Chest radiography revealed elevation of both sides of the diaphragm. All symptoms were ameliorated immediately after cervical laminoplasty, and spirometry revealed improvement of ventilatory function 6 months after surgery. Cervical spondylosis should be considered a factor that can cause respiratory dysfunction.
Spontaneous spinal subdural hematoma associated with low-molecular-weight heparin
Authors: Cha Yoon-Hee , Chi John H. , Barbaro Nicholas M.
Published: May 2009

✓ Spinal subdural hematomas (SDHs) are a rare cause of cord compression and typically occur in the setting of spinal instrumentation or coagulopathy. The authors report the first case of a spontaneous spinal SDH occurring in conjunction with low-molecular-weight heparin use in a patient with a history of spinal radiotherapy.
Spontaneous intracranial hypotension associated with transdural thoracic osteophyte reversed by primary dural repair
Authors: Binder Devin K. , Sarkissian Vahé , Dillon William P. , Weinstein Philip R.
Published: May 2009

✓ Spontaneous intracranial hypotension (SIH) is an increasingly recognized syndrome associated with a specific set of clinical and imaging findings; however, determining the site of spinal cerebrospinal fluid (CSF) leakage in these patients is often difficult, and indications for surgical intervention need to be better defined. The authors report on a 55-year-old woman who presented with posture-related headache, disorientation, and memory impairment. Imaging features were consistent with SIH. Computerized tomography myelography demonstrated a large T2–3 anterior transdural osteophyte associated with a CSF fistula. After an unsuccessful trial of conservative therapy, the patient underwent median sternotomy, T2–3 discectomy and removal of osteophyte, which allowed adequate exposure for primary dural repair. Postoperatively, there was immediate and prolonged resolution of all of her symptoms. This case of SIH was caused by transdural penetration by an anterior osteophyte and CSF leakage in the upper thoracic spine, which was treated effectively by anterior exposure and primary dural repair. Aggressive surgical intervention may be required to treat upper thoracic CSF leaks refractory to other measures.
Pathological features including apoptosis in subacute posttraumatic ascending myelopathy
Authors: Al-Ghatany Mubarak , Al-Shraim Mubarak , Levi Allan D. O. , Midha Rajiv
Published: May 2009

✓ Subacute posttraumatic ascending myelopathy (SPAM) is a rare disorder that may gradually emerge in the first 1 to 3 weeks after a spinal cord injury and is unrelated to syrinx formation or mechanical instability. In addition to several theories that have been put forth to explain the origin of this syndrome, the authors propose a possible role for apoptosis in the causation and the progression of SPAM. They discuss the various theories that have been proposed thus far, to place the role of apoptosis in perspective and use their case as an illustration.
Short-term results of microendoscopic posterior decompression for lumbar spinal stenosis
Authors: Ikuta Ko , Arima Junichi , Tanaka Takayuki , Oga Masayoshi , Nakano Soichiro , Sasaki Kosuke , Goshi Kohei , Yo Masaki , Fukagawa Shingo
Published: May 2009

Object. The authors applied the technique of microendoscopic discectomy to posterior decompression procedures for lumbar spinal stenosis. The purpose of this study was to determine the feasibility of using an endoscopic technique to treat lumbar spinal stenosis and to evaluate the clinical and radiographic results of microendoscopic posterior decompression (MEPD).

Methods. Microendoscopic posterior decompression, which involves a unilateral endoscopic approach for bilateral decompression, was performed in 47 patients. Clinical and radiographic/neuroimaging results were evaluated during the follow-up period (minimum duration 1 year). The clinical results were compared with those of the conventional laminotomy. Radiographic instability and the degree of surgical invasion of the facet joints were evaluated. In a control a group of 29 patients open laminotomy was performed.

The clinical outcome was evaluated in 44 patients. The mean follow-up duration was 22 months. The mean rate of improvement was 72% based on the Japanese Orthopaedic Association score, and good results were obtained in 38 patients. Although the rate of morbidity decreased in the MEPD group, the incidence of complication was slightly higher. Effective decompression was demonstrated in the majority of the patients by using magnetic resonance imaging. Radiographic instability appeared in one patient postoperatively, and based on computerized tomography scanning, a tendency toward invasion of the facet joint on the approach side was noted.

