Placement of pedicle screws in the human cadaveric cervical spine: comparative accuracy of three techniques.

STUDY DESIGN: This investigation was conducted in two parts. In the first part, a morphometric analysis of critical cervical pedicle dimensions were measured to create guidelines for cervical pedicle screw fixation based on posterior cervical topography. In the second part of the study, a human cadaver model was used to assess the accuracy and safety of transpedicular screw placement in the subaxial spine using three different surgical techniques: 1) using surface landmarks established in the first part of the study, 2) using supplemental visual and tactile cues provided by performing laminoforaminotomies, and 3) using a computer-assisted surgical guidance system. OBJECTIVE: To assess the accuracy of transpedicular screw placement in the cervical spine using three surgical techniques. SUMMARY OF BACKGROUND DATA: A three-column fixation device implanted to secure an unstable cervical spine can be a valuable tool with a biomechanical advantage in the spine surgeon's armamentarium. Despite this advantage, concerns over surgical neurovascular complications have surfaced. Cadaver-based morphometric measurements used to guide the surgeon in the placement of a pedicle screw show significant variability, raising legitimate concerns as to whether transpedicular fixation can be applied safely. METHODS: Precise measurements of 14 human cadaveric cervical spines were made by two independent examiners of pedicle dimensions, angulation, and offset relative to the lateral mass boundaries. On the basis of this analysis, guidelines for pedicle screw placement relative to posterior cervical topography were derived. In the second part of the study, 12 human cadaveric cervical spines were instrumented with 3.5-mm screws placed in the pedicles C3-C7 according to one of three techniques. Cortical integrity and neurovascular injury were then assessed by obtaining postoperative computed tomography scans (1-mm cuts) of each specimen. Cortical breaches were classified into critical or noncritical breaches. RESULTS: Linear measurements of pedicle dimensions had a wide range of values with only fair interobservercorrelation. Angular measurements showed similarangulation in the transverse plane (40 degrees ) at each level. With respect to the sagittal plane, both C3 and C4 pedicles were oriented superiorly relative to the axis of the lateral mass, whereas the C6 and C7 pedicles were oriented inferiorly. The dorsal entry point of the pedicle on the lateral mass defined by transverse and sagittal offset had similar mean values with wide ranges, although there often was excellent correlation between observers. There were no significant interlevel, right/left, or male/female differences noted with respect to offset. Using one of three techniques, 120 pedicles were instrumented. In group 1 (morphometric data): 12.5% of the screws were placed entirely within the pedicle; 21.9% had a noncritical breach; and 65. 5% had a critical breach. In group 2 (laminoforaminotomy), 45% of the screws were within the pedicle; 15.4% had a noncritical breach; and 39.6% had a critical breach. In group 3 (computer-assisted surgical guidance system), 76% of the screws were entirely within the pedicle; 13.4% had a noncritical breach; and 10.6% had a critical breach. Regardless of the technique used, the vertebral artery was the structure most likely to be injured. CONCLUSIONS: On the basis of the morphometric data, guidelines for cervical spine pedicle screw placement at each subaxial level were derived. Although a statistical analysis of cadaveric morphometric data obtained from the cervical spine could provide guidelines for transpedicular screw placement based on topographic landmarks, sufficient variation exists to preclude safe instrumentation without additional anatomic data. Insufficient correlation between different surgeons' assessments of surface landmarks attests to the inadequacy of screw insertion techniques in the cervical spine based on such specific topographic guide

Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations.

