Esophageal perforations after anterior cervical surgery.

An esophageal perforation after anterior cervical surgery is an uncommon but well recognized complication. During the past 25 years, 44 patients have presented to Craig Hospital (Rocky Mountain Regional Spinal Injury Center) with esophageal perforations; this is the largest series reported to date. There were 34 patients whose esophageal injury was related to the operations performed for cervical fractures, of which 28 patients had plate and screw fixation. The most frequently occurring clinical symptoms were that of neck and throat pain, odynophagia, dysphagia, hoarseness, and aspiration. The most common clinical findings were an elevated temperature, localized induration and neck tenderness, crepitus or subcutaneous air in the neck and anterior chest wall, an unexplained tachycardia, and blood in the nasogastric tube. Imaging studies indicated an esophageal injury in only 32 (72.7%) patients. Twenty-two patients experienced cervical osteomyelitis or an abscess of the neck. Nonoperative treatment is fraught with a high mortality, and 42 patients required surgical repair of their esophageal injury. The length of hospital stay averaged 253 days. Successful management of esophageal perforations depends on the physicians' awareness of the causes, prompt recognition of the symptoms and clinical findings, and immediate institution of treatment.

Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization.

STUDY DESIGN: A retrospective study to review the results of unstable thoracolumbar burst fractures managed with casting or bracing and early ambulation in neurologically healthy patients. OBJECTIVES: To determine the clinical outcome of patients with unstable burst fractures of the thoracolumbar spine treated without surgery, and to identify any variables that may adversely influence the final outcome. SUMMARY OF BACKGROUND DATA: The management of unstable fractures of the thoracolumbar spine as described by Bedbrook involves a period of recumbency for 6-8 weeks followed by gradual mobilization. Newer techniques of surgical stabilization of the fracture and decompression of the neural elements have become popular because immediate stability of the spine is created and because the need for prolonged bedrest and hospitalization is eliminated. There have been only three reports in the literature describing the nonoperative management of these fractures with early mobilization; some authors believe that this is appropriate only if the posterior column is intact. The results reported in the literature of nonoperative management of thoracolumbar burst fractures have indicated that this is an effective method of management. METHODS: A retrospective review of 26 patients with unstable burst fractures in the thoracolumbar region (T11-L2) was performed; follow-up evaluation was obtained from 24 patients. Clinical follow-up examination was performed by the use of a questionnaire in which the patients were asked to rate their pain, ability to work, ability to perform in recreational activities, and their overall satisfaction with treatment. RESULTS: Mean follow-up time for the 24 patients was 34.3 months. Mean duration of hospitalization was 8.2 days; those patients who did not have injuries other than their spine fracture had a mean hospitalization time of 5.9 days. Kyphotic deformity could be corrected with hyperextension casting but tended to recur during the course of mobilization and healing. No correlation was found between kyphosis and clinical outcome. At final follow-up evaluation, 19 patients (79%) had little or no pain; 18 patients (75%) had returned to work; 18 (75%) stated that they had little or no restrictions in their ability to work, and 16 (67%) stated that they had little or no restrictions in their ability to participate in recreational activities. Only one patient (4%) reported being dissatisfied with the initial nonoperative treatment of his spine fracture. Ten patients were found to have evidence of spinous process widening on plain films; there was no significant difference in the clinical or radiographic outcome of these 10 patients when compared with the 14 others who did not have interspinous widening. CONCLUSIONS: Nonoperative management of thoracolumbar burst fractures with hyperextension casting or bracing was proven to be a safe and effective method of treatment in selected patients. Clinical results were favorable; no neurologic deterioration was observed; hospitalization times were minimized, and patient satisfaction was high. The authors do not believe that ligamentous injury of the posterior column is a contraindication to nonoperative management of thoracolumbar burst fractures.

Stabilization of thoracic spine fractures resulting in complete paraplegia. A long-term retrospective analysis.

