bluuebunny/crossref_metadata_2025 huggingface dataset:
The impact of automatic retractors on the esophagus during anterior cervical surgery: an experimental in vivo study in a sheep model
Authors: Çavuşoğlu Halit , Tuncer Cengiz , Tanik Canan , Mutlu Zihni , Zengin Ebruhan , Karabağli Murat , Aydın Yunus
Published: February 2011

Object

Postoperative dysphagia is a well-recognized complication of the anterior surgical approach to the cervical spine. However, its incidence and etiology remain unknown. The aim of this study was to investigate the impact of automatic retractor use on the esophagus and to describe the related pathological changes that might occur during cervical spine surgery.

Methods

A single-level cervical discectomy was performed via an anterior approach in 16 skeletally mature female sheep. Continuous retraction was applied with an automatic retractor system during surgery. The sheep model was chosen because of anatomical similarities to the human esophagus. The esophageal tract in every animal was examined using contrast radiographic examination. Eight animals were killed 3 days after the operation (Group 1). The remaining sheep were killed 4 weeks after the operation (Group 2). The esophagi were removed for histopathological study, which was performed using H & E and Masson trichrome staining. The changes in esophageal innervation were examined with nicotinamide adenine dinucleotide diphosphate–diaphorase histochemical staining.

Results

Only 1 animal (a Group 1 sheep) demonstrated any postoperative radiographic abnormality. In Group 1 sheep, histopathological study of the esophagi at the treated level revealed edema between the muscular fibers in the outer longitudinal and inner circular layers of the muscularis propria. At some points, obvious signs of vascular congestion, vascular damage, and inflammation were observed. In the Group 2 animals, there was mild-to-moderate fibrosis extending from the outer surface of the esophagus to the longitudinal layers of the muscularis propria in the area to which retraction had been applied. Enzyme-histochemical staining revealed the presence of normal myenteric plexus and ganglion cells, and nitrergic innervation in all parts of the esophagus wall.

Conclusions

The results of this study demonstrate that direct pressure induced by the medial retractor blade on the esophagus wall leads to local injury. Postoperative dysphagia in human patients who have undergone anterior cervical spine surgery could be a clinical manifestation of this phenomenon.
Stress fracture of the lumbar pedicle bilaterally: surgical repair using a percutaneous minimally invasive technique
Authors: Johnson Jeremiah N. , Wang Michael Y.
Published: February 2011

Bilateral pedicle fractures in the spine are uncommon in the absence of bony abnormality, previous surgery, or trauma. The authors report a case of spontaneous bilateral lumbar pedicle fracture in a 50-year-old sedentary woman, which caused intractable pain and did not respond to months of conservative management. The fractures were surgically treated using a percutaneous, minimally invasive technique with screws placed directly through the fractures into the vertebral body. The pedicles were strategically tapped to achieve the lag effect and reapproximate the posterior fragment with the anterior elements. The patient tolerated the procedure well and experienced early improvement of her symptoms, and follow-up imaging showed evidence of fracture healing. Transpedicular fixation and the use of the lag effect could be a useful strategy in the treatment of future cases involving poorly healing pedicle fractures causing persistent symptoms.
Morphological changes of the multifidus muscle in patients with symptomatic lumbar disc herniation
Authors: Franke Jörg , Hesse Thomas , Tournier Clement , Schuberth Walter , Mawrin Christian , LeHuec Jean Carles , Grasshoff Henning
Published: February 2011

Object

Lumbar disc herniations are associated with segmental muscle alterations of the ipsilateral segmental multifidus muscle. The aim of the present study was a histopathological analysis of the myopathological changes of the multifidus muscle and correlation with the duration of radicular symptoms.

Methods

Multifidus muscle biopsies were performed in 20 patients during discectomy. Specimens were obtained from the area of the multifidus muscle innervated by the nerve from the level of the affected disc. Histopathological findings were classified according as neurogenic tissue syndrome and nonspecific myopathological syndrome, and these results were correlated with the duration of radicular symptoms.

Results

Results of multifidus muscle biopsies were classified as neurogenic tissue syndrome in 12 patients and as nonspecific myopathological syndrome in 8. The mean (± SD) duration of radicular symptoms was 10.75 ± 7.9 months in patients with neurogenic tissue syndrome and 4.37 ± 3.9 months in patients with a nonspecific myopathological syndrome. There was a positive correlation between group assignment and symptom duration (correlation coefficient 0.457, p = 0.043).

Conclusions

A long duration of radicular symptoms is associated with a neurogenic tissue syndrome, whereas a nonspecific myopathological tissue syndrome is seen in patients with shorter duration of symptoms. This suggests that patients with long duration of radicular symptoms originating from a lumbar disc herniation have an increased risk for neurogenic muscular changes, and that consideration should be given to an earlier surgical intervention.
Effective lordosis: analysis of sagittal spinal canal alignment in cervical spondylotic myelopathy
Authors: Gwinn David E. , Iannotti Christopher A. , Benzel Edward C. , Steinmetz Michael P.
Published: February 2011

Object

Analysis of cervical sagittal deformity in patients with cervical spondylotic myelopathy (CSM) requires a thorough clinical and radiographic evaluation to select the most appropriate surgical approach. Angular radiographic measurements, which are commonly used to define sagittal deformity, may not be the most appropriate to use for surgical planning. The authors present a simple straight-line method to measure effective spinal canal lordosis and analyze its reliability. Furthermore, comparisons of this measurement to traditional angular measurements of sagittal cervical alignment are made in regards to surgical planning in patients with CSM.