STUDY DESIGN: A prospective clinical study using magnetic resonance imaging of the cervical spine in a consecutive series of patients with cervical spine dislocations. OBJECTIVES: To determine the incidence of intervertebral disc herniations and injury to the spinal ligaments before and after awake closed traction reduction of cervical spine dislocations. SUMMARY OF BACKGROUND DATA: Prior series in which the prereduction imaging of disc herniations in the dislocated cervical spine are described have been anecdotal and have involved small numbers of patients. In addition, no uniform clinical criteria to define the presence of an intervertebral disc herniation in the dislocated cervical spine has been described. The incidence of disc herniations in the unreduced dislocated cervical spine is unknown. METHODS: Eleven consecutive patients with cervical spine dislocations who met the clinical criteria for an awake closed traction reduction had prereduction and postreduction magnetic resonance imaging. Using strict clinical criteria for the definition of an intervertebral disc herniation, the presence or absence of disc herniation, spinal ligament injury, and cord injury was determined. Neurologic status before, during, and after the closed reduction maneuver was documented. RESULTS: Disc herniations were identified in 2 of 11 patients before reduction. Awake closed traction reduction was successful in 9 of the 11 patients. Of the nine patients with a successful closed reduction, two had disc herniations before reduction, and five had disc herniations after reduction. No patient had neurologic worsening after attempted awake closed traction reduction. CONCLUSIONS: The process of closed traction reduction appears to increase the incidence of intervertebral disc herniations. The relation of these findings, however, to the neurologic safety of awake closed traction reduction remain unclear.

The changing nature of admissions to a spinal cord injury center: violence on the rise.

The purpose of this study was to analyze changing etiologies for admission to a spinal cord injury center. This study was designed to retrospectively analyze the etiology of admissions to a spinal cord injury center during a 15-year period, specifically gunshot versus nongunshot wound injuries. Gunshot wounds are a well-recognized cause of spinal cord injury. In some centers, up to 52% of admissions are due to this, and these trends are believed to be increasing. All patients with spinal cord injury admitted to our center between 1979 and 1993 were analyzed. Frequencies of specific etiologies were determined and then comparisons were made between gunshot wound and nongunshot wound groups. Factors analyzed included age, male/female ratio, ethnic make-up, marital status, employment status, level of injury, and neurologic status. One thousand eight hundred seventeen patients were included. Overall, gunshot wound spinal cord injuries compromised 16.9% of injuries. A clear trend of increasing numbers of admissions was seen between 1984 and 1993 because of this. Gunshot wounds and nongunshot wounds differed dramatically in terms of age, ethnic make-up, marital status, employment status, and neurologic status. Cost attributed to treating gunshot wound injuries at our center for 1993 was 5.4 million dollars. Gunshot wounds as a cause of spinal cord injury are increasing at an alarming rate. The demographics of the gunshot wounds and nongunshot wound spine cord injuries differ significantly.

Foraminal pressure changes during intervertebral distraction simulating anterior cervical discectomy.

Distraction of the disc space over baseline height has been shown to increase foraminal size. The purpose of this procedure is to determine pressure changes, with disc space distraction simulating an anterior cervical discectomy and fusion (ACDF). An analysis of pressure changes during disc space distraction at C5-C6 was performed. Data were analyzed for maximal pressure observed and for pressure change with prolonged distraction. Five cadaveric specimens underwent a discectomy at the C5-C6 level. Distraction of the disc space was performed and pressure measurements were obtained from within the foramen. Measurements were made for maximal pressure with an intact posterior longitudinal ligament (PLL), divided PLL, and with the nerve root removed from within the foramen. Pressures were also recorded with prolonged distraction until a steady state was achieved. Incremental distraction of +2, +4, and +6 mm resulted in pressure increases within the foramen. Sectioning of the PLL did not affect these increases. Removal of the nerve root from the foramen resulted in pressure increases; however, these were not significantly different from baseline. Prolonged distraction produced an initial increase and a gradual return toward baseline. Final pressures still differed significantly from baseline. Increase intraforaminal pressures can be seen with increasing disc space distraction such as occurs during an ACDF. This suggests that either the foramen narrows in at least one dimension and/or soft-tissue attachments to the nerve produce a tensile force in the nerve as they tighten. The pressure increases relax over time.

Accuracy of SPECT scanning in diagnosing pseudoarthrosis: a prospective study.

