bluuebunny/crossref_metadata_2025 huggingface dataset:
Benign sacral tumors
Authors: Deutsch Harel , Mummaneni Praveen V. , Haid Regis W. , Rodts Gerald E. , Ondra Stephen L.
Published: January 2008

Primary tumors of the sacrum are rare. In adults, the most common sacral tumors are metastases. The most common primary sacral tumor is a chordoma. Chordomas along as well as tumors such as chondrosarcomas, osteosarcomas, myxopapillary ependymomas, myelomas, and Ewing sarcomas are considered malignant. In this article the authors focus on benign sacral tumors.
Diagnosis and management of sacral Tarlov cysts
Authors: Acosta Frank L. , Quinones-Hinojosa Alfredo , Schmidt Meic H. , Weinstein Philip R.
Published: January 2008

Perineurial (Tarlov) cysts are meningeal dilations of the posterior spinal nerve root sheath that most often affect sacral roots and can cause a progressive painful radiculopathy. Tarlov cysts are most commonly diagnosed by lumbosacral magnetic resonance imaging and can often be demonstrated by computerized tomography myelography to communicate with the spinal subarachnoid space. The cyst can enlarge via a net inflow of cerebrospinal fluid, eventually causing symptoms by distorting, compressing, or stretching adjacent nerve roots. It is generally agreed that asymptomatic Tarlov cysts do not require treatment. When symptomatic, the potential surgery-related benefit and the specific surgical intervention remain controversial. The authors describe the clinical presentation, treatment, and results of surgical cyst fenestration, partial cyst wall resection, and myofascial flap repair and closure in a case of a symptomatic sacral Tarlov cyst. They review the medical literature, describe various theories on the origin and pathogenesis of Tarlov cysts, and assess alternative treatment strategies.
Anatomy of the sacrum
Authors: Cheng Joseph S. , Song John K.
Published: January 2008

One of the basic tenets of performing surgery is knowledge of the relevant anatomy. Surgeons incorporate this knowledge along with factors, such as biomechanics and physiology, to develop their operative approaches and procedures. In the diagnosis and management of sacral tumors, the need to be familiar with the anatomy of the sacrum is no less important than knowledge of the pathological entity involved. This article will provide an overview of the embryology and anatomy of the sacrum, along with concepts as applied to surgical intervention.
Lumbosacropelvic junction reconstruction resulting in early ambulation for patients with lumbosacral neoplasms or osteomyelitis
Authors: Mindea Stefan A. , Salehi Sean A. , Ganju Aruna , Rosner Michael K. , O'Shaughnessy Brian A. , Jorge Allan , Ondra Stephen L.
Published: January 2008

Lumbosacropelvic junction instability may result from a variety of disease processes including primary and meta-static sacral tumors and degenerative disease. Regardless of the origin of the disease, restoring or maintaining spinal stability at this junction is essential for normal translation of axial forces from the lumbar spine and sacrum to the pelvis. Spinal stability is also critical for maintaining structural integrity, preventing neurological function deterioration, and alleviating resultant mechanical or axial pain. In this report, the authors describe one option for safe and effective spinal pelvic stabilization by using a transiliac rod and iliac bolt construct, which results in early postoperative ambulation, preserved neurological function, and reduced axial pain in selected patients.
CyberKnife frameless single-fraction stereotactic radiosurgery for tumors of the sacrum
Authors: Gerszten Peter C. , Ozhasoglu Cihat , Burton Steven A. , Welch William C. , Vogel William J. , Atkins Barbara A. , Kalnicki Shalom
Published: January 2008

Object

The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. The experience with radiosurgery for the treatment of spinal and sacral lesions is more limited. Sacral lesions should be amenable to radiosurgical treatment similar to that used for their intracranial counterparts. The authors evaluated a single-fraction radiosurgical technique performed using the CyberKnife Real-Time Image-Guided Radiosurgery System for the treatment of the sacral lesion.

Methods

The CyberKnife is a frameless radiosurgery system based on the coupling of an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, which guides the therapy beam to the intended target without the need for frame-based fixation. All sacral lesions were located and tracked for radiation delivery relative to fiducial bone markers placed percutaneously. Eighteen patients were treated with single-fraction radiosurgery. Tumor histology included one benign and 17 malignant tumors.

Dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Planning treatment volume was defined as the radiographically documented tumor volume with no margin. Tumor dose was maintained at 12 to 20 Gy to the 80% isodose line (mean 15 Gy). Tumor volume ranged from 23.6 to 187.4 ml (mean 90 ml). The volume of the cauda equina receiving greater than 8 Gy ranged from 0 to 1 ml (mean 0.1 ml). All patients underwent the procedure in an outpatient setting. No acute radiation toxicity or new neurological deficits occurred during the mean follow-up period of 6 months. Pain improved in all 13 patients who were symptomatic prior to treatment. No tumor progression has been documented on follow-up imaging.

