Acute respiratory failure from Surgifoam expansion after anterior cervical surgery: case report.

A 65-year-old woman underwent an uneventful C3-4 anterior cervical discectomy and fusion for a large, symptomatic disc herniation. On postoperative Day 1 the patient suffered a sudden, acute respiratory compromise. Emergency fiberoptic intubation revealed significant anterior neck swelling with concern for physical obstruction of the airway. Computed tomography of the neck did not demonstrate an expanding hematoma. The patient was managed with surgical wound exploration and washout. Examination of the anterior neck after incision of the prior surgical site revealed a large volume of Surgifoam under high pressure, which was greater than the amount used during the initial surgery. Thorough washout of the surgical site did not reveal any swelling of the prevertebral soft tissues or hematoma, and the Hemovac drain did not appear to be occluded. The patient was extubated on the 2nd postoperative day and is symptom free 12 months after surgery. To the authors' knowledge, this report represents the first reported complication of acute respiratory failure from Surgifoam overexpansion after anterior cervical surgery.

Increased incidence of cage migration and nonunion in instrumented transforaminal lumbar interbody fusion with bioabsorbable cages.

OBJECT: Recent advances in the field of spinal implants have led to the development of the bioabsorbable interbody cage. Although much has been written about their advantageous characteristics, little has been reported regarding complications associated with these cages. The authors conducted this prospective cohort study to compare fusion and complication rates in patients undergoing transforaminal lumbar interbody fusion (TLIF) with carbon fiber cages versus biodegradable cages made from 70/30 poly(l-lactide-co-d,l-lactide) (PLDLA). METHODS: Between January 2005 and May 2006, 81 patients with various degenerative and/or structural pathologies affecting the lumbar spine underwent single- or multilevel TLIF with posterior segmental pedicle screw fixation using implants made of carbon fiber (37 patients) or 70/30 PLDLA (44 patients). Clinical and radiological follow-up was performed at 6 weeks, 3 months, 6 months, and 1 year, and is ongoing. The incidence of nonunion, screw breakage, and cage migration were compared between the 2 groups. RESULTS: There was no significant difference in demographic data between the 2 groups, the mean number of lumbar levels operated, or distribution of the levels operated. There was a significantly increased incidence of nonunion (8 patients, 18.2%) and cage migrations (8 patients, 18.2%) in patients receiving the PLDLA implants compared with carbon fiber implants (no patients) (p = 0.006 and 0.007, respectively). There was no significant difference in demographic data between patients with cage migration and the rest of the patient population. Five of the 8 cases of migration occurred at the L5-S1 level while the remaining 3 occurred at the L4-5 level. The mean time to implant failure was 9.3 months. CONCLUSIONS: This study showed an increased incidence of nonunion (18.2%) and postsurgical cage migration (18.2%) in patients undergoing TLIF with biodegradable cages versus carbon fiber implants (0%) (p = 0.006 and 0.007, respectively).

Uncorrected sagittal plane imbalance predisposes to symptomatic instrumentation failure.

