bluuebunny/crossref_metadata_2025 huggingface dataset:
Timing of surgical stabilization after cervical and thoracic trauma
Authors: Albert Todd J. , Kim David H.
Published: May 2009

✓ Appropriate timing for surgical intervention following destabilizing cervical or thoracic spine trauma remains controversial. Clinical investigators have failed to provide convincing evidence that the timing of surgery significantly affects neurological outcome in most situations. Nevertheless, early surgical stabilization of the injured spine has been shown to provide significant nonneurological benefits such as more rapid patient mobilization, facilitation of treating associated injuries, reduction in rates of pulmonary and pressure sore complications, reduction in duration of intensive care unit and hospital stays, and a decrease in overall medical costs.

The findings of basic science studies have improved our understanding of the molecular and cellular events surrounding initial and secondary spinal cord injury (SCI), and analysis of these findings suggests that the early postinjury period may present a unique opportunity for meaningful intervention. This possibility has been supported by results obtained in animal studies that demonstrate the potential for improving functional outcome when surgical intervention is performed within a few hours following experimental SCI. Despite the absence of significant neurological recovery in most clinical studies, the results of most recent clinical studies strongly support the overall clinical benefits of early surgical intervention, particularly in the setting of unstable thoracic spinal column injury with associated SCI. Based on the best available scientific and clinical evidence, the authors report that it is therefore recommended that surgical stabilization be performed in as timely a fashion as possible, particularly for unstable thoracic spine trauma, within the constraints of the patient's overall medical condition and availability of appropriate resources.
Long-term results after expansive open-door laminoplasty for the segmental-type of ossification of the posterior longitudinal ligament of the cervical spine: a comparison with nonsegmental-type lesions
Authors: Ogawa Yuto , Chiba Kazuhiro , Matsumoto Morio , Nakamura Masaya , Takaishi Hironari , Hirabayashi Hisashi , Hirabayashi Kiyoshi , Nishiwaki Yuji , Toyama Yoshiaki
Published: May 2009

Object. The segmental-type of ossification of the posterior longitudinal ligament (OPLL) of the cervical spine is distinct from other types in its morphological features. Whether the results of expansive open-door laminoplasty for the segmental-type are different from those for other types remains unclear. To clarify this issue, the long-term results after surgical treatment of segmental-type OPLL were compared with those of other types.

Methods. Clinical results were documented in 57 patients who underwent expansive open-door laminoplasty and were followed for a minimum of 7 years, results were quantified using the Japanese Orthopaedic Association (JOA) scoring system to determine function. Segmental-type OPLL was observed in 10 patients (Group 1) and other types in 47 patients (Group 2). Preoperative JOA scores were not significantly different between the two groups. As many as 5 years after surgery, clinical results were favorable and maintained in both groups, and no significant intergroup difference in postoperative JOA scores was observed; however, after 5 years postoperatively, JOA scores decreased in both groups. The decrease was greater in Group 1, and a significant intergroup difference in JOA scores was demonstrated when analyzing final follow-up data. In Group 1, the authors found that the degree of late-onset deterioration relating to cervical myelopathy positively correlated with the cervical range of motion.

Conclusions. The long-term results of expansive open-door laminoplasty in the treatment of segmental-type OPLL were inferior to those for other types. Cervical mobility may contribute to the development of late deterioration of cervical myelopathy.
Anterior decompression combined with corpectomies and discectomies in the management of multilevel cervical myelopathy: a hybrid decompression and fixation technique
Authors: Ashkenazi Ely , Smorgick Yossi , Rand Nahshon , Millgram Michael A. , Mirovsky Yigal , Floman Yizhar
Published: May 2009

Object. The authors retrospectively evaluated the safety and efficacy of a decompression and fixation technique in the treatment of patients with multilevel cervical spondylotic myelopathy (CSM).

Methods. The authors describe the “hybrid decompression fixation” technique, a procedure involving a combination of corpectomies and discectomies to preserve a vertebra intact within the area of the decompression, thus augmenting mechanical stability. The authors retrospectively reviewed outcomes in 25 patients with multilevel CSM in whom the hybrid technique was performed between 1999 and 2003. Twelve patients underwent a single-level corpectomy and three-level discectomies. In 13 patients a two-level corpectomy and adjacent four-level discectomies were conducted, leaving a vertebral bridge the middle. All patients underwent fusion involving placement of disc and vertebral body cages filled with autogenous local bone and supplemental anterior dynamic plate fixation.

The mean preoperative Nurick grade was 3 and improvement in status was reflected by a postoperative decrease to 2.6 (p < 0.05). In one patient neurological deterioration was demonstrated. At the end of the follow-up period (mean 29 months) radiography revealed evidence of osseous fusion in 24 patients; fusion status could not be determined in one patient. No evidence of late-onset instrumentation-related failure was observed in any of the 25 patients.

Conclusions. The authors found the hybrid technique to be safe and efficient for anterior decompression in patients with multilevel CSM. The use of this technique obviates the need for staged circumferential procedures.
Radiculopathy of C-5 after anterior decompression for cervical myelopathy
Authors: Ikenaga Minoru , Shikata Jitsuhiko , Tanaka Chiaki
Published: May 2009

Object. The authors conducted a study to examine the incidence and causes of postoperative C-5 radiculopathy, and they suggest preventive methods for C-5 palsy after anterior corpectomy and fusion.