The present study attempted to analyze the efficacy of single photon emission computed tomography (SPECT) in diagnosing pseudoarthrosis after fusion using surgical exploration as the gold standard. This study examined the SPECT scans of 38 patients before they underwent surgical exploration of their fusion mass for suspected pseudoarthrosis or in conjunction with instrumentation removal. Surgical findings were compared with the radiologists' findings to determine the efficacy of SPECT in diagnosing pseudoarthrosis. Radiographic determination of pseudoarthrosis has been difficult after attempted fusion of the spine. Multiple radiographic modalities have been touted as accurate depicters of the failure of spinal fusion. However, no method has been found to be highly accurate in the clinical setting. Thirty-eight patients (mean age = 42.8, 21 males/17 females, 35 of 38 with instrumentation) underwent SPECT scans before surgical exploration of their fusion mass for suspected pseudoarthrosis or in conjunction with instrumentation removal as part of this prospective study. The average interval from their fusion procedure until their SPECT scan was 23.9 months (range, 9-120 months). All surgical findings were recorded with regard to solidity of the fusion and the level of the possible pseudoarthrosis. All SPECT scans were read at a time after surgery by an independent nuclear radiologist who had not read their SPECT scans before surgery and who did not know the results of exploration. Results of the radiologist's reading were then compared with surgical exploration findings, and sensitivity and specificity was calculated. There were 24 solid fusions and 14 pseudoarthroses. SPECT scans correctly identified 7 of the 14 pseudoarthroses and 14 of the 24 solid fusions. This represents a sensitivity of 0.50 and a specificity of 0.58. SPECT scanning correctly diagnosed the one solid fusion and two pseudoarthrosis patients in the three patients who had no instrumentation. This study demonstrates that SPECT scanning alone is inaccurate in diagnosing pseudoarthrosis when using surgical exploration as the gold standard. Given recent pressures for cost containment, we cannot recommend SPECT scanning as a routine modality for use in the diagnosis of pseudoarthrosis. We cannot define the accuracy of SPECT scanning used together with computed tomography scans, plain films, or other radiographic modalities in the diagnosis of pseudoarthrosis.

Neurologic deterioration after cervical spinal cord injury.

Neurologic deterioration after cervical spinal cord injury (SCI) at a regional spinal cord center was examined. This study examined the incidence of neurologic deterioration as well as associated risk factors in our patient population. Up to 5.8% of cervical SCI patients have been noted to deteriorate neurologically after admission. Risk factors have been early surgery, halo application, traction, and Stryker frame rotation. All cervical SCI patients admitted between 1978 and 1993 who had neurologic deterioration were studied for characteristics of their event, operative status, risk factors, mortality, and neurologic return at 1 year postinjury. Patients were divided into minor and major groups based on the degree of neurologic loss. Nineteen of 1,031 patients were identified as neurologically deteriorated (1.84%). There were 8 major and 11 minor group patients. The average time from injury to deterioration was 3.95 days. Of 10 patients undergoing surgery at < or =5 days, 8 deteriorated postoperatively. Potential risk factors were ankylosing spondylitis (three patients), sepsis (four patients), and intubation (four patients). Neurologic recovery at 1 year showed that 11 of 12 patients were improved. Neurologic deterioration occurred in 1.84% of our patients. Deteriorations were associated with surgery at <5 days after injury, ankylosing spondylitis, sepsis, and intubation.

Long-term evaluation of vertebral artery injuries following cervical spine trauma using magnetic resonance angiography.