Conclusions. Microendoscopic posterior decompression is a minimally invasive procedure and is as useful as other conventional procedures in treating lumbar spinal stenosis; however, a few technical problems remain to be solved.
Use of a polymethylmethacrylate cervical cage in the treatment of single-level cervical disc disease
Authors: Chen Jyi-Feng , Wu Chieh-Tsai , Lee Sai-Cheung , Lee Shih-Tseng
Published: May 2009

Object.Polymethylmethacrylate (PMMA) bone cement has been used as a spacer in the treatment of patients with cervical disc disease with good long-term outcomes, but solid bone fusion has not been demonstrated in all cases. To achieve cervical interbody fusion, the authors designed a modified PMMA cervical cage that they filled with spongy bone for the treatment of single-level cervical disc herniation.

Methods.Sixty-three patients underwent anterior cervical microdiscectomy and implantation of a PMMA cervical cage filled with autograft cancellous bone and were followed for a minimum of 2 years. The fusion rates were 90.5 and 100% at the 6- and 12-month follow-up examinations, respectively. The mean intervertebral disc height gain was 3.4 ± 1.9 mm when preoperative and 24-month postoperative values were compared. Neck pain, measured using the Huskissan visual analog scale (0 mm, no pain; 100 mm, worst possible pain), decreased from 71 ± 13 mm at preoperative baseline to 28 ± 17 at 6, 23 ± 19 at 12, and 31 ± 19 mm at 24 months. Based on the same scale, radicular pain decreased from 83 ± 15 mm at preoperative baseline to 24 ± 11 at 6, 27 ± 13 at 12, and 22 ± 11 mm at 24 months. The self-rated clinical outcome was excellent in 45 (71.4%) and good in 18 (28.6%) of the 63 patients.

Conclusions.The autograft cancellous bone—filled PMMA cage is safe and effective for cervical interbody fusion in the treatment of single-level cervical disc herniation and monoradiculopathy.
Effects of age on the perioperative characteristics and short-term outcome of posterior lumbar fusion surgery
Authors: Kilinçer Cumhur , Steinmetz Michael P. , Sohn Moon Jun , Benzel Edward C. , Bingaman William
Published: May 2009

Object.Although advances in patient care have enabled surgeons to perform posterior lumbar decompression and fusion (PLDF), increased age remains a major concern when designing a treatment strategy. The authors conducted a study to evaluate if increased age has any effect on lumbar fusion surgery in terms of perioperative events.

Methods.This retrospective study comprised 129 patients (age range 25–91 years) with spondylolisthesis, lumbar stenosis and/or disc degeneration/herniation with instability, or unsuccessful results after a failed previous PLDF. The patients were stratified by age: those younger than 65 years of age (85 patients) and those at least 65 years of age (44 patients). The parameters reviewed included comorbid conditions, American Society of Anesthesiologists score, instrumentation technique (pedicle screws, a combination of pedicle screw fixation [PSF] and posterior lumbar interbody fusion [PLIF], or non-instrumented fusions), number of fused levels, operative time, estimated blood loss (EBL), complications, and hospital length of stay (LOS).

Fusion strategies in the elderly tended to be more conservative. Repeated operations and PSF/PLIF procedures were less frequent in the older age group. Older age did not result in increased complications, EBL, and operative time. Longer hospital LOS was observed in the older age group (7 ± 3.5 days) compared with the younger age group (5.5 ± 1.9 days) (p = 0.022).

Conclusions.Complications and perioperative events following PLDF in the elderly are comparable with those observed in younger patients. Withholding lumbar spine fusion solely based on advanced age is not warranted.
Clinical analysis of percutaneous facet screw fixation after anterior lumbar interbody fusion
Authors: Jang Jee-Soo , Lee Sang-Ho
Published: May 2009

Object. The authors performed a retrospective study to evaluate the results of percutaneous facet screw fixation (PFSF) after anterior lumbar interbody fusion (ALIF) in comparison with the gold standard, post-ALIF pedicle screw fixation (PSF).

Methods. Of 84 patients treated for degenerative spondylolisthesis or degenerative disc disease at the authors' institution, 44 underwent PFSF (Group 1) and 40 underwent PSF (Group 2 [control population]) after ALIF. Function was assessed using the Oswestry Disability Index (ODI) scoring system, and outcome was measured using the Macnab criteria. At 3, 6, 12, and 24 months after surgery, dynamic lateral (flexion—extension) radiography and computerized tomography scanning were conducted to evaluate the osseous union status. After a minimum follow-up period of 2 years, analysis showed no intergroup statistical difference in terms of ODI score and Macnab outcome criteria (p > 0.05).