Methods

Twenty preoperative lateral cervical digital radiographs of patients with CSM were analyzed by 3 independent observers on 3 separate occasions using a software measurement program. Sagittal measurements included C2–7 angles utilizing the Cobb and posterior tangent methods, as well as a straight-line method to measure effective spinal canal lordosis from the dorsal-caudal aspect of the C2–7 vertebral bodies. Analysis of variance for repeated measures or Cohen 3-way (kappa) correlation coefficient analysis was performed as appropriate to calculate the intra- and interobserver reliability for each parameter. Discrepancies in angular and effective lordosis measurements were analyzed.

Results

Intra- and interobserver reliability was excellent (intraclass coefficient > 0.75, kappa > 0.90) utilizing all 3 techniques. Four discrepancies between angular and effective lordotic measurements occurred in which images with a lordotic angular measurement did not have lordosis within the ventral spinal canal. These discrepancies were caused by either spondylolisthesis or dorsally projecting osteophytes in all cases.

Conclusions

Although they are reliable, traditional methods used to make angular measurements of sagittal cervical spine alignment do not take into account ventral obstructions to the spinal cord. The effective lordosis measurement method provides a simple and reliable means of determining clinically significant lordosis because it accounts for both overall alignment of the cervical spine as well as impinging structures ventral to the spinal cord. This method should be considered for use in the treatment of patients with CSM.
Effect of apolipoprotein E genotype on the outcome after anterior cervical decompression and fusion in patients with cervical spondylotic myelopathy
Authors: Setzer Matthias , Vrionis Frank D. , Hermann Elvis J. , Seifert Volker , Marquardt Gerhard
Published: February 2011

Object

The authors examined a possible association between apolipoprotein E (APOE) gene polymorphism and the outcome after anterior microsurgical decompression in patients with cervical spondylotic myelopathy (CSM).

Methods

The authors conducted a prospective study of 60 consecutive patients (40 men, 20 women) with CSM who underwent anterior microsurgical decompression. The patients ranged in age from 26 to 86 years (mean 61.5 ± 14.6 years). Neurological deficits were classified according to the modified Japanese Orthopaedic Association Scale. Mean follow-up was 18.8 ± 4.6 months and APOE genotyping was carried out by isolation of DNA from venous blood samples. The APOE genotypes were determined by polymerase chain reaction followed by restriction enzyme digestion and polyacrylamide gel electrophoresis of digested fragments. Categorical variables were analyzed with the chi-square test, continuous data with the Mann-Whitney U-test, and for multiple groups with the Kruskal-Wallis H-test. A backward stepwise binary logistic regression analysis was performed to determine the effect of APOE in a multivariate model.

Results

Of the 60 patients with CSM, 35 (58.3%) improved and 25 (41.7%) did not improve or suffered deterioration (no-improvement group). In the improvement group 5 patients (8.3%) possessed the ε4 allele compared with 16 patients (26.7%) in the no-improvement group (p = 0.002, OR 3.3, 95% CI 1.7–6.1). In a multivariate model, the occurrence of the ε4 allele was a significant independent predictor for no improvement after anterior decompression and fusion (p = 0.004, OR 8.6, 95% CI 5.1–20.6).

Conclusions

The results of this study show that APOE gene polymorphism influences the short-term outcome of CSM patients after surgical decompressive and stabilizing therapy in the way that the presence of the APOE ε4 allele is an independent predictor for a no improvement. The presence of APOE may explain in part the different responses to operative therapies in patients with cervical myelopathy.
Changes in cervical range of motion and sagittal alignment in early and late phases after total disc replacement: radiographic follow-up exceeding 2 years
Authors: Ahn Poong-Gi , Kim Keung Nyun , Moon Sung Whan , Kim Keun Su
Published: February 2011

Object

This was a retrospective clinical study in which the follow-up period exceeded 2 years. The authors investigated the time course of radiographic changes in the cervical range of motion (ROM) and sagittal alignment after cervical total disc replacement involving the ProDisc-C artificial disc.

Methods

Eighteen patients who underwent C5–6 total disc replacement were followed for an average of 27 months. Cervical neutral and flexion-extension lateral radiographs were obtained before and at 1 and 3 months after surgery for early-phase observations and at the last follow-up for late-phase observation. Segmental ROM values in the treated, superior, and inferior adjacent segments were measured. For whole-neck motion, C2–7 ROM was also measured. The percentage contributions of ROM at functional and adjacent segments to whole-neck motion were calculated. For evaluating sagittal alignment, C2–7 and C5–6 Cobb angles were measured. All data from ProDisc-C arthroplasty were compared with the results obtained in 22 patients who underwent C5–6 interbody fusion in which a Solis cage was used and who were followed for an average of 25 months

Results

In the ProDisc-C group, C2–7 and C5–6 ROM significantly decreased in the early phase after surgery and returned to preoperative levels in the late phase. Both superior and inferior adjacent segments showed significantly decreased ROM in the acute phase after surgery and returned to the preoperative values in the late phase. In terms of contributions to whole-neck motion, the ROM of the functional and adjacent segments did not change significantly compared with the preoperative ROM. In the cage group, C2–7 ROM was also significantly decreased in the early phase after surgery and returned to preoperative levels at the late phase. Both superior and inferior adjacent segments exhibited significantly increased ROM and percentage contributions to whole-neck motion in the early and late phases. Sagittal alignment of the whole cervical spine became significantly more lordotic in the late phase in the ProDisc-C group. The C5–6 Cobb angle became significantly lordotic in the ProDisc-C group, whereas there was no significant change in C5–6 Cobb angle in the cage group.