STUDY DESIGN: A prospective study to determine the long-term outcome of traumatically induced vertebral artery injuries. Magnetic resonance angiography was performed at the time of cervical injury and at a follow-up office visit. OBJECTIVE: To determine the long-term outcome in terms of arterial flow competency of traumatically induced vertebral artery injuries. SUMMARY OF BACKGROUND DATA: Vertebral artery injury associated with cervical spine trauma has been well documented; however its healing or nonhealing potential has not been elucidated. METHODS: During the 7-month period from July 1993 to January 1994, all patients admitted to the authors' institution with cervical spine injuries underwent magnetic resonance imaging and magnetic resonance angiography of the cervical spine to determine the patency of their vertebral arteries. Magnetic resonance angiography was performed at the time of injury and at a follow-up office visit. Twelve of 61 patients were found to have a lack of signal flow within one of their vertebral vessels during this study period. RESULTS: Eighty-three percent of the patients (five of six) who were available for follow-up observation in this study did not manifest flow reconstitution of their vertebral arteries after an average 25.8-month follow-up period. CONCLUSIONS: According to these data, most patients with vertebral artery injuries after nonpenetrating cervical spine trauma do not reconstitute flow in the injured vertebral arteries. This lack of flow must be considered if future surgery in this region of the cervical spine is contemplated.

Magnetic resonance imaging analysis of lumbar disc changes below scoliosis fusions. A prospective study.

STUDY DESIGN: The authors of this prospective study examined the preoperative and 3-year postoperative magnetic resonance images of 14 patients undergoing anterior and posterior fusion and/or posterior fusion only for scoliosis. All magnetic resonance images were ready by two independent neuroradiologists, who were blinded to the purposes of the study, for the presence of disc narrowing, signal decrease on T2, or herniated nucleus pulposus before and after surgery. Particular attention was paid to the disc changes at the level directly below the end vertebral level of the fusion and two levels below the fusion in the lumbosacral spine existing before surgical intervention. OBJECTIVES: To evaluate the potential for disc degeneration distal to long scoliosis fusions with end fusion levels in the mid to lower lumbar spine. SUMMARY OF BACKGROUND DATA: The determination of end levels of fusion for contructs presently used to manage adult scoliotic deformity has been evaluated in terms of correction of curvature and late decompensation in coronal and sagittal plane balance after fusion. However, the natural history of the caudal, free-motion segments in terms of degeneration and/or correlation with pain has not yet been addressed. METHODS: Fourteen patients undergoing scoliosis fusion underwent magnetic resonance imaging before surgery and approximately 3 years after surgery. The scans were reviewed by two independent neuroradiologists who looked at three degenerative indices at the disc below the area of scoliosis fusion. The authors analyzed rates of change of the three degenerative indices in the pre- and postoperative magnetic resonance images and created associations between the observed changes on the magnetic resonance images and the clinical outcomes of pain, the presence or absence of solid fusion, and the need for repeat surgery. RESULTS: Estimates of the rates of change of the three degenerative indices one or two levels below the fusion were as follow: the chance of disc narrowing, .2-34%; the chance of a decreasing signal on T2, 5-54%, with a 23% incidence among this group; and the chance of herniated nucleus pulposus, 0-34%. There was a significant correlation between the presence of back and/or leg pain and the signal decrease one level below the fusion (P = .04). CONCLUSIONS: If these results are corroborated in a larger sample size, surgeons who manage deformity may have to consider altering fusion levels at the time of fusion based on magnetic resonance imaging predictors. The present data may help to inform patients about the risk of developing junctional degenerative changes and potential symptoms from these changes below scoliosis fusions.

Neurologic outcome of early versus late surgery for cervical spinal cord injury.

STUDY DESIGN: A prospective analysis evaluating neurologic outcome after early versus late surgery for cervical spinal cord trauma. OBJECTIVES: The study was conducted to determine whether neurologic and functional outcome is improved in traumatic cervical spinal cord-injured patients (C3-T1, American Spinal Injury Association grades A-D) who had early surgery (<72 hours after spinal cord injury) compared with those patients who had late surgery (>5 days after spinal cord injury). SUMMARY OF BACKGROUND DATA: There is considerable controversy as to the appropriate timing of surgical decompression and stabilization for cervical spinal cord trauma. There have been numerous retrospective studies, but no prospective studies, to determine whether neurologic outcome is best after early versus late surgical treatment for cervical spinal cord injury. METHODS: Patients meeting appropriate inclusion criteria were randomized to an early (<72 hours after spinal cord injury) or late (>5 days after spinal cord injury) surgical treatment protocol. The neurologic and functional outcomes were recorded from the acute hospital admission to the most recent follow-up. RESULTS: Comparison of the two groups showed no significant difference in length of acute postoperative intensive care stay, length of inpatient rehabilitation, or improvement in American Spinal Injury Association grade or motor score between early (mean, 1.8 days) versus late (mean, 16.8 days) surgery. CONCLUSIONS: The results of this study reveal no significant neurologic benefit when cervical spinal cord decompression after trauma is performed less than 72 hours after injury (mean, 1.8 days) as opposed to waiting longer than 5 days (mean, 16.8 days).