Excellent or good outcome was obtained in 40 (90.9%) of the 44 patients in Group 1 and 37 (92.5%) of the 40 patients in the control Group 2 (p > 0.05). No patient required a blood transfusion in either group. At 24 months after surgery fusion rates were 95.8% in Group 1 and 97.5% in Group 2.

Conclusions. The results of PFSF following ALIF appear to be clinically equivalent to those achieved after PSF, and the procedure represents a safe and minimally invasive modality with which to achieve solid fusion in the lumbar spine.
Spinal cord infarction complicating acute hydrocephalus secondary to a colloid cyst of the third ventricle
Authors: Siu Timothy L. T. , Bannan Paul , Stokes Bryant A. R.
Published: May 2009

✓ Occipital lobe infarction secondary to tentorial herniation is a rare but well-recognized complication of posterior cerebral artery interruption during acute hydrocephalus; however, a similar event in which tonsillar herniation leads to symptomatic occlusion of the anterior spinal arteries (ASAs) has not been reported. The authors present the case of a third ventricular colloid cyst in a previously healthy 24-year-old man who presented with symptoms and signs of critically raised intracranial pressure. He subsequently survived the ictus of insults following emergency external cerebrospinal fluid drainage and definitive resection of the colloid cyst, but he sustained occipital lobe and spinal cord infarction despite the absence of systematic hypotension. The presence of watershed cervicothoracic cord infarction on magnetic resonance imaging suggested that the most likely causes were compromise of ASAs during the period of acute hydrocephalus and the accompanying downward brain herniation. To the authors' knowledge, this is the first report to provide evidence that acute hydrocephalus may lead to ASA syndrome.
Outcome after less-invasive decompression of lumbar spinal stenosis: a randomized comparison of unilateral laminotomy, bilateral laminotomy, and laminectomy
Authors: Thomé Claudius , Zevgaridis Dimitris , Leheta Olaf , Bäzner Hansjörg , Pöckler-Schöniger Christiane , Wöhrle Johannes , Schmiedek Peter
Published: May 2009

Object

Recently, limited decompression procedures have been proposed in the treatment of lumbar stenosis. The authors undertook a prospective study to compare the safety and outcome of unilateral and bilateral laminotomy with laminectomy.

Methods

One hundred twenty consecutive patients with 207 levels of lumbar stenosis without herniated discs or instability were randomized to three treatment groups (bilateral laminotomy [Group 1], unilateral laminotomy [Group 2], and laminectomy [Group 3]). Perioperative parameters and complications were documented. Symptoms and scores, such as visual analog scale (VAS), Roland—Morris Scale, Short Form—36 (SF-36), and patient satisfaction were assessed preoperatively and at 3, 6, and 12 months after surgery.

Adequate decompression was achieved in all patients. The overall complication rate was lowest in patients who had undergone bilateral laminotomy (Group 1). The minimum follow up of 12 months was obtained in 94% of patients. Residual pain was lowest in Group 1 (VAS score 2.3 ± 2.4 and 4 ± 1 in Group 3; p < 0.05 and 3.6 ± 2.7 in Group 2; p < 0.05). The Roland—Morris Scale score improved from 17 ± 4.3 before surgery to 8.1 ± 7, 8.5 ± 7.3, and 10.9 ± 7.5 (Groups 1–3, respectively; p < 0.001 compared with preoperative) corresponding to a dramatic increase in walking distance. Examination of SF-36 scores demonstrated marked improvement, most pronounced in Group 1. The number of repeated operations did not differ among groups. Patient satisfaction was significantly superior in Group 1, with 3, 27, and 26% of patients unsatisfied (in Groups 1, 2, and 3, respectively; p < 0.01).

Conclusions

Bilateral and unilateral laminotomy allowed adequate and safe decompression of lumbar stenosis, resulted in a highly significant reduction of symptoms and disability, and improved health-related quality of life. Outcome after unilateral laminotomy was comparable with that after laminectomy. In most outcome parameters, bilateral laminotomy was associated with a significant benefit and thus constitutes a promising treatment alternative.
Clinical experience using incubated autologous macrophages as a treatment for complete spinal cord injury: Phase I study results
Authors: Knoller Nachshon , Auerbach Gustavo , Fulga Valentin , Zelig Gabriel , Attias Josef , Bakimer Ronit , Marder Jonathan B. , Yoles Eti , Belkin Michael , Schwartz Michal , Hadani Moshe
Published: May 2009

Object. A Phase I, open-label nonrandomized study was conducted to assess the safety and tolerability of incubated autologous macrophages administered to patients with acute complete spinal cord injury (SCI).