Conclusions

In the early phase after ProDisc-C replacement, the ROM of the entire neck as well as functional and adjacent segments decreased but, at the late phase, they returned to the preoperative state. Contributions of functional and adjacent segments to whole-neck motion were not changed after ProDisc-C replacement. Adjacent-segmental motion could be saved by ProDisc-C replacement instead of interbody cage fusion. Segmental degenerative kyphosis was significantly corrected in patients who underwent ProDisc-C replacement.
Microvascular system of the lumbar dorsal root ganglia in rats. Part II: neurogenic control of intraganglionic blood flow
Authors: Kobayashi Shigeru , Mwaka Erisa Sabakaki , Baba Hisatoshi , Kokubo Yasuo , Yayama Takafumi , Kubota Masafumi , Nakajima Hideaki , Meir Adam
Published: February 2011

Object

The dorsal root ganglion (DRG) should not be overlooked when considering the mechanism of low-back pain and sciatica, so it is important to understand the morphological features of the vascular system supplying the DRG. However, the neurogenic control of intraganglionic blood flow has received little attention in the past. The authors used an immunohistochemical technique to investigate the presence and distribution of autonomic and sensory nerves in blood vessels of the DRG.

Methods

Ten Wistar rats were used. To investigate the mechanism of vasomotion on the lumbar DRG, the authors used immunohistochemical methods. Sections were incubated overnight with antisera to tyrosine hydroxylase (TH), aromaticl-amino-acid decarboxylase (AADC), 5-hydroxytryptamine, substance P (SP), calcitonin gene–related peptide (CGRP), vasoactive intestinal peptide (VIP), somatostatin (SOM), neuropeptide Y (NPY), leucine-enkephalin, and cholineacetyl transferase (Ch-E). The avidin-biotin complex method was used as the immunohistochemical procedure, and the sections were observed under a light microscope.

Results

In the immunohistochemical study, TH-, AADC-, SP-, CGRP-, VIP-, SOM-, NPY-, and Ch-E–positive fibers were seen within the walls of blood vessels in the DRG. This study revealed the existence of a comprehensive perivascular adrenergic, cholinergic, and peptidergic innervation of intraganglionic blood vessels, with a possible role in neurogenic regulation (autoregulation) of intraganglionic circulation.

Conclusions

The presence of perivascular nerve plexuses around intraganglionic microvessels suggests that autonomic nerves play an important role in intraganglionic circulation.
Percutaneous pulsed radiofrequency applied to the L-2 dorsal root ganglion for treatment of chronic low-back pain: 3-year experience
Authors: Tsou Hsi-Kai , Chao Shao-Ching , Wang Chao-Jan , Chen Hsien-Te , Shen Chiung-Chyi , Lee Hsu-Tung , Tsuei Yuang-Seng
Published: February 2011

Object

The authors assessed the effectiveness of percutaneous pulsed radiofrequency treatment for providing pain relief in patients with chronic low-back pain with or without lower-limb pain.

Methods

Data were obtained in 127 patients who had chronic low-back pain with or without lower-limb pain due to a herniated intervertebral disc or previous failed back surgery and who underwent pulsed radiofrequency treatment. Their conditions were proven by clinical features, physical examination, and imaging studies. Low-back pain was treated with pulsed radiofrequency applied to the L-2 dorsal root ganglion (DRG) and lower-limb pain was treated with pulsed radiofrequency applied to the L3–S1 DRG. Patients underwent uni- or bilateral treatment depending on whether their low-back pain was unilateral or bilateral. A visual analog scale was used to assess pain. The patients were followed up for 3 years postoperatively.

Results

In patients without lower-limb pain (Group A), 27 (55.10%) of 49 patients had initial improvement ≥ 50% at 3-month follow-up. At 1-year follow-up, 20 (44.44%) of 45 patients in Group A had pain relief ≥ 50%. An analysis of patients with pain relief ≥ 50% for at least 1 month showed that the greatest effect was at 3 months after treatment. In patients with low-back pain and lower-limb pain (Group B), 37 (47.44%) of 78 patients had initial improvement ≥ 50% at 3-month follow-up. At 1-year follow-up, 34 (45.95%) of 74 patients had pain relief effect ≥ 50%. An analysis of patients in Group B with pain relief ≥ 50% for at least 1 month showed that the greatest effect was at 1 month after treatment.