Conclusions

Stereotactic radiosurgery was found to be feasible, safe, and effective for the treatment of both benign and malignant sacral lesions. The major potential benefits of radiosurgical ablation of sacral lesions are relatively short treatment time in an outpatient setting and minimal or no side effects. This new technique offers a new and important therapeutic modality for the primary treatment of a variety of sacral tumors or for lesions not amenable to open surgical techniques.
Recurrent lumbar disc herniation
Authors: Swartz Karin R. , Trost Gregory R.
Published: January 2008

Recurrent lumbar disc herniation is a common disease process. It has been noted to occur in 5 to 15% of cases surgically treated for primary lumbar disc herniation. Outcomes in one series approached those after the initial operations, although this is not the case in the experience of most surgeons.

The removal of recurrent lumbar disc herniations requires meticulous surgical technique. Great care is taken to identify the osseous margins of the previous surgical site. Identification and dissection of scar from the dura mater is greatly aided with the use of a microscope.
Lumbar myofascial flap for pseudomeningocele repair
Authors: Misra Sanjay N. , Morgan Howard W. , Sedler Ross
Published: January 2008

Object

Initial management for lumbar pseudomeningoceles entails the closed external drainage of cerebrospinal fluid (CSF) with or without blood patch application. The presence of longstanding pseudomeningoceles and those associated with nonmicroscopic dural tears can be more problematic. Additionally the failure of nonoperative measures may necessitate surgery. Ideally the procedure should involve repairing the dural defect, removing the encapsulated cavity of the pseudomeningocele, and obliterating the extraspinal dead space to minimize the recurrence of the problem.

Methods

The authors describe a technique performed in 12 patients with large (> 5-cm-diameter) pseudomeningoceles referred for management following the failure of less aggressive measures. Diagnosis was based on symptoms of lumbar wound swelling, postural headaches, back and leg pain, and was confirmed by imaging studies. In all patients subarachnoid CSF drainage and initial operative attempts to obliterate the pseudomeningocele had failed. They were treated between July 1990 and July 1998. The cause of the pseudomeningoceles was lumbar discectomy (four patients), lumbar decompression (one patient), lumbar decompression and placement of instrumentation (five patients), and intradural procedures (two patients). Their mean age was 47.9 years (range 20–67 years), and they presented at a mean of 5.5 months postoperatively (range 3 weeks–37 months). In all cases there was a satisfactory repair of the pseudomeningocele, dead space obliteration, and long-term symptomatic resolution.

Conclusions

Lumbar myofascial advancement for this problem is a useful technique in cases of symptomatic pseudomeningoceles. This technique requires the medial advancement of the musculofascial units of the paravertebral muscles for a layered closure over the exposed spinal canal with obliteration of the pseudomeningocele.
Is spinal instrumentation a risk factor for late-onset infection in cases of distant infection or surgery?
Authors: Naderi Sait , Acar Feridun , Mertol Tansu
Published: January 2008

As a cause of revision spinal surgery, spinal epidural abscess after instrumentation-assisted fusion is rare in neurosurgical practice. Postoperative infections are frequently seen in the time period soon after surgery.

The authors report on the case of a 45-year-old woman who had undergone posterior instrumentation-augmented fusion for L4–5 degenerative spondylolisthesis. Ten months after the operation she presented to the neurosurgery clinic with complaints of severe low-back pain and radicular right lower-extremity pain. She had undergone laparoscopic surgery for acute cholecystitis 1 month prior to readmission. Radiological study revealed a spinal epidural abscess in communication with a right psoas abscess at L4–5. The abscess was drained percutaneously with the aid of C-arm fluoroscopic guidance, and a 6-week course of parenteral antibiotic therapy was administered.

Retrograde lymphatic bacterial translocation, hematopoietic spread, and the suitable charectaristics in the host may facilitate the development of infection around the implant. Thus, distant surgery and infection may be a risk factor in cases in which spinal instrumentation is placed. In such cases a prolonged antibiotic therapy for distant infection after surgery is recommended.
The biomechanics of iatrogenic spinal destabilization and implant failure
Authors: Schlenk Richard P. , Stewart Todd , Benzel Edward C.
Published: January 2008

Revision spinal surgery is usually indicated in cases of persistent or recurrent symptoms related to neural compression, spinal deformity, or construct failure. An understanding of fundamental biomechanical principles of both spinal decompression and reconstructive strategies is essential to avoid unnecessary subsequent spinal operations.
Management of strut graft failure in anterior cervical spine surgery
Authors: Thongtrangan Issada , Balabhadra Raju S. V. , Kim Daniel H.
Published: January 2008