Relationship of total hip arthroplasty outcomes to other orthopaedic procedures.

The Medical Outcomes Study Short Form-36 was used preoperatively and 2 years postoperatively to compare patients' self reported assessment of health and function between 151 patients who had primary total hip replacement and 49 patients who had total hip revision, 149 patients who had primary total knee replacements, 41 patients who had lumbar laminectomy, and 43 patients who had scoliosis surgery. Primary total hip arthroplasty and lumbar laminectomy posted equivalent followup scores. Primary total hip arthroplasty showed significant improvements in physical function and health perception when compared with revision total hip arthroplasty; all other health parameters were similar. Primary total hip arthroplasty showed significantly better followup scores and greater improvement in scores in four of nine categories of the SF-36 when compared with primary total knee arthroplasty (despite identical scores preoperatively). Despite a higher level of assessed health preoperatively, patients who had scoliosis surgery compared least favorably with patients who had primary total hip arthroplasty at 2 years followup. In terms of patient self assessment of health and function, primary total hip arthroplasty and lumbar laminectomy for radiculopathy gave the best results.

Bivector traction for unstable cervical spine fractures: a description of its application and preliminary results.

The management of acute, displaced odontoid fractures requires the restoration of sagittal alignment and rigid external or internal immobilization to prevent late instability and achieve union. This report introduces a new traction technique for the reduction of posteriorly displaced type 2 odontoid fractures. Seven patients with traumatic injuries to the dens were placed in bivector traction for an awake closed reduction. Sagittal alignment was restored and maintained in all patients with no neurologic deterioration or traction-related complications during an average of 11 days (range, 2-28 days) in traction. The overall sagittal alignment corrected from an initial average of 12.2 mm (range, 5-22 mm) of posterior displacement to an average of 1.1 mm (range, 0-3 mm) at the completion of reduction. Only one patient had residual angulation, which measured 5 degrees. Three patients achieved an osseous union and the remaining four required a posterior C1-C2 fusion for nonunion. Although operative stabilization may be the preferred approach in this patient population and injury pattern, we conclude that bivector traction is a safe and effective technique for the initial management of posteriorly displaced odontoid fractures. In addition, its role can be expanded to the closed reduction of lower cervical spine fractures in patients with fixed flexion deformities secondary to ankylosing spondylitis or disseminated intraosseous segmental hyperostosis.

Steroids and gunshot wounds to the spine.

OBJECTIVE: The second National Acute Spinal Cord Injury Study demonstrated that there were neurological benefits from "spinal cord injury" doses of methylprednisolone for blunt spinal cord injuries. In this review, we examined the relative risk/benefit ratio of intravenously treating spinal gunshot wound victims with steroids. METHODS: A retrospective review was conducted of 254 consecutive patients who were treated between 1979 and 1994 for gunshot wounds to the spine (C1-L1) and a spinal cord injury. Three subgroups were established based on the administration of the steroids methylprednisolone (National Acute Spinal Cord Injury Study 2 protocol), dexamethasone (initial dose, 10-100 mg), and no steroids. All patients who received steroids were initially treated at another hospital and then transferred. No patients received steroids at our institution. The data analyzed included neurological outcome and infectious and noninfectious complications. RESULTS: No statistically significant neurological benefits were demonstrable from the use of steroids (methylprednisolone, dexamethasone). Infectious complications were increased in both groups receiving steroids (not statistically significant). Gastrointestinal complications were significantly increased in the dexamethasone group (P = 0.021), and pancreatitis was significantly increased in the methylprednisolone group (P = 0.040). The mean duration of follow-up was 56.3 months. CONCLUSION: In this retrospective, nonrandomized review, no neurological benefits were detectable from intravenously administered steroids after a gunshot wound to the spine. Both infectious and noninfectious complication rates were higher in the groups receiving steroids. Patients who sustain a spinal cord injury secondary to a gunshot wound to the spine should not be treated with steroids until the efficacy of such treatment is proven in a controlled study.