Conclusions

The results of this prospective analysis showed that treatment with pulsed radiofrequency applied at the L-2 DRG is safe and effective for treating for chronic low-back pain. Satisfactory pain relief was obtained in the majority of patients in Group A with the effect persisting for at least 3 months. The results indicate that pulsed radiofrequency provided intermediate-term relief of low-back pain. Further studies with long-term follow-up are necessary.
Giant destructive myxopapillary ependymomas of the sacrum
Authors: Quraishi Nasir A. , Wolinsky Jean-Paul , Bydon Ali , Witham Timothy , Gokaslan Ziya L.
Published: February 2011

Myxopapillary ependymomas rarely present as a primary intrasacral lesion, and extensive sacral osteolysis is unusual. The authors report a case series of 6 patients with these complex tumors causing extensive sacral destruction, who underwent resection, lumbopelvic reconstruction, and fusion. The operative procedure, complications, and outcome are summarized after a mean follow-up of 3.55 years (range 18–80 months).
A clinical analysis of 4- and 6-year follow-up results after cervical disc replacement surgery using the Bryan Cervical Disc Prosthesis
Authors: Goffin Jan , van Loon Johan , Van Calenbergh Frank , Lipscomb Bailey
Published: February 2011

Object

In this study, long-term results are presented from clinical studies of the Bryan Cervical Disc Prosthesis at University Hospital Gasthuisberg in Leuven, Belgium. A total of 98 patients (89 with 1-level and 9 with 2-level implantations) agreed to participate in follow-up studies for up to 10 years postoperatively. This article focuses on the 4- and 6-year results. Patients in one of the clinical studies had either radiculopathy or myelopathy associated with spondylosis and/or disc herniations that did not respond to conservative treatment. Patients from the other clinical study received commercially available Bryan devices and the study protocol did not have specific inclusion/exclusion criteria. More than 90% of the patients were considered to have radiculopathy.

Methods

Clinical measurements discussed in the article include the 36-Item Short Form Health Survey, Neck Disability Index, numerical ratings of neck and arm pain, neurological outcomes, and Odom classification. Angular motion findings from lateral flexion-extension radiographs are also presented. The occurrence of adverse events and second surgeries are examined as an indicator of device safety.

Results

The clinical outcomes at 4 and 6 years postoperatively appear consistent with the previously reported results at 1 and 2 years postoperatively. The mean angular motion results at 4 and 6 years postoperatively for 1-level patients were 7.3 and 7.7°, respectively. Two-level patients had slightly less motion at 4 and 6 years postoperatively with mean caudad values of 5.7 and 6.0°, respectively, and cephalad values of 4.2 and 6.2°, respectively. Efforts were made to capture adverse events, regardless of their nature and relatedness to the study surgery. This effort resulted in a relatively high number of recorded events. However, only 6 patients experienced events that were judged by the investigator to be related, either possibly or definitely, to the Bryan device. These events included device migration, device removal, and hoarseness and vocal cord paralysis, as well as 3 cases involving pain and neurological symptoms. Eight patients underwent further neck surgery to treat symptoms.

Conclusions

The favorable clinical and angular motion outcomes that were previously noted at 1- and 2-years' follow-up after cervical disc replacement with the Bryan Cervical Disc Prosthesis appear to persist after 4 and 6 years of follow-up.
Erosion of the spinous process: a potential cause of interspinous process spacer failure
Authors: Miller Jimmy D. , Miller Mary C. , Lucas Marsha G.
Published: February 2011

Interspinous process spacers have recently become available for treatment of symptomatic lumbar spinal stenosis. To date, there have been few data regarding the causes of failure. The authors present 2 cases in which there was erosion of the spinous processes adjacent to the interspinous process spacers. In 1 patient, the recurrence of symptoms was likely related to the erosive changes. Such abnormal changes allow settling of the posterior spinal elements and probably results from continued motion at the treated levels.
Which lumbar interbody fusion technique is better in terms of level for the treatment of unstable isthmic spondylolisthesis?
Authors: Kim Jin-Sung , Lee Kil-Yong , Lee Sang-Ho , Lee Ho-Yeon
Published: February 2011

Object

The purpose of this study was to investigate and compare clinical and radiographic outcomes of 2 kinds of lumbar interbody fusion (LIF) for the treatment of adult low-grade isthmic spondylolisthesis at L4–5 and L5–S1 levels.

Methods

The medical records and radiographs of 86 patients who underwent anterior LIF (ALIF) (L4–5, 42 patients; L5–S1, 44 patients) and 42 patients who underwent transforaminal LIF (TLIF) (L4–5, 22 patients; L5–S1, 20 patients) between 2001 and 2004 were retrospectively reviewed. Clinical results were investigated using the visual analog scale (VAS) and Oswestry Disability Index (ODI) scores, and using radiographic measurements, including disc height (DH), degree of spondylolisthesis, segmental lordosis, whole lumbar lordosis (WL), sacral slope (SS), and pelvic tilt; the L-1 axis S-1 distance (LASD) and pelvic incidence were also obtained.

Results

In both groups, VAS and ODI scores had significantly improved at both treatment levels. Statistical analysis showed no significant difference in postoperative VAS scores between groups at the L4–5 level and in postoperative VAS/ODI scores at the L5–S1 level. However, ODI scores were better in the TLIF than in the ALIF group at the L4–5 level. In terms of radiological changes, there were no significant differences between the 2 groups at the L4–5 level; however, at the L5–S1 level, radiographic results indicated that ALIF was superior to TLIF in its capacity to restore DH, WL, SS, and LASD. The radiological evidence of fusion shows no intergroup difference and no interlevel difference.