Although successfully used, long strut grafts are vulnerable to dislodgment, displacement, fracture, and nonunion, which can require revision surgery; thus, meticulous preparation of the vertebral endplate along with exact sizing and harvesting of the bone graft with plating are essential for successful outcomes. Biomechanical data and previous clinical studies support the addition of posterior fusion and fixation following multilevel (more than two-level) corpectomy. The additional posterior instrumentation moves the instantaneous axis of rotation posteriorly, thus approximating its normal location in the posterior vertebral body (VB). Biomechanically, this protects the graft from excessive loads while in extension and explains the clinical success of circumferential instrumentation for long-segment corpectomy reconstructions. If strut fracture occurs with minimal displacement and the graft position is still satisfactory, application of a halo vest and judicious observation are recommended. Significant displacement, kyphosis, or loss of contact of the graft and VB require revision surgery. In patients requiring revision surgery for nonunion, placement of fibular autograft or allograft with use of bone morphogenetic protein is likely to be beneficial. If questions remain regarding bone quality or construct stability, the supplemental use of posterior stabilization is recommended. Various surgical approaches have been advocated for treatment of symptomatic anterior cervical pseudarthroses or nonunion. It remains controversial as to whether the anterior or posterior approach is best. Adequate understanding of the graft and implant biomechanics are essential for a successful outcome.
Postlaminectomy cervical deformity
Authors: Deutsch Harel , Haid Regis W. , Rodts Gerald E. , Mummaneni Praveen V.
Published: January 2008

Postlaminectomy cervical kyphosis is an important consideration when performing surgery. Identifying factors predisposing to postoperative deformity is essential. The goal is to prevent postlaminectomy cervical kyphosis while exposing the patient to minimal additional morbidity. When postlaminectomy kyphosis does occur, surgical correction is often required and performed via an anterior, posterior, or combined approach. The authors discuss the indications for surgical approaches as well as clinical results.
Surgery for postarthrodesis adjacent–cervical segment degeneration
Authors: Azmi Hooman , Schlenk Richard P.
Published: January 2008

Anterior cervical decompression and fusion has gained popularity because of its applicability to a variety of cervical spine disorders. The authors of long-term follow-up studies have demonstrated the development of degenerative changes in segments adjacent to fusion. So-called adjacent-segment disease causes symptomatic deterioration in up to 25% of the patients who have undergone anterior cervical decompression and fusion for cervical spondylotic myelopathy. The causes of this condition are debated in the literature. The authors provide a review of the available literature on the pathogenesis, prevention, and treatment of postarthrodesis adjacent-segment degenerative disease.
Revision strategies for lumbar pseudarthrosis
Authors: Ondra Stephen L. , Marzouk Shaden
Published: January 2008

Management and avoidance of lumbar pseudarthrosis are among the most common and challenging tasks faced by reconstructive spine surgeons. The risks of peudarthrosis can be broadly divided into two categories: those within a surgeon's control and those not within his/her control. These include biological factors, graft choices, site preparation, and surgical design. The authors review the biological factors that affect fusion and how they can be manipulated to avoid or manage lumbar pseudarthrosis. Surgical planning and construct design to prevent or treat pseudarthrosis will also be discussed. Additionally, the importance of restoring sagittal balance will be reviewed.
Deferoxamine-induced attenuation of brain edema and neurological deficits in a rat model of intracerebral hemorrhage
Authors: Nakamura Takehiro , Keep Richard F. , Hua Ya , Schallert Timothy , Hoff Julian T. , Xi Guohua
Published: January 2008

Object

In the authors' previous studies they found that brain iron accumulation and oxidative stress contribute to secondary brain damage after intracerebral hemorrhage (ICH). In the present study they investigated whether deferoxamine, an iron chelator, can reduce ICH-induced brain injury.

Methods

Male Sprague–Dawley rats received an infusion of 100 μl of autologous whole blood into the right basal ganglia and were killed 1, 3, or 7 days thereafter. Iron distribution was examined histochemically (enhanced Perl reaction). The effects of deferoxamine on ICH-induced brain injury were examined by measuring brain edema and neurological deficits. Apurinic/apyrimidinic endonuclease/redox effector factor–1 (APE/Ref-1), a repair mechanism for DNA oxidative damage, was quantitated by Western blot analysis.

Iron accumulation was observed in the perihematoma zone beginning 1 day after ICH. Deferoxamine attenuated brain edema, neurological deficits, and ICH-induced changes in APE/Ref-1.

Conclusions

Deferoxamine and other iron chelators may be potential therapeutic agents for treating ICH. They may act by reducing the oxidative stress caused by the release of iron from the hematoma.
Update on management of intracerebral hemorrhage
Authors: Pouratian Nader , Kassell Neal F. , Dumont Aaron S.
Published: January 2008

Intracerebral hemorrhage (ICH) is a lingering cause of significant mortality and morbidity rates in contemporary society. Despite its established burden, considerably less investigative attention has been devoted to the study of ICH than other forms of stroke. Only a limited number of clinical studies have been performed to examine the surgical (both craniotomy and minimally invasive) and medical management of patients with ICH. No consistently efficacious strategies have been identified through such investigations. Limitations in study design and execution have universally impaired the interpretation and impact of available data. Management of ICH unfortunately remains heterogeneous across institutions, and it continues to suffer from the lack of proven medical and surgical effectiveness. Urgently needed are further prospective randomized controlled trials in which investigators consider the shortcomings of previous endeavors in the management of ICH. In the present article the authors review the current management practices of ICH, discuss the controlled trials, and highlight recent trials and future avenues of further study.
Intracerebral hematoma from aneurysm rupture
Authors: Abbed Khalid M. , Ogilvy Christopher S.
Published: January 2008

Object

Patients who present with an intraparenchymal hematoma associated with a ruptured aneurysm usually require urgent clot evacuation and aneurysm obliteration. The impact of the presence of hematoma on outcome has been poorly characterized. The authors report on 460 patients who had dense subarachnoid hemorrhage (SAH) (Fisher Grades 3 and 4) with and without associated hematoma.