STUDY DESIGN: The impact of surgical stabilization on initial rehabilitation and complications in patients with traumatic thoracic level paraplegia was investigated. One hundred thirteen patient records were retrospectively reviewed. SUMMARY OF BACKGROUND DATA: Forty-six patients had been treated with surgical stabilization and fusion. Nineteen patients had been treated by laminectomy alone. Forty-eight patients had been treated nonoperatively. The most common mechanism of injury was a motor vehicle accident (52.6%). The mean follow-up was 8.4 years. METHODS: All inpatient and outpatient records at Craig Hospital were reviewed for patients who had sustained a thoracic spine fracture (T2-T9) that resulted in complete paraplegia (Frankel A). All patients were followed for a minimum of 5 years. Data were collected regarding initial length of inpatient rehabilitation, as well as early and late complications that affected rehabilitation and function during follow-up. This information was analyzed by treatment group. RESULTS: There was a statistically significant difference in the length of initial rehabilitation days between the surgically stabilized group and the laminectomy-only group. There was a trend toward fewer in-patient rehabilitation days between the surgically stabilized group and the nonoperatively treated group. The surgically treated group had twice as many complications as the nonoperative group. CONCLUSIONS: The surgical stabilization of thoracic (T2-T9) spine fractures with complete paraplegia tends to decrease initial rehabilitation days but is associated with increased overall complications. The treatment of this patient group clearly must be individualized.

Soft-tissue injuries of the cervical spine.

Cervical sprain syndrome is usually the result of a hyperextension injury of the neck; symptoms include neck, intrascapular and arm pain, and headache. Associated complaints of the head, neck, and upper extremities are common. The mechanism and pathophysiology of this injury, and the occurrence of associated injuries are discussed. Patient evaluation, treatment, and prognosis are reviewed. A thorough understanding of this common injury should facilitate treatment and provide the patient and physician with realistic expectations for recovery.

Localization of the gene for the ciliary neurotrophic factor receptor (CNTFR) to human chromosome 9.

Ciliary neurotrophic factor (CNTF) has recently been found to be important for the survival of motor neurons and has shown activity in animal models of amyotrophic lateral sclerosis (ALS). CNTF therefore holds promise as a treatment for ALS, and it and its receptor (CNTFR) are candidates for a gene involved in familial ALS. The CNTFR gene was mapped to chromosome 9 by PCR on a panel of human/CHO somatic cell hybrids and localized to 9p13 by PCR on a panel of radiation hybrids.

Neuropathic (Charcot) arthropathy of the spine after traumatic spinal paraplegia.

Neuropathic (Charcot) arthropathy of the spine is a relatively rare problem that, nonetheless, must be considered in the differential diagnosis of any patient with degeneration of one or more levels of the spine associated with diminished or absent protective sensation. This study presents 15 patients in whom Charcot arthropathy of the spine developed after traumatic paraplegia. Eight were successfully treated with surgical fusion, and the remaining seven were treated nonoperatively. By the use of combined anterior and posterior fusion with extensive debridement, autogenous grafting, and posterior instrumentation, successful fusion can be achieved in patients with Charcot arthropathy of the spine. However, the surgical technique is demanding, the rehabilitation must be carefully supervised, and the postoperative complication rate remains high. The possibility of developing secondary levels of arthropathy below a previously successful fusion must be considered.

The natural history of thoracic disc herniation.

Fifty-five patients with 72 thoracic disc herniations were retrospectively reviewed in an effort to ascertain the natural history of this disease. The treatment programs given to these patients were evaluated, and 15 (27%) of the 55 patients eventually required surgery. The majority, however, did not require surgery and have continued to perform activities of daily living, some even participating in vigorous sports activities (eg, skiing) without any apparent neurologic consequences. Thoracic disc herniations, similar to cervical and lumbar disc herniations, do not always lead to major neurologic compromise. A less aggressive surgical approach therefore can be considered.