Methods. This therapy was first tested in rat models of spinal cord transection and contusion, in which it was shown to promote motor recovery. The procedure developed for clinical use consists of isolating monocytes from patient blood and incubating them ex vivo with autologous dermis. The resulting incubated autologous macrophages were injected into the patient's spinal cord immediately caudal to the lesion within 14 days of injury. Patients underwent preoperative and follow-up neurological assessment (American Spinal Injury Association [ASIA] standards), electrophysiological monitoring (motor evoked and/or somatosensory evoked potentials), magnetic resonance imaging, and safety monitoring. Before macrophage administration, complete neurological functional loss (ASIA Grade A) was confirmed in all patients. Of the eight patients in the study, three recovered clinically significant neurological motor and sensory function (ASIA Grade C status). During the study period, some adverse events were encountered, the most serious of which involved two cases of pulmonary embolism and one case of osteomyelitis that were treated and resolved without further complication. These and other adverse events appear to be similar to those encountered in other spinal cord—injured patients and are not considered a consequence of the experimental therapy.

Conclusions. It is concluded that incubated autologous macrophage cell therapy is well tolerated in patients with acute SCI. Further clinical evaluation is warranted.
Surgical management of giant herniated thoracic discs: analysis of 20 cases
Authors: Hott Jonathan S. , Feiz-Erfan Iman , Kenny Kathy , Dickman Curtis A.
Published: May 2009

Object. The authors evaluated the clinical and surgical outcomes obtained in patients with giant herniated thoracic discs (HTDs), defined as occupying more than 40% of the spinal canal. Surgery-related considerations and functional outcomes in patients with small- and medium-sized HTDs were compared.

Methods. The authors reviewed 140 cases of surgically treated HTDs, 20 (14%) of which were giant. Before and after surgery, all patients underwent computerized tomography myelography, magnetic resonance imaging, or both. Functional outcomes were assessed using the Frankel grading system preoperatively, immediately after surgery, and at long-term follow-up examination. The results observed in patients with giant HTDs were compared with those with small- and medium-sized HTDs. The mean overall follow-up period was 2.6 years.

Sixty-six patients (47%) presented with myelopathy, including 19 (95%) with a giant HTD. Of the latter, 16 (80%) underwent anterior, eight thoracoscopic, and eight open thoracotomy approaches. Four patients (20%) with laterally oriented giant HTDs within the spinal canal underwent surgery via a posterolateral approach.

Based on analysis of long-term follow-up data, 53% of patients with giant HTDs improved neurologically by one Frankel grade. Progression of myelopathy was arrested in 42%, and in 5% the Frankel grade worsened by one. In patients with small- and medium-sized HTDs, the Frankel grade improved by one in 77%, stabilized in 23%, and worsened in 0%. Patients with giant HTDs who underwent thoracoscopic surgery had worse short- and long-term functional outcomes than those in whom open thoracotomy was performed.

Conclusions. Patients with giant HTDs presented more frequently with myelopathy and experienced worse functional outcomes than those with smaller HTDs. Based on their experience, the authors recommend open thoracotomy rather than thoracoscopy for the treatment of midline giant HTDs.
Surgical treatment of lumbar ossification of the posterior longitudinal ligament
Authors: Tamura Mutsuhiro , Machida Masafumi , Aikawa Daisuke , Fukuda Kentaro , Kono Hitoshi , Suda Yoshio , Shioda Masanobu , Saito Masashi , Yamagishi Masaaki
Published: May 2009

✓ The authors report two cases of patients with lumbar ossification of the posterior longitudinal ligament (OPLL). One patient underwent surgery via the single posterior approach, and the other patient underwent combined anterior—posterior surgery. The authors consider the anterior approach for excision of the ossified lesion to be the most reasonable for treatment of lumbar OPLL. It is extremely important, however, to select the surgical procedure according to the individual patient's condition.
Pyogenic spondylitis in the cervicothoracic junction with high-positioned aortic arch
Authors: Yoshimoto Hisashi , Sato Shigenobu , Hyakumachi Takahiko , Yanagibashi Yasushi , Masuda Takeshi
Published: May 2009