Methods

Of the 959 consecutive patients who presented with SAH, 460 patients with Fisher Grade 3 and 4 SAH were analyzed and divided into two groups: those with (Group 1) and those without (Group 2) hematoma. The presenting Hunt and Hess grade and 6-month outcomes of the two groups were compared.

Of the 460 patients, 116 (25%) had intraparenchymal hematomas and admission Hunt and Hess grades were worse in Group 1 compared with Group 2. Outcome scores were worse for Group 1 compared with Group 2; however, when comparing Group 1 and Group 2 within the same initial Hunt and Hess score, there was no statistical difference in outcome.

Conclusions

Intraparenchymal hematoma in association with SAH does not differ significantly from those patients without associated hematomas. We therefore recommend aggressive clot evacuation and aneurysm obliteration.
Treatment of metastatic spinal epidural disease: a review of the literature
Authors: Klimo Paul , Kestle John R. W. , Schmidt Meic H.
Published: January 2008

Object

Spinal cord compression is one of the most dreaded complications of metastatic cancer. It can lead to a number of sequelae, including pain, spinal instability, neurological deficits, and a reduction in the patient's quality of life. Except in selected circumstances, treatment is palliative. Treatment options include surgery, radiation, and chemotherapy. The goal of this study was to summarize the existing data on the outcomes of various treatment methods for metastatic spinal epidural disease and to make appropriate recommendations for their use.

Methods

The authors used a search strategy that included an electronic database search, a manual search of journals, analysis of bibliographies in relevant review papers, and consultation with the senior author. There is good evidence, including Class I data, that steroid drugs constitute a beneficial adjunctive therapy in patients with myelopathy from epidural compression. Historically, conventional radiation therapy has been viewed as the first-line treatment because it has been shown to be as effective as a decompressive laminectomy, with a lower incidence of complications (Class II data). Nevertheless, in the last 20 years there has been remarkable progress in surgical techniques and technology. Currently, the goals of surgery are to achieve a circumferential decompression of the spinal cord, and to reconstruct and immediately stabilize the spinal column. Results in a large body of literature support the belief that surgery is better at retaining or regaining neurological function than radiation and that surgery is highly effective in relieving pain. Most of the data on the treatment of metastatic spinal disease are Class II or III, but the preliminary results of a well-designed, randomized controlled trial in which surgery is compared with standard radiation therapy represents the first Class I data.

Conclusions

As the number of treatment options for metastatic spinal disease has grown, it has become clear that effective implementation of these treatments can only be achieved by a multidisciplinary approach.
Stereotactic radiosurgery for hemangiomas and ependymomas of the spinal cord
Authors: Ryu Stephen I. , Kim Daniel H. , Chang Steven D.
Published: January 2008

Object

The optimal treatment for intramedullary spinal tumors is controversial, because both resection and conventional radiation therapy are associated with potential morbidity. Stereotactic radiosurgery can theoretically deliver highly conformal, high-dose radiation to surgically untreatable lesions while simultaneously mitigating radiation exposure to large portions of the spinal cord. The purpose of this study was to evaluate the authors' initial experience with frameless stereotactic radiosurgery for intramedullary spinal tumors.

Methods

Between 1998 and 2003, 10 intramedullary spinal tumors were treated with stereotactic radiosurgery at the authors' institution. Seven hemangioblastomas and three ependymomas were treated in four men and three women. These patients either had recurrent tumors, had undergone several previous surgeries, had medical contraindications to surgery, or had declined open resection. Conformal treatment planning delivered a prescribed dose of 1800 to 2500 cGy (mean 2100 cGy) to the lesions in one to three stages. No significant treatment-related complications have been recorded. The mean radiographic and clinical follow-up duration was 12 months (range 1–24 months). One ependymoma and two hemangioblastomas were smaller on follow-up neuroimaging. The remaining tumors were stable at the time of follow-up imaging.

Conclusions

Stereotactic radiosurgery for intramedullary spinal tumors is feasible and safe in selected cases and may prove to be another therapeutic option for these challenging lesions.
Lumbosacral ependymomas: a review of the management of intradural and extradural tumors
Authors: Fassett Daniel R. , Schmidt Meic H.
Published: January 2008

Object

The goal of this study was to review the management of intra- and extradural ependymomas. Spinal ependymomas most commonly occur as intramedullary tumors throughout the spinal axis. In the lumbosacral region, ependymomas are most commonly associated with the conus medullaris and cauda equina, but can also occur extradurally in the sacrum, presacral tissues, or subcutaneous tissues over the sacrum. These two tumor locations produce different management concerns. Intradural ependymomas, especially those in the lumbosacral region, are now recognized for their potential to spread throughout the central nervous system (CNS), whereas extradural tumors elicit more concern for their association with extraneural metastases.