Conclusions

Considering the clinical and radiological outcomes in both groups, the authors recommend that instrumented mini-TLIF is preferable at the L4–5 level, whereas instrumented mini-ALIF might be preferable at the L5–S1 level for the treatment of unstable isthmic spondylolisthesis.
Simultaneous double-rod rotation technique in posterior instrumentation surgery for correction of adolescent idiopathic scoliosis
Authors: Ito Manabu , Abumi Kuniyoshi , Kotani Yoshihisa , Takahata Masahiko , Sudo Hideki , Hojo Yoshihiro , Minami Akio
Published: February 2011

The authors present a new posterior correction technique consisting of simultaneous double-rod rotation using 2 contoured rods and polyaxial pedicle screws with or without Nesplon tapes. The purpose of this study is to introduce the basic principles and surgical procedures of this new posterior surgery for correction of adolescent idiopathic scoliosis. Through gradual rotation of the concave-side rod by 2 rod holders, the convex-side rod simultaneously rotates with the the concave-side rod. This procedure does not involve any force pushing down the spinal column around the apex. Since this procedure consists of upward pushing and lateral translation of the spinal column with simultaneous double-rod rotation maneuvers, it is simple and can obtain thoracic kyphosis as well as favorable scoliosis correction. This technique is applicable not only to a thoracic single curve but also to double major curves in cases of adolescent idiopathic scoliosis.
Long-term back pain after a single-level discectomy for radiculopathy: incidence and health care cost analysis
Authors: Parker Scott L. , Xu Risheng , McGirt Matthew J. , Witham Timothy F. , Long Donlin M. , Bydon Ali
Published: February 2011

Object

The most common spinal procedure performed in the US is lumbar discectomy for disc herniation. Longterm disc degeneration and height loss occur in many patients after lumbar discectomy. The incidence of mechanical back pain following discectomy varies widely in the literature, and its associated health care costs are unknown. The authors set out to determine the incidence of and the health care costs associated with mechanical back pain attributed to segmental degeneration or instability at the level of a prior discectomy performed at their institution.

Methods

The authors retrospectively reviewed the data for 111 patients who underwent primary, single-level lumbar hemilaminotomy and discectomy for radiculopathy. All diagnostic modalities, conservative therapies, and operative treatments used for the management of postdiscectomy back pain were recorded. Institutional billing and accounting records were reviewed to determine the billed costs of all diagnostic and therapeutic measures.

Results

At a mean follow-up of 37.3 months after primary discectomy, 75 patients (68%) experienced minimal to no back pain, 26 (23%) had moderate back pain requiring conservative treatment only, and 10 (9%) suffered severe back pain that required a subsequent fusion surgery at the site of the primary discectomy. The mean cost per patient for conservative treatment alone was $4696. The mean cost per patient for operative treatment was $42,554. The estimated cost of treatment for mechanical back pain associated with postoperative same-level degeneration or instability was $493,383 per 100 cases of first-time, single-level lumbar discectomy ($4934 per primary discectomy).

Conclusions

Postoperative mechanical back pain associated with same-level degeneration is not uncommon in patients undergoing single-level lumbar discectomy and is associated with substantial health care costs.
Epidemiological trends of spine and spinal cord injuries in the largest Canadian adult trauma center from 1986 to 2006
Authors: Pirouzmand Farhad
Published: February 2011

Object

In this study the author documents the epidemiology of spine and spinal cord injuries (SCIs) over 2 decades at the largest Level I adult trauma center in Canada. He describes the current state of spine injuries (SIs), their changing patterns over the years, and the relative distribution of different demographic factors in a defined group of trauma patients.

Methods

Data on all trauma patients admitted to Sunnybrook Health Sciences Centre between 1986 and 2006 were collected from the Sunnybrook Trauma Registry Database. Aggregate data on SIs and SCIs, including demographic information, etiology, severity of injuries (injury severity score [ISS]), and associated injuries, were recorded. The data were analyzed in a main category of spinal fracture and/or dislocation with or without SI and in two subgroups of patients with SIs, one encompassing all forms of SCIs and the other including only complete SCIs (CSCIs). Collected data were evaluated using univariate techniques to depict the trend of variables over the years. The number of deaths per year and the length of stay (LOS) were used as crude measures of outcome. Several multivariate analysis techniques, including Poisson regression, were used to model the frequency of death and LOS as functions of various trauma variables.

Results

There were 12,192 trauma patients in the study period with 23.2% having SIs, 5.4% having SCIs, and 3% having CSCIs. The SCIs constituted 23.3% of all SIs. The respective characteristics of the SI, SCI, and CSCI groups were as follows: median age 36, 33, and 30 years; median LOS 18, 27, and 29 days; median ISS 29, 30, and 34; female sex ratio 34, 24, and 23%; and case fatality rate 16.7, 16.6, and 21%. Seventy-nine percent of patients had associated head injuries; conversely, 24% of patients with head injuries had SIs. The mean admission age of patients increased by ~ 10 years over the study period, from the early 30s to the early 40s. The relative incidence of SIs remained stable at ~ 23%, but the incidence of SCIs decreased ~ 40% over time to 4.5%. Motor vehicle accidents remained the principal etiology of trauma, although falling and violence became more frequent contributors of SIs. The average annual ISS remained stable over time, but the LOS was reduced by 50% in both the SI and SCI groups. Age, ISS, and SCIs were associated with a longer LOS. The case fatality rate remained relatively unchanged over time. Poisson analysis suggested that the presence of an SCI does not change the case fatality rate.