Methods. The authors included in the study 18 patients with postoperative C-5 radiculopathy from 563 patients who underwent anterior decompression and fusion for cervical myelopathy.

There were 10 cases of ossification of the posterior longitudinal ligament (OPLL) and eight cases of cervical spondylotic myelopathy (CSM). All patients received conservative treatment. Posttreatment full recovery was present in eight patients, and Grade 3/5 strength was documented in six in whom some weakness remained.

Radiographic evaluation revealed that the C3–4 and C4–5 cord compression was significantly more severe in patients with paralysis than in those without paralysis. The incidence of paralysis was higher in patients with OPLL than in those with CSM (chi-square test, p = 0.03). The incidence of paralysis increased in parallel with the number of fusion levels (correlation coefficient r = 0.94). Multivariate analysis revealed that the final manual muscle testing (MMT) value was closely related to the preoperative MMT value (computed t value 4.17; p < 0.01) and preoperative Japanese Orthopaedic Association (JOA) score for cervical myelopathty (computed t value, 2.75; p < 0.05).

Conclusions. Preexisting severe stenosis at C3–4 or C4–5 in patients with OPLL is a risk factor for paralysis. Preoperative muscle weakness and a low JOA score are factors predictive of poor recovery.
Minimally invasive transforaminal lumbar interbody fusion with ipsilateral pedicle screw and contralateral facet screw fixation
Authors: Jang Jee-Soo , Lee Sang-Ho
Published: May 2009

Object. The purpose of this study was to introduce a minimally invasive transforaminal lumbar interbody fusion (TLIF) technique that involves ipsilateral pedicle screw (PS) and contralateral facet screw (FS) fixation.

Methods. Eight men and 15 women (mean age 59.5 years, range 48–68) underwent the aforementioned TLIF procedure for degenerative spondylolisthesis and uni- or bilateral radiculopathy.

Twenty-two patients underwent one-level fusion and one patient two-level fusion (L4—S1). In all cases the various procedures were undertaken via one small incision. There were no intraoperative complications. The mean estimated blood loss (EBL) was 310 ml, and the mean operative time was 150 minutes in cases of one-level fusion.

The follow-up period ranged from 13 to 28 months (mean 19 months). The mean Numeric Rating Scale score reflected improvement-reductions from 7.5 (back pain) and 7.4 (leg pain) to 2.3 and 0.7, respectively (p < 0.0001). The mean Oswestry Disability Index (ODI) scores also reflected improved status (ODI of 33.1 before the surgery to 7.6 after the surgery; p < 0.0001). Examination indicated that 22 of 24 fusion sites exhibited osseous union. At the last follow-up examination, satisfactory outcomes were observed in 21 out of 23 patients.

Conclusions. The TLIF with ipsilateral PS and contralateral FS fixation has the advantages over the conventional TLIF of reduced EBL and diminished soft-tissue injury.
Balloon kyphoplasty for vertebral compression fractures secondary to polyostotic fibrous dysplasia
Authors: Gordon Deen H. , Fox Thomas P.
Published: May 2009

✓ This 25-year-old woman with polyostotic fibrous dysplasia (McCune-Albright syndrome) suffered low-back pain after a minor traumatic injury. Neurological examination demonstrated normal status. Magnetic resonance imaging revealed cystic lesions in multiple thoracic and lumbar vertebral bodies, consistent with polyostotic fibrous dysplasia. Severe vertebral compression fractures (VCFs) were seen at T-8 and L-2. Balloon kyphoplasty was performed to treat the T-8 and L-2 VCFs and also prophylactically at T-9 and T-10 to forestall impending fractures at those levels. The patient tolerated the procedures very well and reported complete resolution of back pain. Balloon kyphoplasty may be an option in patients with painful VCFs caused by fibrous dysplasia.
Progression of an osteoid osteoma to an osteoblastoma
Authors: Bruneau Michaël , Polivka Marc , Cornelius Jan Frédérick , George Bernard
Published: May 2009

✓ The authors report the unusual case of a 25-year-old man with occipitocervical pain related to a lesion of the C-1 lateral mass. Initially this lesion measured 8 mm and exhibited radiological features of an osteoid osteoma. Seven years later, as pain increased and became unresponsive to antiinflammatory drugs, computerized tomography scanning demonstrated progression to a 16-mm lesion, highly suspicious of an osteoblastoma. After mobilization of the vertebral artery from the C-1 groove, the lesion was completely resected via an anterolateral approach. Complete symptomatic relief, restoration of cervical range of motion and preservation of cervical stability were achieved immediately after surgery, and the results were confirmed at the 4-year follow-up examination. Pathological examination of tissue samples confirmed the diagnosis of osteoblastoma.