Methods

The authors have reviewed the literature regarding both of these distinct tumors and have summarized recommendations for the management of intra- and extradural lumbosacral ependymomas. For both tumors, it appears that gross-total resection is the treatment of choice when feasible. The role of radiation therapy has not been adequately studied for either tumor location, but most clinicians use this modality in patients with subtotal resection of intradural ependymomas, local recurrence, or CNS dissemination. Data supporting the use of radiation therapy for extradural ependymomas are lacking. There does not appear to be a significant role for chemotherapy in either tumor location.

Conclusions

Despite the risk for local recurrence and CNS dissemination, the prognosis for intradural lumbosacral ependymomas is good, with a greater than 90% 10-year patient survival in most series. The prognosis for extradural ependymomas does not appear to be as good. Much depends on extradural tumor location, however; the outlook is better for dorsal sacral tumors than presacral tumors.
En bloc spondylectomy for spinal metastases: a review of techniques
Authors: Yao Kevin C. , Boriani Stefano , Gokaslan Ziya L. , Sundaresan Narayan
Published: January 2008

Object

Spinal metastases are prevalent in the population of patients with cancer. Effective cancer therapy must incorporate treatment strategies for these lesions. Increasingly, surgery is being recognized as an effective treatment modality both for the patient's quality of life and potential oncological cure. En bloc spondylectomy is the surgical procedure of choice to obtain these goals. The purpose of this study was to examine critically the rationale, indications, and outcomes of en bloc spondylectomy for spinal metastases.

Methods

Outcomes in the authors' series of patients who underwent en bloc spondylectomy for spinal metastases are critically analyzed. The rationale and indications for this procedure are discussed. The Weinstein, Boriani, and Biagini surgical staging system for spinal tumors is described. A review of the literature is performed to examine further the rationale underlying this aggressive surgical approach to metastatic spinal disease.

Conclusions

En bloc spondylectomy is the treatment of choice for solitary and oligometastatic spinal metastases with biologically favorable histological findings. In appropriately selected patients, neurological outcome, pain control, and oncological control are significantly better after en bloc spondylectomy compared with radiation therapy. Oncological outcomes also exceed those of intralesional techniques. The Weinstein, Boriani, and Biagini surgical staging system provides a standard with which to plan surgical approaches and to compare surgical outcomes.
Retrospective analysis and modifications of retractor systems for anterior odontoid screw fixation
Authors: Shalayev Stan G. , Mun In Ki , Mallek Gregory S. , Palmer Sylvain , Levi Allan D. , Lasner Todd M. , Kantrowitz Allen B.
Published: January 2008

The authors present an in-depth retrospective analysis of retractor systems for anterior odontoid screw fixation. They discuss various modifications and innovations of such systems and describe their own tubular retractor system, in which a beveled end conformal to the ventral surface of the vertebral column at the C2–3 level is introduced together with an incorporated light source. This new retractor system allows optimal anatomical exposure for controlled odontoid screw placement with improved protection of surrounding vital structures.
History of spinal surgery: one neurosurgeon's perspective
Authors: McDonnell Dennis E.
Published: January 2008

Spinal surgery has advanced from decompression procedures to complex spinal reconstruction and internal stabilization within the last 25 years, as a result of a broad-based technological boom that began in the 1970s with the advent of spinal computerized tomography and magnetic resonance imaging. These technological advances have coincided with, and developed as a result of, the concomitant rise of a complex, economically driven consortium of innovative surgeons and researchers, academic institutions, government agencies, and private industry, to form a Medical–Industrial Complex (MeIC). A major growth industry has formed, resulting in an overall societal benefit. Nevertheless, it has impacted graduate medical education and has significantly increased the cost of treating spinal disorders. Back pain and spinal disorders are a major societal health problem that is associated with a high demand for treatment services. There is a potential for abuse as well as a benefit in offering these services. The MeIC has contributed to the overall rise in the cost of health care insurance and in the migration of manufacturing jobs abroad as a solution for lowering production costs. The increased cost has had a negative impact on local and regional economies.
Nelson's wound: treatment of spinal cord injury in 19th and early 20th century military conflicts
Authors: Hanigan William C. , Sloffer Chris
Published: January 2008