✓ The authors report the case of an 87-year-old woman who suffered from T1–2 pyogenic spondylitis resulting in progressive and severe paraplegia. Debridement and anterior manubrium-splitting fusion were difficult because a high-positioned aortic arch was very close to the infectious lesion. Because adequate intravenous antibiotic agents had nearly resolved the inflammation, the authors undertook anterior debridement and posterior fusion that involved costotransversectomy and the placement of a posterior cervical pedicle screw fixation system. At 1.5 years postoperatively, there were no signs of recurrent infection. Solid osseous union was documented, and the patient's paraplegia had improved.

A high-positioned aortic arch will likely interfere with an anterior approach to the cervicothoracic junction. If adequate antibiotic therapy has successfully controlled the spinal infection, anterior debridement and posterior fusion can be conducted in cases involving such anatomical limitations.
The use of closed-suction irrigation systems to manage spinal infections
Authors: Vender John R. , Hester Sydney , Houle Paul J. , Choudhri Haroon F. , Rekito Andy , McDonnell Dennis E.
Published: May 2009

Object.Management of infection in the hardware system—fixated spine has proven to be problematic. In many cases, instrumentation is required to provide stability or to maintain correction of deformity, and removal could be hazardous. The authors describe the use of closed continuous irrigation to treat spinal wound infections in patients with fixation systems; irrigation can be used in all parts of the spine with excellent results.

Methods.The authors conducted a retrospective chart-based review of cases in which spinal instrumentation procedures were performed consecutively during a 10-year period.

Infection developed in 36 patients. The infections involved the cervical, thoracic or thoracolumbar, and lumbar regions. Anterior and posterior drains were placed in one patient. In one patient refractory infections responded to replacement of the dual-inflow port drainage system. In all cases the wound infection completely resolved. There were no cases that required the removal of the fusion mass or instrumentation. In all cases progression to solid fusion was achieved.

Conclusions.Closed irrigation systems can be used effectively to manage anterior or posterior cervical, thoracic, and lumbar wound infections. These systems preclude the explantation of the instrumentation and allow spinal stability to be preserved. The authors noted no evidence of recurrent infection or failed fusion.
Stereotactic radiosurgery for spinal metastases from renal cell carcinoma
Authors: Gerszten Peter C. , Burton Steven A. , Ozhasoglu Cihat , Vogel William J. , Welch William C. , Baar Joseph , Friedland David F.
Published: May 2009

Object.The role of stereotactic radiosurgery in treating renal cell carcinoma (RCC) metastases to the spine has previously been limited. In this study the authors evaluated the clinical outcome in patients with spinal RCC who underwent single-fraction radiosurgery.

Methods.Forty-eight patients with 60 RCC metastases to the spine (six cervical, 26 thoracic, 18 lumbar, and 10 sacral) were treated with a single-fraction radiosurgery technique and were followed for a period of 14 to 48 months (median 37 months).

All patients were successfully treated in an outpatient setting. The tumor volume ranged from 5.5 to 203 cm3(mean 61.9 cm3). Forty-two of the total 60 lesions had been previously treated with external-beam radiation therapy (EBRT). The maximum tumor dose was maintained at 17.5 to 25 Gy (mean 20 Gy). The volume of the spinal cord exposed to greater than 8 Gy ranged from 0.01 to 3 cm3(mean 0.64 cm3); the volume of the spinal canal at the cauda equina level exposed to greater than 8 Gy ranged from 0.01 to 2.2 cm3(mean 0.65 cm3). No radiation-induced toxicity occurred during the follow-up period. Axial and radicular pain improved in 34 (89%) of 38 patients who were treated primarily for pain. Tumor control was demonstrated in seven of eight patients treated primarily for radiographically documented tumor progression. In time six patients required open surgical intervention for tumor progression that had caused neurological dysfunction after radiosurgery.

Conclusions.Spinal radiosurgery can be a successful therapeutic modality for the delivery of large-dose single-fraction radiation to RCC spinal metastases that are often poorly controlled with conventional EBRT modalities.
Olfactory glia transplantation into cervical spinal cord contusion injuries
Authors: Collazos-Castro Jorge E. , Muñetón-Gómez Vilma C. , Nieto-Sampedro Manuel
Published: May 2009

Object. The results of olfactory ensheathing cell (OEC) transplantation have raised great expectations as a potential treatment for spinal cord injury (SCI). Its capacity to promote functional neural repair, however, remains unclear. The authors studied axonal growth and locomotor recovery after C-7 contusion injury and OEC transplantation in adult rats.