Conclusions

Data in this analysis will provide useful information to guide future studies on changing SI patterns, possible etiologies, and efficient resource allocation for the management of these diseases.
Cervicosternotomy as an anterior approach to the upper thoracic and cervicothoracic spinal junction
Authors: Fuentes Stéphane , Malikov Sergueï , Blondel Benjamin , Métellus Philippe , Dufour Henry , Grisoli François
Published: February 2011

Object

The cervicothoracic junction is always a difficult area to approach. When operating on this specific area (for tumor or trauma), the aim is generally to decompress and stabilize the spine. The authors describe an improved median sternotomy method for reaching the anterior aspect of the spine down to T-5.

Methods

Seven patients with a mean age of 40 years (range 17–68 years) were included in this study. The vertebral lesion was due to trauma in 4 cases and tumor in the other 3. A single vertebral body was involved in 2 cases, 2 in 3 cases, and 3 in 2 cases. The vertebra most often involved was T-3 (6 cases), although T-4 was involved in 2 cases, T-5 in 2 cases, and T-1 and T-2 in 1 case each. All patients underwent the same preoperative workup: CT scanning, MR imaging, and CT angiography of the aortic arch.

Results

The median sternotomy made it possible to effectively decompress and stabilize the spinal cord. An anterior screw plate was used in 5 cases. The plate extended from T-2 to T-5 in 3 cases, from T-2 to T-4 in 2 cases, and from C-7 to T-4 in 1 case. The mean duration of surgery was 195 minutes (range 180–240 minutes). No neurological deterioration occurred. The mean hospital stay was 8 days (range 6–15 days). In 2 cases (28.6%), recurrent left nerve palsy was observed postoperatively; the palsy was transient in both of these cases, and full recovery occurred within 3 months. The mean follow-up among this series of patients was 29 months (range 22–38 months).

Conclusions

The median sternotomy provided a good means of reaching the upper thoracic spine (T2–5) and cervicothoracic junction. It enables surgeons to decompress the spinal cord and stabilize the spine.
Accuracy and pitfalls of multidetector-row computed tomography in detecting spinal dural arteriovenous fistulas
Authors: Yamaguchi Satoshi , Nagayama Tetsuya , Eguchi Kuniki , Takeda Masaaki , Arita Kazunori , Kurisu Kaoru
Published: February 2011

Object

The purpose of this study was to evaluate the accuracy of multidetector-row CT angiography (MDCTA) in demonstrating spinal dural arteriovenous fistulas (SDAVFs).

Methods

The authors studied 10 patients with SDAVFs, including 2 with spinal epidural AVFs, who underwent preoperative MR imaging, MDCTA, and digital subtraction angiography (DSA). In the evaluation of coronal sections of multiplanar reformation MDCTA images, inspection was focused on the presence of the following findings: 1) dilated perimedullary veins in the spinal canal; 2) focal enhancement of the nerve root, suggesting the location of the AVF, around the dural sleeve; and 3) a radicular vein that drains the AVF into perimedullary veins. The utility of MDCTA was assessed by comparing its findings with those of DSA in each case.

Results

Digital subtraction angiography confirmed that the AVFs were located in the thoracic spine in 4 patients and in the lumbar spine in 6 patients, and MDCTA detected dilated perimedullary veins in all 10 patients. In 8 patients, there was focal enhancement of the nerve root. The radicular vein that drains the AVF into the perimedullary veins was found in 8 cases. In 8 cases, the MDCTA-derived level and side of the AVF and its feeder corresponded with those shown by DSA. In 2 patients, however, the MDCTA-derived side of the feeder was on the side contralateral to the feeding artery confirmed by DSA. These lesions were interpreted as spinal epidural AVFs with perimedullary drainage. In 2 cases, MDCTA could not detect the multiplicity of their feeders.

Conclusions

The use of MDCTA preceding DSA can be helpful to focus the selective catheter angiography on certain spinal levels. However, one should keep in mind that epidural AVFs with perimedullary drainage may resemble SDAVFs and also that MDCTA cannot exclude the possibility of multiple feeders. Further research should elucidate how broadly selective angiography should explore around the MDCTA-suggested target.
The evolution of military neurosurgery in the Turkish army
Authors: Izci Yusuf
Published: February 2011

The history of neurosurgery in the Turkish army is not long and complex. Neurosurgery was first practiced in the Ottoman army by Cemil Pasha, who was a general surgeon. After the fall of the Ottoman Empire, the Republic of Turkey was established and modern neurosurgical procedures were applied at the Gulhane Military Medical Academy (GMMA). Maj. Zinnur Rollas, M.D., was the founder of the Department of Neurosurgery at GMMA in 1957. A modern neurosurgical program and school was established in 1965 by Col. Hamit Ziya Gokalp, M.D., who completed his residency training in the US. Today, 26 military neurosurgeons are on active duty in 11 military hospitals in Turkey. All of these neurosurgeons work in modern clinics and operating theaters. In this paper, military neurosurgery in the Turkish army is reported in 3 parts: 1) the history of neurosurgery in the Turkish military, 2) the Department of Neurosurgery at the GMMA, and 3) the duties of a military neurosurgeon in the Turkish army.
Management of unilateral cervical radiculopathy in the military: the cost effectiveness of posterior cervical foraminotomy compared with anterior cervical discectomy and fusion
Authors: Tumialán Luis M. , Ponton Ryan P. , Gluf Wayne M.
Published: February 2011

Object

To review the cost effectiveness for the management of a unilateral cervical radiculopathy with either posterior cervical foraminotomy (PCF) or anterior cervical discectomy and fusion (ACDF) in military personnel, with a particular focus on time required to return to active-duty service.