BACKGROUND CONTEXT: Elucidation of the factors responsible for symptomatic failure of spinal instrumentation has been a keen interest for many investigators. PURPOSE: To quantitate the number of symptomatic instrumentation failures (SIFs) encountered during a 2-year period. The effect of sagittal plane imbalance (corrected or uncorrected) on the rate of SIF was evaluated. STUDY DESIGN: Retrospective evaluation of all patients requiring spinal instrumentation to determine which factors predispose toward instrumentation failure. PATIENT SAMPLE: All patients requiring spinal instrumentation over a 2-year period were retrospectively studied. OUTCOME MEASURES: Sagittal plane imbalance pre- and postoperatively was determined using Cobb angle analysis on plain X-rays. SIF was defined as screw back-out and/or breakage, pseudarthrosis, cage migration, or rod disconnection in patients with concordant symptoms. Asymptomatic patients did not demonstrate instrumentation failure on the routine postoperative X-rays. METHODS: Of the 355 patients who fit the criteria, 47 patients presented with either idiopathic or secondary sagittal plane deformity preoperatively. Additionally, long-segment fixation, smoking, age, and fixation across junctional segments were evaluated as risk factors for SIF. RESULTS: Of the 47 patients with sagittal plane deformity, 40 patients (85%) achieved correction demonstrated on postoperative radiographs whereas in 7 (15%), the sagittal plane imbalance was not corrected. Of these seven cases, five suffered instrumentation failure (failure rate 71.5%) versus no instrumentation failures (failure rate 0%) for the remaining 40 patients. SIF was demonstrated in 10 patients overall (failure rate of 2.8%). There was no correlation found between factors such as age, indications for surgery, or long-segment fixation, and instrumentation failure. CONCLUSIONS: Failure to correct sagittal plane deformity intraoperatively predisposes patients to SIF regardless of age, level of surgery, or indication of surgery.

Stress-shielding compared with load-sharing anterior cervical plate fixation: a clinical and radiographic prospective analysis of 50 patients.

OBJECT: In a prospective analysis the authors evaluated the clinical and radiographic outcome of 50 consecutive patients who underwent anterior cervical discectomy and fusion and fixation in which either a stress-shielding or a load-sharing plate (Orion and Premier, respectively) was placed. Data obtained in the two cohorts were analyzed to determine whether clinical or radiographic differences would emerge. METHODS: All patients underwent either one- or two-level fusion in which freeze-dried allogenic tricortical iliac crest bone graft was used. In the first cohort of 25 patients entered into the study, fixation was achieved using a stress-shielding anterior cervical plate (ACP) system, whereas in the second cohort of 25 patients a load-sharing plate system was employed. Patients were evaluated during a follow-up period that ranged from 12 to 35 months. Outcome was determined using a standard questionnaire by which the authors gauged the level of pain, disability, and satisfaction following surgery. The success of surgical fusion and the magnitude of the translation were determined by radiographic evaluation. There was no statistically significant difference between the two cohorts with respect to age, sex, smoking rate, and postoperative complications. With regard to pain and functionality, there was a significant difference (p < 0.05) in favor of the load-sharing system. The fusion rates with the load-sharing and stress-shielding systems were 96 and 92%, respectively, and this difference was not significant. There was no significant difference between the two cohorts with regard to overall satisfaction. The magnitude of vertical translation was significantly greater in the stress-shielding ACP group (p < 0.05) for treatment at one level but not at two. Clinical and radiographic data were available in all patients. CONCLUSIONS: Load-sharing ACP systems exhibited superior clinical results compared with stress-shielding ACPs in this series of patients. The symptomatic pseudarthrosis rate was lower in the load-sharing ACP-treated patients, although this was not statistically significant.

Harvey Cushing's Meningiomas text and the historical origin of resectability criteria for the anterior one third of the superior sagittal sinus.

The search for the origin of the commonly held principle in current neurosurgery regarding the resectability of the anterior one third of the superior sagittal sinus unravels the many fascinating developments that occurred in neurosurgery during the early 20th century. All these occurrences can be traced back to, and are uniquely contextualized in, Harvey Cushing's seminal text, Meningiomas, Their Classification, Regional Behaviour, Life History, and Surgical End Results. Written with Louise Eisenhardt and published in 1938, Meningiomas is a monograph of incredible description and detail. The meticulous categorization of meningiomas, their presentation, clinical outcome, and surgical therapies are even further supplemented by Cushing's personal commentary, questions, and recollections. Cushing's genius was evident in his ability not only to make insightful clinical observations, but also to synthesize these ideas within the neurosurgical context of his era. As he says in Meningiomas, "Thus the pathological curiosity of one day becomes in its proper time a commonplace... most of which are one and the same disorder--had, for their interpretation, to await the advent of the Neurosurgeon."