Methods. Twenty-four male Wistar rats underwent a mild C-7 contusion injury that completely disrupted the dorsal corticospinal tract (DCST). In 14 rats OECs were transplanted into the lesion, and 10 were used as controls. At 3 months postcontusion, the kinematics of locomotion were assessed, and the CST was traced by injecting dextran tetramethylrhodamine bilaterally into the cerebral cortex. The animals were killed 2 weeks after tracer injection, and their spinal cords were studied immunohistochemically.

Although the survival of transplanted cells varied, they were present in all cases. The authors observed neither OEC migration nor DCST axon regeneration in any of the cell transplant—treated rats. Corticospinal axons ended in retraction bulbs at the proximal edge of the lesion or, exceptionally, a few micrometers inside the transplant. The results of neurofilament immunohistochemical analysis provided evidence of neurites from systems other than the DCST growing into the transplant, but in some cases these neurites formed loops of pathological appearance. Contusion injury of C-7 caused chronic locomotor deficits that did not improve after OEC transplants.

Conclusions. The findings in this study indicate that OEC transplants alone are not sufficient for neural repair and functional recovery after SCI. In addition, OECs can induce abnormal axonal growth, making further studies necessary before considering their clinical use.
Use of dual transarticular screws to fixate simultaneous occipitoatlantal and atlantoaxial dislocations
Authors: Gonzalez L. Fernando , Klopfenstein Jeffrey D. , Crawford Neil R. , Dickman Curtis A. , Sonntag Volker K. H.
Published: May 2009

✓ Occipitoatlantal dislocation and atlantoaxial vertical distraction are caused by similar mechanisms, and few individuals survive these injuries. It is hypothesized that the injurious vertical force manifests as a traumatic lesion at different levels of the same ligamentous complex. The authors report the cases of two patients who presented with this combined lesion, describe surgical alternatives for stabilization, and introduce a new technique that combines the use of transarticular screws in a “dual” construct, without involving the unaffected spine.
Clinical and prognostic analysis of ossified ligamentum flavum in a Chinese population
Authors: He Shisheng , Hussain Nazakat , Li Shaohua , Hou Tiesheng
Published: May 2009

Object.The authors performed a retrospective study of clinical and radiological data obtained in 27 Chinese patients with myelopathy induced by ossification of the ligamentum flavum (OLF) who underwent surgery between March 1990 and March 2002. The factors related to surgical outcome of thoracic OLF-induced myelopathy were also assessed.

Methods.The preoperative clinical features and radiological findings were reviewed retrospectively. Preoperative and postoperative neurological status was assessed using the Japanese Orthopaedic Association (JOA) scoring system and the Nurick Scale. The ossified lesions were classified into five types (lateral, extended, enlarged, fused, and tuberous). Multiple linear regression and logistic regression analyses were performed to establish the factors affecting surgical outcome. The patients' chief complaints were lower-limb weakness and gait disturbance (93%), numbness and sensory deficit (89%), and low-back pain (48%). The coexisting pathological entities were disc herniation, canal stenosis, and ossification of posterior longitudinal ligament. The ossified ligamentum flavum was mainly located at the T10–12 (67%) and T1–3 (15%) levels. Symptoms in 26 patients improved but resolved completely in only 14 after surgery. The mean overall JOA score was 5.3 ± 1.9 preoperatively and 7.9 ± 2.3 postoperatively. There is a significant difference between the pre- and postoperative neurological status (p < 0.05) determined by the Student t-test. The recovery rate was 46.3 ± 9.4%. Multiple regression analysis revealed negative correlation between the duration of preoperative symptoms and surgical outcome as well as a positive correlation between the preoperative JOA score and surgical outcome. Logistic regression analysis demonstrated that fecal and/or urinary incontinence, positive patellar and/or ankle clonus, and intramedullary high T2-weighted magnetic resonance (MR) imaging signal change had negative effects on the surgical outcome.