Methods

Following internal review board approval, the authors conducted a retrospective review of 38 cases in which patients underwent surgical management of unilateral cervical radiculopathy. Nineteen patients who underwent PCF were matched for age, treatment level, and surgeon to 19 patients who had undergone ACDF. Successful outcome was determined by return to full, unrestricted active-duty military service. The difference in time of return to active duty was compared between the groups. In addition, a cost analysis consisting of direct and indirect costs was used to compare the PCF group to the ACDF group.

Results

A total of 21 levels were operated on in each group. There were 17 men and 2 women in the PCF group, whereas all 19 patients in the ACDF group were men. The average age at the time of surgery was 41.5 years (range 27–56 years) and 39.3 years (range 24–52 years) for the PCF and ACDF groups, respectively. There was no statistically significant difference in operating room time, estimated blood loss, or postoperative narcotic refills. Complications included 2 cases of transient recurrent laryngeal nerve palsy in the ACDF group. The average time to return to unrestricted full duty was 4.8 weeks (range 1–8 weeks) in the PCF group and 19.6 weeks (range 12–32 weeks) in the ACDF group, a difference of 14.8 weeks (p < 0.001). The direct costs of each surgery were $3570 for the PCF and $10,078 for the ACDF, a difference of $6508. Based on the 14.8-week difference in time to return to active duty, the indirect cost was calculated to range from $13,586 to $24,045 greater in the ACDF group. Total cost (indirect plus direct) ranged from $20,094 to $30,553 greater in the ACDF group.

Conclusions

In the management of unilateral posterior cervical radiculopathy for military active-duty personnel, PCF offers a benefit relative to ACDF in immediate short-term direct and long-term indirect costs. The indirect cost of a service member away from full, unrestricted active duty 14.8 weeks longer in the ACDF group was the main contributor to this difference.
Posterior lumbar interbody fusion versus posterolateral fusion with instrumentation in the treatment of low-grade isthmic spondylolisthesis: midterm clinical outcomes
Authors: Müslüman Ahmet Murat , Yılmaz Adem , Cansever Tufan , Çavuşoğlu Halit , Çolak İbrahim , Genç H. Ali , Aydın Yunus
Published: February 2011

Object

The purpose of this study was to compare the methods of posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) in cases of isthmic Grades 1 and 2 lumbar spondylolisthesis, and to evaluate the clinical efficacy of the procedures.

Methods

Operations were performed in 50 patients with lumbar spondylolisthesis in the authors' clinics between 2001 and 2007. Indications for surgery were low-back pain with or without sciatica and neurogenic claudication that had not improved after at least 6 months of conservative treatment. The study included 33 female and 17 male patients, with mean ages of 50.6 years in the PLIF group and 47.3 years in the PLF group.

These patients were randomly allocated into 2 groups: decompression, posterior transpedicular instrumentation, and PLF (Group 1; 25 patients) and decompression, posterior transpedicular instrumentation, and PLIF (Group 2; 25 patients). In the PLIF group, titanium cages were used, and autograft material was obtained from the decompression. In the PLF group, bone fragments collected from the iliac crest were used as autografts. A minimum 18-month follow-up was available in all patients. For clinical evaluation, a visual analog scale, Oswestry Disability Index, and the 36-Item Short Form Health Survey were used. Improvements in pre- and postoperative spondylolisthesis, segmental angles, fusion ratios, and postoperative complications were evaluated radiologically.

Results

The average follow-up period was 3.3 years. Based on the etiologies, isthmic spondylolisthesis was detected in all patients. The spondylolisthesis levels in the patients who underwent PLIF were located at L3–4 (5 patients, 20%); L4–5 (14, 56%); and L5–S1 (6, 24%), whereas the levels in the ones treated with PLF were located at L3–4 (4 patients, 16%); L4–5 (13, 52%); and L5–S1 (8, 32%). In the clinical evaluations, good or excellent results were obtained in 22 (88%) cases in the PLIF group and 19 (76%) cases in the PLF group. Fusion ratios were 100% in the PLIF group and 84% in the PLF group. Both lumbar lordosis and the segmental angle showed greater improvement in the PLIF group. There was no difference in the complication rates for each group.

Conclusions

Based on early clinical outcomes and the fusion ratios of adult isthmic spondylolisthesis, the authors found PLIF to be superior to PLF.
A novel modification for removal of the polyethylene core in artificial disc retrieval using a transpsoas minimally invasive technique
Authors: Cheng Wayne K. , Jadhav Vikram , Palmer Daniel K.
Published: February 2011