Cervical disk disease and the keyhole foraminotomy: proven efficacy at extended long-term follow up.

Eighty-four consecutive patients with posterolateral cervical disk herniation treated by keyhole foraminotomy between 1980 and 1987 were reviewed. Radicular pain was the most common presenting complaint. Weakness was present in 59 patients. Sixty patients were available for long-term follow up, averaging 6.1 years. Fifty-six patients' results were graded as excellent. Three patients had good results and one fair result was noted. There were no poor results. Preoperative pain symptoms were relieved in all patients. There were no significant complications. The posterolateral keyhole foraminotomy is an efficient means of decompressing lateral soft disk herniations, without the risk of an anterior approach or iliac crest bone harvest. Careful patient selection and use of an operative microscope are essential in obtaining consistent, excellent results.

Anterior plate instrumentation for disorders of the subaxial cervical spine.

Anterior cervical plate instrumentation is useful in the maintenance of cervical alignment, the prevention of graft extrusion, and the development of late deformity as well as potentially avoiding the need for a secondary posterior cervical procedure in the setting of cervical trauma. Its role in cervical reconstruction after decompression for cervical spondylosis is evolving. The definite risks of anterior cervical instrumentation should be considered, that is, screw and plate displacement or screw violation of neurologic structures, before the implementation of this form of fixation.

Health outcome assessment before and after lumbar laminectomy for radiculopathy.

STUDY DESIGN: Forty-one patients undergoing lumbar laminectomy for radiculopathy resulting from herniated discs assessed their health status using a generic health outcome instrument (Medical Outcomes Study Short Form 36) before surgery and at an average of 2 years after surgery. OBJECTIVES: To assess whether lumbar laminectomy for herniated nucleus pulposus is a useful intervention when patients evaluate their own perception of health. SUMMARY OF BACKGROUND DATA: The medical Outcomes Study Short Form 36 has been used in multiple studies assessing various medical conditions. It is brief, generic, and reliable. Although surgical treatment for radiculopathy by lumbar laminectomy has been shown to be successful using specific criteria for patient selection and an algorithmic approach, the authors are not aware of any study using a patient-based health outcome assessment to evaluate the results of this type of surgery. METHODS: Forty-one patients (82% completed follow-up evaluation; average follow-up period, 2.08 years) completed Medical Outcomes Study Short Form 36 before and after surgery. Scores from before and after surgery were compared. RESULTS: Statistically significant improvements (P < 0.01) were seen in eight of the nine health scores comparing scores from before and after surgery at follow-up evaluation. These included physical function, social function, role function resulting from physical limitations, role function resulting from emotional limitations, mental health, vitality, pain, and perceived health change. No significant change was seen in the patients' health perception after surgery. CONCLUSIONS: This study shows that the patients' self-reported health outcomes after lumbar laminectomy correlate with the excellent results previously seen using physician-driven outcome measures in an appropriately selected population with radiculopathy. The excellent results shown here did not deteriorate with age (> 40 years compared with < 40 years) or with complications after surgery.

Thoracolumbar infections in penetrating injuries to the spine.