Osteoid osteoma rarely evolves to osteoblastoma. Deterioration of a patient's ability to control pain is a warning sign. Insight into such cases underlines the importance of close long-term radiological follow-up examination in patients with conservatively treated osteoid osteomas.
Aberrant vertebral artery course in a case of Chiari malformation and occipitoatlantal assimilation
Authors: Hotta Shinji , Morita Akio , Seichi Atsushi , Kirino Takaaki
Published: May 2009

✓ The authors report an unusual case of a patient with combined vertebral artery and Chiari malformation anomalies. Unless such anomalies are properly recognized prior to decompression and fusion, this condition can have grave surgical consequences. The diagnostic and surgery-related implications of such anomalous codiseases are discussed.
Segmental cutaneous hemangioma and spinal arteriovenous malformation (Cobb syndrome)
Authors: Maramattom Boby V. , Cohen-Gadol Aaron A. , Wijdicks Eelco F. M. , Kallmes David
Published: May 2009

✓ The discovery of either a dermatomal cutaneous nevus or a spinal arteriovenous malformation (AVM) should raise the suspicion of Cobb syndrome. The Cobb syndrome is a neurocutaneous syndrome in which there are metameric cutaneous and spinal AVMs. The authors present the case of a patient with acute cervical myelopathy and subtle cutaneous hemangiomas in whom a cervical perimedullary fistula was discovered. They also acknowledge Harvey Cushing's contribution to the recognition of this syndrome.
Single-level lumbar fusion in chronic discogenic low-back pain: psychological and emotional status as a predictor of outcome measured using the 36-item Short Form
Authors: Derby Richard , Lettice John J. , Kula Thomas A. , Lee Sang-Heon , Seo Kwan-Sik , Kim Byung-Jo
Published: May 2009

Object. The authors examined the effect of psychological and emotional status on the outcome in patients with suspected chronic discogenic low-back pain (LBP) who have undergone lumbar fusion.

Methods. The authors retrospectively analyzed the medical records, including the results of the 36-item Short Form (SF-36), of 57 consecutive patients (mean age 42.7 years) who underwent single-level lumbar reconstructive surgery between 1994 and 2000. The SF-36 physical component summary (PCS) and mental component summary (MCS) domains were evaluated. Data were sorted into the following categories: excellent, good, fair, same, and worse. Scores greater than 40 for MCS and PCS were defined as “normal” according to US general population data provided by the Medical Outcomes Trust.

Of 57 patients, 47 completed postoperative SF-36 surveys at 1 year and 36 completed the 2-year follow-up surveys. Analysis showed that preoperative MCS scores exhibited a significant, direct correlation with PCS score improvements at 1 (r = 0.584, p = 0.000) and 2 (r = 0.623, p = 0.000) years after surgery. In patients in whom preoperative MCS scores reflected normal status, outcomes were excellent or good in 60% at 1-year (18 of 30 cases) and 2-year (15 of 25 cases) follow-up intervals. Patients in whom MCS scores represented abnormal status had less satisfactory outcomes, with excellent or good outcome in only two (18.2%) of all patients at the 2-year follow-up study.

Conclusions. Analysis of the data suggests that psychological and emotional distress may negatively affect postoperative outcome in patients with chronic discogenic LBP. The SF-36 may be easily and effectively used to measure both preoperative psychosocial distress and postoperative outcome.
Spinal stenosis due to ossified lumbar lesions
Authors: Kawaguchi Yoshiharu , Oya Takeshi , Abe Yumiko , Kanamori Masahiko , Ishihara Hirokazu , Yasuda Taketoshi , Nogami Shigeharu , Hori Takeshi , Kimura Tomoatsu
Published: May 2009

Object. Spinal stenosis due to lumbar ossified lesions is a rare pathological entity. The authors retrospectively evaluated the clinical features and surgical results associated with cases involving lumbar ossified lesion—induced stenosis.

Methods. Data obtained in 20 surgically treated patients with lumbar hyperostotic spinal stenosis were included. To evaluate the background of the disease, body mass index and general complications were assessed. Whole-spine radiological examination was conducted. The presence of ossification of the posterior longitudinal ligament or ossification of the ligamentum flavum was evaluated. Surgical results were classified according to the Japanese Orthopaedic Association (JOA) scale. In the patients in whom neurological deterioration was observed during follow up, the causes of deterioration were reviewed. Seven patients (35%) were obese and six patients (30%) suffered diabetes mellitus. Twelve patients harbored coexisting cervical and/or thoracic ossified lesions. The overall mean JOA score improved from 10.2 to a peak of 22.5; at last follow-up examination the mean JOA score was 20.9. In female and older patients with a long history of preoperative symptoms, a low preoperative JOA score, and other spinal lesions, recovery tended to be poorer. Recovery was poor in one patient, and neurological deterioration due to coexisting ossified spinal lesions occurred in another patient during the follow-up period.

Conclusions. Because coexisting ossified lesions were frequently seen, whole-spine analysis is recommended. Early diagnosis and appropriate treatment are important to achieve a better surgical outcome.
Coralline hydroxyapatite and laminectomy-derived bone as adjuvant graft material for lumbar posterolateral fusion
Authors: Hsu Chien-Jen , Chou Wen-Ying , Teng Hsiu-Peng , Chang Wei-Ning , Chou Yi-Jiun
Published: May 2009

Object.The purpose of this study was to evaluate the effectiveness of coralline hydroxyapatite (CHA) and laminectomy-derived bone as an adjuvant graft material when combined with autogenous iliac bone graft (AIBG) in posterolateral fusion (PLF).