During the first half of the 19th century, warfare did not provide a background for a systematic analysis of spinal cord injury (SCI). Medical officers participating in the Peninsular and Crimean Wars emphasized the dismal prognosis of this injury, although authors of sketchy civil reports persuaded a few surgeons to operate on closed fractures. The American Medical and Surgical History of the War of the Rebellion was the first text to provide summary of results in 642 cases of gunshot wounds of the spine. The low incidence of this injury (0.26%) and the high mortality rate (55%) discouraged the use of surgery in these cases. Improvements in diagnoses and the introduction of x-ray studies in the latter half of the century enabled Sir G. H. Makins, during the Boer War, to recommend delayed intervention to remove bone or bullet fragments in incomplete injuries. The civil experiences of Elsberg and Frazier in the early 20th century promoted a meticulous approach to treatments, whereas efficient transport of injured soldiers during World War I increased the numbers of survivors. Open large wounds or cerebrospinal fluid leakage, signs of cord compression in recovering patients, delayed clinical deterioration, or intractable pain required surgical exploration. Wartime recommendations for urological and skin care prevented sepsis, and burgeoning pension systems provided specialized long-term rehabilitation. By the Armistice, the effective surgical treatment and postoperative care that had developed through decades of interaction between civil and military medicine helped reduce incidences of morbidity and dispel the hopelessness surrounding the combatant with an SCI.
A brief history of therapy for traumatic spinal cord injury
Authors: Lifshutz Jason , Colohan Austin
Published: January 2008

There are few more devastating injuries that afflict man than those associated with spinal cord injury (SCI). The economic, psychological, and social impact are encompassing and enormous to the individual and society. During the last several years, there has been a renewed interest in the study of SCI, with the hope of finding a cure. It is appropriate, then, to examine the efforts accomplished throughout medical history. With this retrospective view, potential avenues for future treatment become more apparent and clear. As in the past, the integration of basic science and clinical innovation will create the path toward progress for treatment of this disease.
Sciatica: a historical perspective on early views of a distinct medical syndrome
Authors: Karampelas Ioannis , Boev Angel N. , Fountas Kostas N. , Robinson Joe Sam
Published: January 2008

The authors offer a brief overview of early theories and treatments of sciatica. Tracing medical traditions through early Greek, Roman, and Eastern epochs, the authors demonstrate the slow sequential steps that were required to delineate this disease as a uniquely human affliction.
The “tract” of history in the treatment of lumbar degenerative disc disease
Authors: Chedid Khalil J. , Chedid Mokbel K.
Published: January 2008

In this paper past, present, and future treatments of degenerative disc disease (DDD) of the lumbar spine are outlined in a straight forward manner. This is done to review previous knowledge of the disease, define current treatment procedures, and discuss future perspectives. An analysis of a subject of this magnitude dictates that one describes as accurate a history as possible: an anatomical/historical “tract” with emphasis on all possible deviations.

Although spinal disorders have been recognized for a long time, the view of DDD as a particular disease entity is a more recent development. In this paper, the authors attempt to outline the history of DDD of the lumbar spine in an unbiased and scientific fashion. Physiological, diagnostic, and therapeutic implications will all be addressed in this study.
Anterior cervical plates: a historical perspective
Authors: Moftakhar Roham , Trost Gregory R.
Published: January 2008

The development of anterior cervical plates (ACPs) represents a rapidly changing aspect of spine surgery. This paper focuses on a historical overview of ACPs. The authors discuss the disadvantages of earlier generations of plates and demonstrate how current plates have been designed to overcome the presumed shortcomings of their predecessors.

This historical review begins with the earliest plates—unrestricted backout plates—and moves on to newer plates—restricted backout plates and their different subcategories.

Virtually all modern ACPs work equally well in cervical stabilization; however, there are differences in design that warrant future studies to understand the long-term performances of different plates.
Intraoperative monitoring for tethered cord surgery: an update
Authors: Kothbauer Karl F. , Novak Klaus
Published: January 2008

Object

Intraoperative neurophysiological recording techniques have found increasing use in neurosurgical practice. The development of new recording techniques feasible while the patient receives a general anesthetic have improved their practical use in a similar way to the use of digital recording, documentation, and video technology. This review intends to provide an update on the techniques used and their validity.

Methods

Two principal methods are used for intraoperative neurophysiological testing during tethered cord release. Mapping identifies functional neural structures, namely nerve roots, and monitoring provides continuous information on the functional integrity of motor and sensory pathways as well as reflex circuitry. Mapping is performed mostly by using direct electrical stimulation of a structure within the surgical field and recording at a distant site, usually a muscle. Sensory mapping can also be performed with peripheral stimulation and recording within the surgical site. Monitoring of the motor system is achieved with motor evoked potentials. These are evoked by transcranial electrical stimulation and recorded from limb muscles and the external anal sphincter. The presence or absence of muscle responses are the parameters monitored. Sensory potentials evoked by tibial or pudendal nerve stimulation and recorded from the dorsal columns via an epidurally inserted electrode and/or from the scalp as cortical responses are used to access the integrity of sensory pathways. Amplitudes and latencies of these responses are then interpreted. The bulbocavernosus reflex, with stimulation of the pudendal nerve and recording of muscle responses in the external anal sphincter, is used for continuous monitoring of the reflex circuitry. Presence or absence of this response is the pertinent parameter that is monitored.