Relationship between vertebral intraosseous pressure, pH, PO2, pCO2, and magnetic resonance imaging signal inhomogeneity in patients with back pain. An in vivo study.

The cause of back pain in many patients in unknown. The pain experienced by patients with osteoarthritis of large joints has been associated with intraosseous abnormalities of elevated pressure, venous dilatations, and abnormalities of pH, pCO2, and pO2. Magnetic resonance imaging demonstrates an abnormal signal in the vertebral bodies of some patients with degenerative disc disease. The intraosseous pressure as well as the intraosseous pH, pO2, and pCO2 in a group of patients undergoing anterior spine surgery was studied, and the results were correlated to the preoperative magnetic resonance imaging appearance. Vertebral bodies with an abnormal magnetic resonance imaging signal had pressures 55% higher than vertebral bodies with a homogeneous signal; they also had significantly decreased pH and increased pCO2. Bodies with Type I changes had pressures 73% higher than those with a normal signal. No differences in pO2 were identified. These findings suggest that abnormalities of intraosseous pressure or blood gas concentrations may be related to mechanisms of pain production in some patients with back pain. These abnormalities can be identified by magnetic resonance imaging. Further investigation is needed to determine if therapeutic manipulation of these variables can be effective in relieving axial spinal pain.

Analysis of factors related to truncal decompensation following Cotrel-Dubousset instrumentation.

Spinal imbalance following Cotrel-Dubousset (CD) instrumentation for adolescent idiopathic scoliosis is a problem that is recognized with increasing frequency. We reviewed the clinical records and radiographs of 41 consecutive patients treated with CD instrumentation and attempted to identify factors related to postoperative worsening of spinal balance. Spinal balance was determined by the perpendicular distance of C7 to the center sacral line. Twenty-five were decompensated postoperatively. Sixteen patients had balance that was worse relative to the preoperative films. Eleven of 16 patients with worsened balance postoperative were King type III curves. Of 16 patients with worsened balance postoperatively, 13 had been fused to or below the lower neutral vertebra. Overcorrection of either the primary curve or the composite curve (sum of the measurable curves) relative to the preoperative bending films was not related to postoperative worsening of spinal balance. Fusion to the neutral or stable vertebra with CD instrumentation runs a high risk for postoperative worsening of spinal balance when the derotation maneuver is used. Consideration should be given to avoiding the derotation maneuver in larger type II curves in order to preserve spinal balance and avoid extension of instrumentation into the middle or lower lumbar spine.

The relationship of age to outcome in myasthenia gravis.

This study, a retrospective review of 165 patients with myasthenia gravis, compares the course of the disease for patients with onset before 50 and at or after 50. There were no significant differences between age groups for presenting symptoms, but more of the older patients had progressed to severe disease. More of the younger than the older patients were in remission or were asymptomatic on medication at the last visit. Sixty-two percent of those treated with steroids developed complications, with a larger portion of these being in the older group. Cataracts, infection, and bone changes were particularly significant for the older population. Complications of azathioprine treatment and plasmapheresis were less common. Thymoma was more common in the older population; these patients did no worse than the population as a whole. Sixty-five percent of our patients have undergone thymectomy, most by a modified transsternal approach. A much larger portion of those who underwent thymectomy were in remission at the last visit than those who did not.

The spine in osteogenesis imperfecta.

A high incidence of spinal curvature, approaching 80 per cent in patients more than twelve years old, was found in a large series of patients with osteogenesis imperfecta. Curves showed early progression and a predictable pattern. In the age range between one and five years the incidence of scoliosis was 26 per cent; thereafter, it rose precipitously. The degree of curvature was greater in the older children. The Milwaukee brace was ineffective in the treatment of the scoliosis and the complications of its use were detrimental. In several patients it deformed the rib cage. It had little or no effect on the progression of the curve. The incidence and degree of curvature was related to the type of bone present. Patients with chest deformities and those who were not ambulatory seemed to have a predilection for scoliosis.