Methods.This prospective, case—control study involved 58 patients who underwent lumbar instrumentation-augmented PLF for degenerative spinal stenosis—induced segmental instability between July 2000 and June 2001. The patients were divided into three groups. Laminectomy bone and AIBG were placed in the right intertransverse process space in Group 1 (20 patients), CHA and AIBG were placed in Group 2 (19 patients), and laminectomy bone and CHA were placed in Group 3 (19 patients). Pure autogenous iliac cancellous bone graft was placed in the left intertransverse process space in all three groups of patients. Successful fusion was determined by two spine surgeons after examining the plain, anteroposterior, bilateral oblique, and lateral flexion—extension radiographs. If the examiners did not agree on fusion status, fine-cut computerized tomography scans of the fusion mass were used to make the final decision. The chi-square test was used to compare the fusion rate at different time intervals among the three groups.

Conclusions.Pure AIBG placed in left intertransverse process space was associated with the best fusion rate. After 6 months, CHA produced a comparable result to laminectomy-derived bone when combined with AIBG. When laminectomy bone was mixed with CHA, the combination failed to yield a satisfactory fusion rate (57.9%) even 1 year after surgery if no AIBG was added.
Clinical and radiological results after parapedicular screw fixation of the thoracic spine
Authors: Vougioukas Vassilios I. , Weber Johannes , Scheufler Kai M.
Published: May 2009

Object. The proximity of thoracic pedicles to the spinal cord and neurovascular structures has prompted numerous efforts to obtain proper screw placement. The aim of this study was to evaluate the feasibility and efficacy of thoracic parapedicular (intercostovertebral) screw fixation by following anatomical landmarks and using fluoroscopy.

Methods. Thoracic parapedicular screw fixation was performed in 41 patients (328 screws). Postoperative computerized tomography scans were obtained in all cases to analyze the position of each screw with respect to the pedicle rib unit, the spinal canal, and the vertebral body (VB) according to a proposed novel grading system. Additionally, screw convergence angles were calculated for each instrumented level.

There was no additional morbidity associated with parapedicular screw insertion. In a single case a screw suspected of entering the spinal canal was revised without causing neurological damage. The remaining screws were placed entirely within the pedicle rib unit and VB without breaching the neural foramina, pleura, or vascular structures.

Conclusions. Thoracic and thoracolumbar instability can be treated adequately and safely by using parapedicular screw fixation guided by anatomical landmarks and fluoroscopic imaging. The use of computer-aided navigation may be beneficial but does not appear to be mandatory.
The therapeutic window for spinal cord decompression in a rat spinal cord injury model
Authors: Shields Christopher B. , Zhang Y. Ping , Shields Lisa B. E. , Han Yingchun , Burke Darlene A. , Mayer Norman W.
Published: May 2009

Object. There are no clinically based guidelines to direct the spine surgeon as to the proper timing to undertake decompression after spinal cord injury (SCI) in patients with concomitant stenosis-induced cord compression. The following three factors affect the prognosis: 1) severity of SCI; 2) degree of extrinsic spinal cord compression; and 3) duration of spinal cord compression.

Methods. To elucidate further the relationship between varying degrees of spinal stenosis and a mild contusion-induced SCI (6.25 g-cm), a rat SCI/stenosis model was developed in which 1.13- and 1.24-mm-thick spacers were placed at T-10 to create 38 and 43% spinal stenosis, respectively. Spinal cord damage was observed after the stenosis—SCI that was directly proportional to the duration of spinal cord compression. The therapeutic window prior to decompression was 6 and 12 hours in the 43 and 38% stenosis—SCI lesions, respectively, to maintain locomotor activity. A significant difference in total lesion volume was observed between the 2-hour and the delayed time(s) to decompression (38% stenosis—SCI, 12 and 24 hours, p < 0.05; 43% stenosis—SCI, 24 hours, p < 0.05) indicating a more favorable neurological outcome when earlier decompression is undertaken. This finding was further supported by the animal's ability to support weight when decompression was performed by 6 or 12 hours compared with 24 hours after SCI.

Conclusions. Analysis of the findings in this study suggests that early decompression in the rat improves locomotor function. Prolongation of the time to decompression may result in irreversible damage that prevents locomotor recovery.
Advanced Chiari malformation Type I with marked spinal cord atrophy
Authors: Ito Yoshiro , Tsuboi Koji , Akutsu Hiroyoshi , Ihara Satoshi , Matsumura Akira
Published: May 2009

✓ The authors discuss the results obtained in patients who underwent foramen magnum decompression for longstanding advanced Chiari I malformation in which marked spinal cord atrophy was present. This 50-year-old woman presented with progressive quadriparesis and sensory disorders. Magnetic resonance imaging revealed the descent of cerebellar tonsils and medulla associated with remarkable C1—L2 spinal cord atrophy. After a C-1 laminectomy—based foramen magnum decompression, arachnoid dissection and duraplasty were undertaken. These procedures resulted in remarkable neurological improvement, even after 40 years of clinical progression. Spinal cord atrophy may be caused by chronic pressure of entrapped cerebrospinal fluid in the spinal canal.
Cervical arthroplasty after previous surgery: results of treating 24 discs in 15 patients
Authors: Sekhon Lali H. S. , Sears William , Duggal Neil
Published: May 2009

Object. The potential role of cervical arthroplasty in patients who have undergone previous cervical surgery is unknown. The authors performed a prospective study involving nonrandomized clinical and radiological assessment in patients who had undergone either previous posterior cervical foraminotomy or anterior interbody fusion and who suffered new or persistent arm/neck symptoms related to neural compression.