Conclusions

Intraoperative neurophysiology provides a wide and reliable set of techniques for intraoperative identification of neural structures and continuous monitoring of their functional integrity.
Management of hydrocephalus in the patient with myelomeningocele: an argument against third ventriculostomy
Authors: Marlin Arthur E.
Published: January 2008

The majority of children with myelomeningocele will have associated hydrocephalus. The management of hydrocephalus can be one of the most trying problems in this patient population. Cerebrospinal fluid (CSF) diversion will be required in these children for the remainder of their lives. Blockage of the outlets of the fourth ventricle and communication of the fourth ventricle with the central canal provides a mechanism for compensation. The signs and symptoms of CSF diversion malfunction, either shunt or third ventriculostomy, can be quite subtle. The objective indications of these malfunctions are less available after third ventriculostomy than when using mechanical shunting. The ease with which the diagnosis of malfunction can be made becomes the major advantage of mechanical shunting over third ventriculostomy.
Pathophysiology of tethered cord syndrome: correlation with symptomatology
Authors: Yamada Shokei , Won Daniel J. , Yamada Shoko M.
Published: January 2008

Tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord. The mechanical cause of TCS is an inelastic structure anchoring the caudal end of the spinal cord that prevents cephalad movement of the lumbosacral cord. Stretching of the spinal cord occurs in patients either when the spinal column grows faster than the spinal cord or when the spinal cord undergoes forcible flexion and extension.

Research in patients and experimental animals suggests that there is a link between the clinical dysfunctions that characterize TCS and putative pathophysiological changes that accompany this syndrome. Among these changes are depression of electrophysiological activity and shifts in the reduction/oxidation ratio of cytochrome oxidase. The latter suggests that there is impairment of oxidative metabolism. These putative pathophysiological changes in TCS occur mainly within the lumbosacral cord under excessive tension.

The authors discuss the pathophysiology of TCS and examine related symptoms.
Tethered spinal cord following repair of myelomeningocele
Authors: Hudgins Roger J. , Gilreath C. Lynn
Published: January 2008

Object

The goal of this paper is to elucidate the clinical presentation of tethered cord syndrome (TCS) following repair of a myelomeningocele.

Methods

Approximately 10 to 30% of children will develop TCS following repair of a myelomeningocele. Because essentially all children with repaired myelomeningocele will have a tethered spinal cord, as demonstrated on MR imaging, the diagnosis of TCS is made based on clinical criteria. The six common clinical presentations of TCS are increased weakness (55%), worsening gait (54%), scoliosis (51%), pain (32%), orthopedic deformity (11%), and urological dysfunction (6%). The primary goal of surgery is to detach the spinal cord where it is adherent to the thecal sac, relieving the stretch on the terminal portion of the cord.

Conclusions

Early diagnosis and surgical release of the tethered cord results in stabilization or improvement in most cases. Because TCS may present with orthopedic and/or urological signs or symptoms, children with myelomeningocele should by followed, ideally in a multidisciplinary clinic, by neurosurgeons, orthopedic surgeons, and urologists who are aware of this condition.
Lumbar interbody fusion after treatment with recombinant human bone morphogenetic protein–2 added to 70:30 poly(L-lactide-co-D,L-lactide) bioresorbable implants
Authors: Lanman Todd H. , Hopkins Thomas J.
Published: January 2008

Object

To evaluate the effectiveness of recombinant human bone morphogenetic protein–2 (rhBMP-2) combined with a bioresorbable implant, the authors conducted a prospective study of 43 patients with degenerative lumbar disc disease who underwent transforaminal lumbar interbody fusion.

Methods

The authors used Infuse bone graft, which consisted of rhBMP-2 applied to an absorbable collagen sponge and contained within a HYDROSORB Telamon bioresorbable implant to perform the fusion. Multilevel fusions were performed in 30% of the 43 patients, for a total of 57 levels. At 6 months postoperatively, x-ray films and computerized tomography (CT) scans demonstrated solid fusion in 98% of 41 patients. Improvement from the baseline Oswestry Disability Rating was demonstrated at 6 months postoperatively in 68% of the patients, based on the Oswestry Disability Questionnaire. At 12 months all 11 patients in whom CT scans were obtained showed complete bridging of bone; there were no device-related complications.

Conclusions

Results in this series provide evidence of the feasibility of using HYDROSORB Telamon biore-sorbable spacers in combination with Infuse bone graft for lumbar spine fusion.
Porous polyethylene implant for cranioplasty and skull base reconstruction
Authors: Liu James K. , Gottfried Oren N. , Cole Chad D. , Dougherty William R. , Couldwell William T.
Published: January 2008

Object

Cranial reconstruction after skull base surgery is important for restoration of function and cosmesis. The authors describe their experience with the Medpor porous polyethylene implant for cosmetic cranioplasty and reconstruction after skull base surgery.

Methods

Medpor, a biocompatible implant, is flexible and can be contoured to facilitate surgical reconstruction of small to medium (< 8 cm) convexity or cranial base defects resulting from a variety of skull base approaches. This method provides similar cosmetic results to standard alloplast cranioplasty while decreasing operating time. The porous nature of the material allows ingrowth of soft tissue and bone to increase implant strength and decrease the risk of infection. This material can also be used safely in reconstruction of the cranium and skull base adjacent to the paranasal sinuses.