Total disc replacement (TDR) surgeries have significantly increased in number since US FDA approval. However, the associated complications such as implant malposition, loosening, subsidence, implant migration, fractures, and infection may necessitate retrieval of the artificial disc and proceeding with interbody fusion. Retrieval of artificial discs in proximity to important vascular, urological, and other vital anatomical structures (for example, L4–5) presents numerous difficulties to spine and approach surgeons. To avoid the impediments of an anterior revision approach, in 2006 Pimenta et al. described an effective transpsoas lateral minimally invasive approach to retrieve the TDR device. In this paper, the authors adopted this technique in their surgical practice; however, they realized that a complex step involved the removal of the polyethylene core. The polyethylene core is compressed between the device endplates and is difficult to remove with the aid of a Kocher clamp as advised by Pimenta et al. Moreover, distraction on the endplates or the vertebral bodies to decrease the compression across the core is laborious, time consuming, and often not possible due to the approach and location of the lumbar plexus. In the present paper, the authors propose a novel modification to the polyethylene core removal with the use of a screw to create a better lever arm, apply effective distraction, and secure a good grip to enable core retrieval. This modification significantly reduced the operating time.
Delayed detection of carotid–cavernous fistulas associated with wartime blast–induced craniofacial trauma
Authors: Vadivelu Sudhakar , Bell Randy Scott , Crandall Ben , DeGraba Tom , Armonda Rocco A.
Published: February 2011

Blast-induced neurotrauma is a leading cause of military casualties. Its effects on cerebrovascular structures are not well understood. Vascular injury resulting from overpressure shock wave impact may have a delayed presentation and detection. The authors present the cases of 2 patients who sustained blast-induced craniofacial trauma and brain injury. Detection of a cervical dissection was delayed in one patient, and detection of carotid-cavernous fistulas was delayed in both patients. The authors report the successful obliteration of both the dissection and the carotidcavernous fistulas via an endovascular approach. Endovascular management provides both a reasonable and effective therapeutic option to blast-induced cerebrovascular injuries.
German military neurosurgery at home and abroad
Authors: Mauer Uwe Max , Schulz Chris , Rothe Ronny , Kunz Ulrich
Published: February 2011

For many years, the experience of neurosurgeons from the German Armed Forces was limited to the peacetime care of patients in Germany. In 1995, German military neurosurgeons were deployed abroad for the first time. Since the beginning of the International Security Assistance Force mission, there has been a rapidly increasing number of opportunities for military neurosurgeons to broaden their experience during deployments abroad.

Since the first deployment of a neurosurgeon to the German field hospital in Mazar-e-Sharif, Afghanistan, a total of 140 neurosurgical procedures have been performed there. Sixty-four surgeries were performed for cranial or spinal neurotrauma management. During the entire period, only 10 International Security Assistance Force members required acute or urgent neurosurgical interventions. The majority of neurosurgical procedures were performed in Afghan patients who received acute and elective treatment whenever the necessary infrastructure was available in the field hospital. Fifteen patients from the Afghan National Army and Police and 115 local patients underwent neurosurgery. Sixty-two procedures were carried out under acute or urgent conditions, and 78 operations were elective.
Combat surgeons before, during, and after war: the legacy of Loyal Davis
Authors: Cannon Jeremy W. , Teff Richard J.
Published: February 2011

By 1942, Loyal Davis had firmly established himself as a preeminent civilian neurosurgeon. With military operations rapidly escalating, he was recruited to serve in the European Theater of Operations as a consultant to the Surgeon General. Davis brought tremendous experience, insight, and leadership to this position; however, he found the military system in which he was suddenly immersed inefficient and impassive. His requests for even basic equipment became mired in endless bureaucracy even as his communiqués to the Chief Surgeon in the European Theater and to the Surgeon General's staff in Washington seemed to fall short of their intended recipients. Then, when he attempted to vent his frustrations to his academic colleagues, he was nearly court-martialed. Notwithstanding, Davis became the first to formally recognize high-altitude frostbite and also developed protective headgear for airmen, and later in his service, he joined a contingent of senior medical leaders who visited the Soviet Union to study their system of combat casualty care. Subsequent to his service on active duty, Davis returned to his academic practice at Northwestern where he used his position as editor of Surgery, Gynecology, and Obstetrics to advocate for change within the military medical corps. Others like Davis have contributed greatly to the advancement of combat casualty care both during active service and long after their time in uniform. This paper examines the lessons from Davis's experiences as a military neurosurgeon and his continued advocacy for change in the medical corps along with additional recent examples of change effected by former military surgeons. For those currently serving, these lessons illustrate the value of contributing wherever a need is recognized, and for those who have served in the past, they demonstrate the importance of having a continued voice with junior combat surgeons and the military leadership.
The evolution of the treatment of traumatic cerebrovascular injury during wartime
Authors: Bell Randy S. , Ecker Robert D. , Severson Meryl A. , Wanebo John E. , Crandall Benjamin , Armonda Rocco A.
Published: February 2011

The approach to traumatic craniocervical vascular injury has evolved significantly in recent years. Conflicts prior to Operations Iraqi and Enduring Freedom were characterized by minimal intervention in the setting of severe penetrating head injury, in large part due to limited far-forward resource availability. Consequently, sequelae of penetrating head injury like traumatic aneurysm formation remained poorly characterized with a paucity of pathophysiological descriptions. The current conflicts have seen dramatic improvements with respect to the management of severe penetrating and closed head injuries. As a result of the rapid field resuscitation and early cranial decompression, patients are surviving longer, which has led to diagnosis and treatment of entities that had previously gone undiagnosed. Therefore, in this paper the authors' purpose is to review their experience with severe traumatic brain injury complicated by injury to the craniocervical vasculature. Historical approaches will be reviewed, and the importance of modern endovascular techniques will be emphasized.