Methods. During a 30-month period, 15 patients who had previously undergone cervical spinal surgery underwent cervical arthroplasty that involved placement of the Bryan disc for neck or arm symptoms related to cervical disc disease. A total of 24 devices were implanted. Six of the 15 patients had undergone a previous posterior foraminotomy, and in nine cases an anterior interbody fusion had been perfomed at some stage prior to surgery. Clinical and radiological evaluations were performed preoperatively and after surgery to assess outcomes.

A total of 24 arthroplasties were performed encompassing between one and three levels. There were no major perioperative complications or immediate device-related failures. Two patients were lost to follow up. The follow-up period ranged from 12 to 43 months (mean 24.2 ± 10.5 months). Good results were obtained in all cases as reflected by an increase in the visual analog scale score of 6.4 in terms of neck/arm pain (p < 0.05). There was no difference in Oswestry Disability Index scores for neck pain (p > 0.05) and no patient required surgery at the same level. In one patient hypermobility developed with internal subluxation of the device, which suggested a compromise adjacent to a two-level fusion at 21 months. The segment was hypermobile preoperatively. The patient has experienced recurrent neck pain but otherwise remains clinically well and has not required revision surgery to date.

Conclusions. Insertion of the Bryan artificial cervical disc in patients who have previously undergone cervical fusion or posterior foraminotomy, in general, appears to be safe. It provided encouraging early clinical results, although patients with preoperative hypermobility should be treated with caution. Issues such as accelerated device-related wear and the use of arthroplasty after aggressive facetectomy resection will need further study; however, in carefully selected patients who have undergone previous surgery cervical arthroplasty may provide an additional tool in the management of cervical disc disease.
Magnetic resonance imaging evaluation of adjacent segments after disc arthroplasty
Authors: Neal Chris J. , Rosner Michael K. , Kuklo Timothy R.
Published: May 2009

Object.Disc arthroplasty in the lumbar spine is an alternative to fusion when treating discogenic pain. Its theoretical benefits include preservation of the motion segment and the potential prevention of adjacent-segment degeneration. Despite the need to evaluate the benefit of preserving the adjacent segments after disc replacement, no study has been conducted to assess the ability of magnetic resonance (MR) imaging to depict the adjacent segments in patients who have undergone disc replacement surgery.

Methods.Postoperative lumbar MR images were obtained in the first 10 patients in whom a metal-on-metal disc arthroplasty system was used to treat the L4–5 or L5—S1 levels. At the superior adjacent level, the superior endplate and disc space were demonstrated on 90% of the images on both T1-weighted fluid-attenuated inversion-recovery (FLAIR) and T2-weighted sequences despite the presence of artifacts. The inferior endplate at this level was documented on 70% of both T1-weighted FLAIR and T2-weighted sequences. At the level below the disc replacement in patients who underwent L4–5 surgery, the superior endplate was demonstrated on 66.7% of the T1-weighted FLAIR sequences but only 33.3% of the T2-weighted images. The disc space and inferior endplate were depicted on 66.7% of both T1-weighted FLAIR and T2-weighted sequences. Axial images revealed an artifact in every adjacent space except at the L5—S1 level.

Conclusions.Based on the results of this pilot study, it appears that sagittal MR imaging can be undertaken to evaluate the adjacent motion segment for degenerative changes following total disc arthroplasty in most patients. This imaging modality will provide an additional measure to assess the long-term efficacy of this intervention compared with other treatment modalities and the natural history of lumbar disc degeneration.
Surgical treatment of thoracic outlet syndrome: a randomized trial comparing two operations
Authors: Sheth Rishi N. , Campbell James N.
Published: May 2009

Object. Various surgical approaches have been proposed for the treatment of thoracic outlet syndrome (TOS). The authors of this study focused on the differences in outcome after supraclavicular neuroplasty of brachial plexus (SNBP [no rib resection]) and transaxillary first rib resection (TFRR) in patients in whom the dominant clinical problem was pain.

Methods. Fifty-five patients were randomized to undergo TFRR or SNBP. Patients with an anomalous cervical rib, intrinsic weakness, and primarily vascular findings were excluded from the study. Preoperatively, the following findings were typically observed: provocation of symptoms by certain postures (the so-called spear-throwing position as well as downward tugging of the shoulder) and marked tenderness in the supraclavicular fossa.

The intergroup severity of the symptoms was comparable. Eight patients were lost to follow up. There were 24 TFRRs (in two cases the procedure was bilateral) and 25 SNBPs. The mean follow-up interval was 37 months. In both groups pain decreased significantly after surgery. By all measures the TFRR operation conferred superior results. Patients reported significantly less pain (39 ± 7 compared with 61 ± 7; score range 0–100 on a visual analog scale), greater percentage of pain relief (52 ± 8% compared with 30 ± 7%), and less pain (3.7 ± 0.4 compared with 5.1 ± 0.5) on an affective scale (all p < 0.05) in the TFRR and SNBP groups, respectively). In the TFRR group, 75% of patients reported good or excellent outcomes compared with 48% in the SNBP group (p < 0.05).