Conclusions

The authors have used the Medpor porous polyethylene implant in 611 standard cranial and skull base procedures and have achieved excellent cosmetic results and no implant-related complications.
Use of polylactide resorbable film as a barrier to postoperative peridural adhesion in an ovine dorsal laminectomy model
Authors: Klopp Lisa S. , Welch William C. , Tai Joseph W. , Toth Jeffery M. , Cornwall G. Bryan , Turner A. Simon
Published: January 2008

Object

The purpose of this study was to evaluate the performance of a resorbable polylactide film in the sheep posterior spine in the presence of a combined laminectomy and durotomy defect.

Methods

A resorbable polylactide film was used to cover the combined defects in the eight sheep used in this study. Two surgical levels were performed in each animal, with randomly assigned control and treated sites. Each surgical level consisted of a full laminectomy followed by a needle-induced durotomy. The treated levels received a resorbable polylactide film cut to size and tucked in under the laminar defect. At 8 to 10 weeks postoperatively, results of myelography and visual dye infiltration showed complete healing of the durotomies for all sites. In addition, evaluation of gross dissection based on volume and tenacity scores as well as histological findings indicates decreased posterior dural adhesions for sites treated with resorbable polylactide film.

Conclusions

The results of this investigation support previous studies in which the use of a resorbable polylactide film was found to be effective in reducing posterior dural adhesions in the spine with no apparent safety issues related to impaired dural healing.
Cervical spine fusion with bioabsorbable cages
Authors: Lippman Caleb R. , Hajjar Michael , Abshire Bret , Martin George , Engelman Robert W. , Cahill David W.
Published: January 2008

Object

Although it improves rates of fusion in surgical arthrodesis, conventional spinal instrumentation is associated with several risks, including hardware extrusion that injures adjacent anatomical structures, and disuse osteopenia as a result of stress shielding. The long-term effects of indwelling spinal instrumentation, although incompletely documented, may be detrimental. One way to avoid such problems would be to use bioabsorbable implantation devices. In this pilot study, performed in 1998 and 1999, the authors evaluated the use of a bioabsorbable interbody fusion device in a goat cervical spine model.

Methods

Forty-two goats underwent two-level anterior cervical discectomy and fusion: eight received iliac crest autograft; 16 received a cage implant composed of 70:30 poly(L-lactide-co-D,L-lactide)/polyglycolic acid (70:30 PLDLLA/PGA) filled with either autograft or recombinant human bone morphogenetic protein–2 (rhBMP-2); and 18 received a cage implant composed of 85:15 PLDLLA/PGA filled with either autograft or rhBMP-2. Animals were killed at 3, 6, and 12 months postsurgery, and their cervical spines were evaluated histologically, radiographically, and physically for fusion.

A primarily fibrous union was demonstrated in all animals killed at 3 months. At 6 months, bone trabeculae had become more prominent and the fibrous response less so in all cohorts. This occurred most frequently in the animals that underwent fusion with the 70:30 PLDLLA/PGA cages filled with rhBMP-2, in which 63% attained a histologically confirmed union that contained quantitatively more bone and less fibrous tissue than in the other cohorts; 63% of the unions in the aforementioned cohort were graded quantitatively as being stable.

Conclusions

In this study the authors have established that the 85:15 PLDLLA/PGA cages are absorbed too quickly to be functionally useful in this model. The 70:30 PLDLLA/PGA cages worked as well as tricortical autograft when filled with cancellous autograft, and better when filled with rhBMP-2. At 6- and 12-month follow-up review, the 70:30 PLDLLA/PGA cages had not yet begun to be absorbed. There was little if any inflammatory response to these cages at 6 months. Future studies should include biomechanical and microradiographic testing, and a longer follow-up period is necessary in this model to determine when the 70:30 PLDLLA/PGA cages are absorbed.
Early findings in a pilot study of anterior cervical interbody fusion in which recombinant human bone morphogenetic protein–2 was used with poly(L-lactide-co-D,L-lactide) bioabsorbable implants
Authors: Lanman Todd H. , Hopkins Thomas J.
Published: January 2008

Object

The goal of this study was to assess the efficacy of bioabsorbable interbody spacers in cervical spine fusion.

Methods

The authors report on a prospective examination of 20 patients with degenerative cervical disc disease who underwent anterior cervical fusion at 28 total levels. The authors used Infuse bone graft (that is, recombinant human bone morphogenetic protein–2 applied to an absorbable collagen sponge and contained within a Cornerstone-HSR bioabsorbable spacer. Multiple-level fusions were performed in 30% of these patients. At 3 months postfusion, radiographs and computerized tomography scans demonstrated bridging bone in 100% of the patients. Improvement from baseline scores in physical functioning, mental health, and bodily pain was demonstrated at 3 months postoperatively according to results of the Short Form–36 Version 2 health survey. There were no device-related complications.

Conclusions

The results in this series indicate that the use of Cornerstone-HSR as a bioabsorbable interbody spacer in combination with Infuse bone graft may be an alternative treatment for cervical spine fusion.