Conclusions.The clinical and radiological features of OLF in the Chinese population are similar to those observed in the Japanese population. The duration of preoperative symptoms and JOA score are the most important predictors of the postoperative JOA score and recovery rate. The patients with fecal and/or urinary incontinence, positive patellar and/or ankle clonus, and intramedullary high T2-weighted MR imaging signal change were at higher risk of poor outcome after surgery.
Quantitative anatomical and morphological classification of the iliac vessels anterior to the lumbosacral vertebrae
Authors: Cho Do-Sang , Kim Sang-Jin , Seo Eui-Kyo , Chung In-Hyuk , Oh Chang-Seok
Published: May 2009

Object.Anterior surgical approaches to the lumbosacral disc spaces are being undertaken with increasing frequency. This increase and the use of minimally invasive techniques themselves have the potential to raise the incidence of major vessel injuries. The purpose of this study was to determine the variability of the vascular anatomy anterior to the lumbosacral spine and to draw conclusions regarding surgical accessibility of the L5—S1 disc space.

Methods.Thirty-five cadavers (age range at the time of death 31–87 years) were obtained to evaluate the anatomical features of iliac vessels with respect to the anterior approach to the lumbosacral spine. Direct measurement and morphological classification regarding the relations of these great vessels to the four arbitrary reference points of the lumbosacral disc space were performed. The mean width and height of the L5—S1 disc were 56.4 mm (range 41.6–65.4 mm) and 18.8 mm (range 10–24 mm), repectively. According to the authors' morphological classification, nine specimens (26%) were found to be Type A (standard), 12 (34%) Type B (narrow), two (6%) Type C (ajar), and 12 (34%) Type D (obstacle).

Conclusions.The authors have noted quite a variation in the venous vascular anatomy anterior to the lumbosacral disc. During surgical planning for the anterior approach to the lumbosacral spine when using any technique, it is vital to assess carefully radiographic and neuroimaging studies to minimize potentially disastrous vascular complications.
Anatomical data on the craniocervical junction and their correlation with degenerative changes in 30 cadaveric specimens
Authors: König Stefan A. , Goldammer Axel , Vitzthum Hans-Ekkehart
Published: May 2009

>Object. The goal of this project was to measure vertebral dimensions at the craniocervical junction and to investigate degenerative changes in this region and their correlations with the anatomical data. These studies will assist in an understanding of biomechanical conditions in this region, which are clinically relevant in cases of cervicogenic headaches and vertigo.

Methods. The authors examined 30 cadaveric specimens obtained from patients ranging in age from 24 to 88 years at death. Measurements of angles of the vertebrae were conducted using an imprint method. Microsections of osseous endplates and articular cartilage were graded according to their degrees of degeneration by using the Petersson classification (0, no sign of degeneration; I, superficial degeneration with several fragmentations; II, deeper degeneration with cartilaginous disintegration and penetrating ulceration; or III, complete cartilaginous degeneration with the appearance of subchondral bone in > 50% of the articular surface).

The authors found Grade I changes in 100% of the occiput specimens. In the superior articular cartilage of C-1 no changes (Grade 0) were found in two specimens, whereas 6% of the specimens exhibited Grade II changes and 89% exhibited Grade I changes. In the inferior articular cartilage of C-1, 57% of the specimens displayed Grade I changes, 14% Grade II, and 20% Grade III changes. In the superior articular cartilage of C-2, 62.5% of the specimens displayed Grade I changes and 25% Grade II changes. At the occiput—C1 level the authors found a higher frequency of degeneration at the upper left articular surface of the atlas (Quadrants 1 and 3), and at the C1–2 level they found a higher frequency of degeneration at the upper left and upper right articular surfaces of the axis (Quadrants 2 and 3, respectively). Using the McNemar test, the authors investigated the frequency of affection of single quadrants in a left—right side comparison (lateral reversal). Significant differences were identified for Quadrant 2 of the upper left articular surface of C-2 and Quadrant 3 of the upper right articular surface of C-2. These results correlate with the analysis of single articular surfaces of the axis, but contradict the results for the atlas, in which no significant difference in the left—right side comparison was found.

Conclusions. Severe degeneration in the atlantooccipital joints appears to be a rare condition, with no Grade II or III degeneration found in the occipital condyles and 6% Grade I, 89% Grade II, but no Grade III changes in the superior articular cartilage of the atlas. Degeneration of the inferior articular cartilage of C-1 and the superior articular cartilage of C-2 indicates that the atlantoaxial joint faces more intense mechanical exposure, which is increased at the upper joint surfaces.