Conclusions. Transaxillary first rib resection provided better relief of symptoms than SNBP. The major compressive element in patients with TOS-associated pain appeared to be the first rib.
Superficial landmarks for the spinal accessory nerve within the posterior cervical triangle
Authors: Tubbs R. Shane , Salter E. George , Wellons John C. , Blount Jeffrey P. , Oakes W. Jerry
Published: May 2009

Object.The spinal accessory nerve (SAN) within the posterior cervical triangle (PCT) is the most commonly iatrogenically injured nerve in the body. Nevertheless, there is a paucity of published information regarding superficial landmarks for the SAN in this region. Additional identifiable landmarks of this nerve may assist the surgeon in identifying it for repair, use of it in peripheral nerve neurotization, or avoiding it as in proximal brachial plexus repair. The present study was undertaken to provide reliable superficial landmarks for the identification of the SAN within the PCT.

Methods.The PCT was dissected in 30 cadaveric sides. Measurements were made between the SAN and surrounding landmarks. The mean distances between the entry site of the SAN into the trapezius and a midpoint of the clavicle, mastoid process, acromion process, and lateral aspect of the sternocleidomastoid (SCM) muscle were 6, 7, 5.5, and 3.5 cm, respectively. The mean distances between the angle of the mandible and the mastoid process and the exit point of the SAN from the posterior border of the SCM muscle were 6 and 5 cm, respectively. The mean width and length of the SAN were 3 and 3.5 cm, respectively.

Conclusions.It is the authors' hope that these data will aid those who may need to locate or avoid the SAN while undertaking surgery in the PCT and thus decrease morbidity that may follow manipulation of this region.
Dural arteriovenous fistula coexisting with a lumbar lipomeningocele
Authors: Rajeev Kariyattil , Panikar Dilip
Published: May 2009

✓ The authors describe the case of a 44-year-old woman who presented with recent onset of progressive paraparesis and bladder involvement; she had an asymptomatic lumbosacral lipomatous swelling that was present since birth. Magnetic resonance imaging confirmed the diagnosis of a lipomeningocele. It also revealed intramedullary hyperintensity on T2-weighted images and serpiginous flow voids suggestive of a dural arteriovenous fistula (DAVF) at the same level; the lesion was confirmed by spinal angiography. Both lesions were surgically managed, and the patient subsequently experienced neurological improvement. The coexistence of a DAVF and a lipomeningocele at the same level is unusual and can lead to treatment failure if missed.
Retrograde intraventricular hemorrhage caused by a traumatic sacral pseudomeningocele in the presence of spina bifida occulta
Authors: Uff Christopher , Bradford Robert
Published: May 2009

✓ The authors present the case of a large, posttraumatic sacral pseudomeningocele in the presence of spina bifida occulta. A pseudomeningocele in the sacral region is associated with trauma and with Marfan syndrome, but only one occurrence has been reported in association with spinal dysraphism. Trauma resulted in bleeding into the pseudomeningocele and retrograde passage of blood and fat into the ventricles. An oculomotor nerve palsy subsequently developed in the patient. The authors suspected a subarachnoid hemorrhage caused by a posterior communicating artery aneurysm, although this hypothesis was refuted on further investigation.

The pseudomeningocele was drained by direct exposure of the neck and opening of the sac. Postoperatively, communicating hydrocephalus developed and the patient underwent ventriculoperitoneal shunt placement, resulting in resolution of the cranial nerve palsies.

This first report of intradural bleeding from direct trauma to a pseudomeningocele illustrates the rare phenomenon of retrograde passage of blood from the sacral region to the brain. It also illustrates a possible but unlikely differential diagnosis of intraventricular blood and fat.
Epithelioid hemangioendothelioma of the spine
Authors: Aquilina Kristian , Lim Christopher , Kamel Mahmoud Hamdy , Marks Charles J. , O'Sullivan Michael G. , Keohane Catherine
Published: May 2009

✓ Epithelioid hemangioendothelioma (EH) is a rare tumor of vascular origin. The authors describe two cases of spinal EH, one involving the T-10 vertebra and the second involving the upper cervical spine. In the first case the patient underwent resection of the tumor; this case represents the longest reported follow-up period for spinal EH. In the second case, extensive involvement of C-2, C-3, and C-4 as well as encasement of both vertebral arteries precluded safe tumor resection, and posterior occipitocervical stabilization was performed. The patient subsequently died of metastatic disease. The findings in these two cases underscore the difficulty in predicting the clinical behavior of spinal EH based solely on histological and clinical features as well as the uncertainty of the roles of surgery, chemotherapy, and radiotherapy in the oncological management of a spinal tumor for which clinical data are very limited.
Split cord malformation with associated Type IV spinal cord perimedullary arteriovenous fistula
Authors: Vitarbo Elizabeth A. , Sultan Ali , Wang David , Morcos Jacques J. , Levi Allan D.
Published: May 2009