A detailed review of the TJUH experience and the published literature on gunshot and stab wounds to the spine has been presented. The following statements are supported. (1) Military (high-velocity) gunshot wounds are distinct entities, and the management of these injuries cannot be carried over to civilian (low-velocity) handgun wounds. (2) Gunshot wounds with a resultant neurologic deficit are much more common than stab wounds and carry a worse prognosis. (3) Spinal infections are rare following a penetrating wound of the spine and a high index of suspicion is needed to detect them. (4) Extraspinal infections (septic complications) are much more common than spinal infections following a gunshot or stab wound to the spine. (5) Steroids are of no use in gunshot wounds to the spine. In fact, there was an increased incidence of spinal and extraspinal infections without a difference in neurologic outcome compared with those who did not receive steroids. (6) Spinal surgery is rarely indicated in the management of penetrating wounds of the spine. The recommendations for treatment at TJUH of victims of gunshot or stab wounds with a resultant neurologic deficit are as follows. (1) Spine surgery is indicated for progressive neurologic deficits and persistent cerebrospinal fluid leaks (particularly if meningitis is present), although these situations rarely occur. (2) Consider spine surgery for incomplete neurologic deficits with radiographic evidence of neural compression. Particularly in the cauda equina region, these surgeries may be technically demanding because of frequent dural violations and nerve root injuries/extrusions. These cases must be evaluated in an individual case-by-case manner. The neurologic outcomes of patients with incomplete neurologic deficits at TJUH who underwent acute spine surgery (usually for neural compression secondary to a bullet) were worse than the outcomes for the patients who did not have spine surgery. A selection bias against the patients undergoing spine surgery was likely present as these patients had evidence of ongoing neural compression. (3) A high index of suspicion is necessary to detect spinal and extraspinal infections. (4) Do not use glucorticoid steroids for gunshot wound victims. (5) Conservative (nonoperative) treatment with intravenous broad spectrum antibiotics and tetanus prophylaxis is the sole therapy indicated in the majority of patients who sustain a penetrating wound to the thoracic or lumbar spines.

Occurrence of infection in anterior cervical fusion for spinal cord injury after tracheostomy.

STUDY DESIGN: This study retrospectively reviewed the outcomes of 11 patients treated for a cervical spine injury with a tracheostomy placed before anterior cervical spine surgery. OBJECTIVES: The primary goal was to show that anterior cervical spine surgery in the setting of spinal cord injury is a viable option in patients with previous tracheostomy. SUMMARY OF BACKGROUND DATA: Respiratory failure after cervical cord injury commonly requires tracheostomy, possibly increasing the risk of soft tissue or bony infection in patients at high risk for morbidity after surgery. Although numerous studies have explored the risk of infection after tracheostomy or anterior cervical spine surgery, no study has been performed to explore the risk of infection in patients with previous tracheostomy at the time of anterior cervical spine surgery. METHODS: A retrospective review of the clinical data of 1800 spinal cord injury patients seen from 1979 to the present at the Regional Spinal Cord Injury Center of the Delaware Valley of Thomas Jefferson University with affiliated institutions of Thomas Jefferson University Hospital and Magee Rehabilitation Hospital was performed. Eleven patients were found who had existing tracheostomy at the time of anterior cervical spine surgery. Clinical follow-up period averaged 28 months with a range of 6-51 months, and radiographic analysis averaged 7 months with a range of 1-51 months. Autogenous iliac crest graft was used in all patients, consisting of an intervertebral graft after a discectomy or a strut graft after a complete corpectomy. Anterior instrumentation was used in more than 50% of the patients. RESULTS: After all patient interviews and review of all radiographs for evidence of infection, no patient was noted to have evidence of a cervical soft tissue or bony infection after surgery. The tracheostomy complications were minor and resolved quickly. CONCLUSIONS: The authors concluded that in patients with cervical cord damage resulting from nonpenetrating trauma, tracheostomy was not found to increase the risk of infection in subsequent anterior cervical surgery. Careful preparation of the skin and placement of the second surgical incision lateral to the tracheostomy site is recommended. Anterior cervical spine surgery remains a viable treatment option in this severely injured patient population.