✓ The authors describe the case of a 62-year-old woman with a Type II split cord malformation (SCM). At the initial time of workup, the authors observed an associated Klippel—Feil deformity at the level of the SCM and a low-lying conus medullaris; however, they discovered an associated Type IV perimedullary spinal cord arteriovenous fistula (AVF) only after the patient continued to deteriorate following a spinal cord untethering procedure. Although prominent blood vessels have been reported within the median cleft of SCMs, an angiographically and surgically proven perimedullary AVF has not previously been described. The potential coexistence of SCM and perimedullary AVF has significant clinical implications and its recognition is critically important prior to surgical treatment.
Translaminar rigid screw fixation of the axis
Authors: Wright Neill M.
Published: May 2009

✓ Rigid fixation of the axis with C1–2 transarticular screws or C-2 pedicle screws results in high fusion rates but remains technically demanding because of the risk of injury to the vertebral artery (VA) and the limitations imposed by anatomical variability. Translaminar fixation of the axis with crossing bilateral screws provides rigid fixation and is technically simple, is not affected by variations in individual anatomy, and does not place the VA at risk. The longterm results in 20 patients treated with translaminar fixation for craniocervical, atlantoaxial, and axial—subaxial instability are presented, with 100% fusion rates and no neurological or vascular complications. Translaminar screws may be a good option for rigid fixation of the axis for surgeons not proficient in the more technically demanding methods of stabilization.
Cervical disc arthroplasty: a controlled randomized prospective study with intermediate follow-up results
Authors: Hacker Robert J.
Published: May 2009

Object. The authors of studies of anterior cervical fusion for disc-related disease have documented satisfying clinical results and infrequent complications. Recently, cervical disc arthroplasty has entered clinical trials as an alternative to fusion. Although the results of anecdotal reports and prospective studies support this procedure, these studies have not conferred the validity of a controlled randomized study. In the present study, the author presents data obtained in such a study.

Methods. After symptoms failed to respond to conservative therapy, 46 patients with one-level discogenic cervical radiculopathy and/or myelopathy were randomized to undergo arthroplasty or fusion as part of a US Food and Drug Administration medical device study. In all patients there was a minimum follow-up duration of 1 year. Equivalent results for the relief of arm pain and neck pain were noted in both treatment groups. Treatment parameters other than operative time were similar. No neurological or serious systemic complications occurred.

Conclusions. Although extended follow-up data and larger patient populations are needed, the results of this study indicate that arthroplasty is a viable alternative to cervical fusion.
Primary spinal syringomyelia
Authors: Batzdorf Ulrich
Published: May 2009

✓ In the present review the author describes the different types of syringomyelia that originate from abnormalities at the level of the spinal cord rather than at the craniovertebral junction. These include posttraumatic and postinflammatory syringomyelia, as well as syringomyelia associated with arachnoid cysts and spinal cord tumors. The diagnosis and the principles of managing these lesions are discussed, notably resection of the entity restricting cerebrospinal fluid flow. Placement of a shunt into the syrinx cavity is reserved for patients in whom other procedures have failed or who are not candidates for other procedures.
Thoracic and lumbar tuberculous spondylitis treated by posterior debridement, graft placement, and instrumentation: a retrospective analysis in 19 cases
Authors: Güzey Feyza Karagöz , Emel Erhan , Bas N. Serdar , Hacisalihoglu Selim , Seyithanoglu Hakan , Karacor Sabri Emin , Özkan Nezih , Alatas Ibrahim , Sel Baris
Published: May 2009

Object.Surgical treatment of thoracic and lumbar tuberculous spondylitis is controversial. An anterior approach is usually recommended. The aim of the present study was to assess the efficacy of posterior debridement and the placement of posterior instrumentation for the treatment of patients with thoracic and lumbar tuberculous spondylitis.

Methods.Nineteen patients with thoracic and lumbar tuberculous spondylitis underwent single-stage posterior decompression and debridement as well as the placement of posterior interbody grafts if necessary, instrumentation and posterior or posterolateral grafts.

No postoperative neurological deterioration was noted. One patient died of myocardial infarction on Day 10. The mean follow-up duration, excluding the one death, was 52.7 months (range 16–125 months). In a 70-year-old patient, a single pedicle screw broke after 3 months. All patients were in better neurological condition after surgery and at the last follow-up examination. Neurological deficits were present in only two patients at the last follow up (one American Spinal Injury Association Grade B and one Grade C deficit preoperatively). Three other patients suffered intermittent back or low-back pain.

The mean angulation measured in 13 patients with kyphotic deformity was 18.2° (range 5–42°) preoperatively; this was reduced to 17.3° (range 0–42°) after surgery. There was a 2.8° loss of correction (range 2–5°) after 44.3 months (16–64 months). Kyphosis did not progress beyond 15 months in any patient.

ConclusionsA posterior approach in combination with internal fixation and posterior or posterolateral fusion (with or without placement of posterior interbody grafts) may be sufficient for the debridement of the infection and to allow spinal stabilization in patients with thoracic and lumbar tuberculous spondylitis. This procedure is associated with easy access to the spinal canal for neural decompression, prevention of loss of corrected vertebral alignment in the long term, and facilitation of early mobilization.
Endoscopic thoracic microdiscectomy
Authors: Oskouian Rod J. , Johnson J. Patrick
Published: May 2009

Object. The purpose of this clinical study was to evaluate prospectively surgical and neurological outcomes after endoscopic thoracic disc surgery.

Methods. The authors assessed the following quantifiable outcome data in 46 patients: operative time, blood loss, duration of chest tube insertion, narcotic use, hospital length of stay (LOS), and long-term follow-up neurological function and pain-related symptoms.

In patients who presented with myelopathy there was a postoperative improvement of two Frankel grades. Pain related to radiculopathy was improved by 75% and in one patient it worsened postoperatively. The authors also present operative data, surgical outcomes, and complications.

Conclusions. Thoracoscopic discectomy can be used to achieve acceptable results. It has several distinct advantages such as reduced postoperative pain, morbidity, and LOS compared with traditional open procedures.
Localized cervical facet joint kinematics under physiological and whiplash loading
Authors: Stemper Brian D. , Yoganandan Narayan , Gennarelli Thomas A. , Pintar Frank A.
Published: May 2009

Object.Although facet joints have been implicated in the whiplash injury mechanism, no investigators have determined the degree to which joint motions in whiplash are nonphysiological. The purpose of this investigation was to quantify the correlation between facet joint and segmental motions under physiological and whiplash loading.

Methods.Human cadaveric cervical spine specimens were exercise tested under physiological extension loading, and intact human head-neck complexes were exercise tested under whiplash loading to correlate the localized component motions of the C4–5 facet joint with segmental extension. Facet joint shear and distraction kinematics demonstrated a linear correlation with segmental extension under both loading modes. Facet joints responded differently to whiplash and physiological loading, with significantly increased kinematics for the same-segmental angulation. The limitations of this study include removal of superficial musculature and the limited sample size for physiological testing.

Conclusions.The presence of increased facet joint motions indicated that synovial joint soft-tissue components (that is, synovial membrane and capsular ligament) sustain increased distortion that may subject these tissues to a greater likelihood of injury. This finding is supported by clinical investigations in which lower cervical facet joint injury resulted in similar pain patterns due to the most commonly reported whiplash symptoms.
An unusual presentation and resolution of syringomyelia after cervical spine injury
Authors: Cusick Joseph , Lidar Zvi
Published: May 2009

✓ The authors describe a case of noncommunicating syringomyelia associated with Chiari malformation Type I in a patient in whom acute symptomatic exacerbation occurred following cervical spine trauma. Surgical stabilization and realignment of the spine resulted in marked resolution of the neurological abnormalities, and subsequent magnetic resonance imaging demonstrated persistent collapse of the syrinx. The authors review the various factors in the pathogenesis of this unusual sequence of events.
A large, erosive intraspinal and paravertebral gout tophus
Authors: Beier Christoph P. , Hartmann Arndt , Woertgen Chris , Brawanski Alexander , Rothoerl Ralf D.
Published: May 2009

✓ Symptomatic gout tophi of the spine are a rare but well-characterized complication of tophaceous gout. The authors report the case of a 29-year-old previously healthy man who presented with L-5 radiculopathy. Lumbar magnetic resonance (MR) imaging revealed a 4.5 × 4.5 × 2.8—cm large gout tophus mimicking a malignant spinal tumor or abscess. The tophus completely destroyed both L-4 and L-5 facet joints and the left L-4 lamina and spread epidurally from L-3 to L-5, compressing the left L-5 nerve root. There has been no similar case reported so far with respect to the extent of bone destruction. The authors describe the case history and present intraoperative, MR imaging, and histological findings.
Spinal intradural arteriovenous fistulas acquired in late adulthood: absent spinal venous drainage in pathogenesis and pathophysiology
Authors: Tender Gabriel C. , Vortmeyer Alexander O. , Oldfield Edward H.
Published: May 2009

✓ Intradural spinal arteriovenous fistulas (AVFs), a subtype of spinal arteriovenous malformation in which there is a direct communication between a spinal artery and a vein on the cord surface or in the subarachnoid space, are generally considered to be congenital lesions caused by maldevelopment of the embryonic vascular system. The authors present the cases of two patients with acquired AVFs of the terminal filum. In each patient an AVF between the distal segment of the anterior spinal artery and its accompanying vein on the terminal filum developed within 1 year of repeated lumbar myelography that had demonstrated no evidence of abnormal vascularity. In both patients spinal arteriography demonstrated the absence of medullary venous drainage in the thoracolumbar region, which, combined with the arterialized venous input from the AVF, permitted the development of venous congestion and myelopathy. The involved segment of the terminal filum was excised; in vitro microarteriography and the histopathological examination demonstrated a single, simple arteriovenous connection in both patients.

The findings in these cases indicate that intradural AVF can spontaneously arise in later life. The development of these lesions and/or their clinical manifestation may require not only the presence of the AVF, but also deficiency of medullary spinal venous drainage. The epidemiology and anatomy of intradural AVFs are compatible with an acquired origin in many cases.
Age and Lumbar Surgery
Authors: Beck David W. , Lovick Darren S.
Published: May 2009

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

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

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

Conclusions. Complications and perioperative events following PLDF in the elderly are comparable with those observed in younger patients. Withholding lumbar spine fusion solely based on advanced age is not warranted.