Management of symptomatic lumbar degenerative disk disease.

Symptomatic lumbar degenerative disk disease, or discogenic back pain, is difficult to treat. Patients often report transverse low back pain that radiates into the sacroiliac joints. Radicular or claudicatory symptoms are generally absent unless there is concomitant nerve compression. Physical examination findings are often unremarkable. Radiographic examination may reveal disk space narrowing, end-plate sclerosis, or vacuum phenomenon in the disk; magnetic resonance imaging is useful for revealing hydration of the disk, annular bulging, or lumbar spine end-plate (Modic) changes in the adjacent vertebral bodies. The use of diskography as a confirmatory study remains controversial. Recent prospective, randomized trials and meta-analyses of the literature have helped expand what is known about degenerative disk disease. In most patients with low back pain, symptoms resolve without surgical intervention; physical therapy and nonsteroidal anti-inflammatory drugs are the cornerstones of nonsurgical treatment. Intradiskal electrothermal treatment has not been shown to be effective, and arthrodesis remains controversial for the treatment of discogenic back pain. Nucleus replacement and motion-sparing technology are too new to have demonstrated long-term data regarding their efficacy.

Cauda equina syndrome.

Cauda equina syndrome is a relatively uncommon condition typically associated with a large, space-occupying lesion within the canal of the lumbosacral spine. The syndrome is characterized by varying patterns of low back pain, sciatica, lower extremity sensorimotor loss, and bowel and bladder dysfunction. The pathophysiology remains unclear but may be related to damage to the nerve roots composing the cauda equina from direct mechanical compression and venous congestion or ischemia. Early diagnosis is often challenging because the initial signs and symptoms frequently are subtle. Classically, the full-blown syndrome includes urinary retention, saddle anesthesia of the perineum, bilateral lower extremity pain, numbness, and weakness. Decreased rectal tone may be a relatively late finding. Early signs and symptoms of a developing postoperative cauda equina syndrome are often attributed to common postoperative findings. Therefore, a high index of suspicion is necessary in the postoperative spine patient with back and/or leg pain refractory to analgesia, especially in the setting of urinary retention. Regardless of the setting, when cauda equina syndrome is diagnosed, the treatment is urgent surgical decompression of the spinal canal.

Acute cervical osteomyelitis and prevertebral abscess after routine tonsillectomy.

BACKGROUND CONTEXT: Tonsillectomy is among the most commonly performed surgical procedures. The development of severe infection after tonsillectomy is a very rare but potentially fatal complication that has not been described in the orthopedic, neurosurgical, or spine literature. PURPOSE: To present acute cervical osteomyelitis and prevertebral abscess formation as a complication of a routine tonsillectomy. STUDY DESIGN: Case report, literature review. METHODS: A case report was prepared on the clinical and radiographic data of a patient presenting with prevertebral abscess and acute cervical osteomyelitis 6 weeks after routine tonsillectomy. A review of relevant literature was additionally performed. RESULTS: The patient presented 6 weeks after tonsillectomy with evidence of a deep cervical infection. Operative debridement with anterior and posterior surgical stabilization was performed. The patient completed a 6-week course of intravenous antibiotics. At 24-month follow-up, the patient showed no signs of infection and demonstrated a stable fusion mass. CONCLUSIONS: The development of prevertebral abscess and acute cervical osteomyelitis has been discussed in a small number of otolaryngology case reports and has not been previously reported in the orthopedic, neurosurgical, or spine literature. Symptoms may be nonspecific, and so a high index of clinical suspicion is needed. Delay in treatment may lead to significant morbidity and even mortality. Successful treatment can be obtained through operative debridement and intravenous antibiotic therapy.

Bioabsorbable interbody spacers.

Bioabsorbable polymers have been used in surgery for more than four decades. With increased reliability and decreased incidence of complications, their application has become widespread. Although their role in spinal surgery continues to evolve, the theoretic biomechanical and biologic advantages over contemporary metallic and composite implant materials make bioabsorbable interbody spacers an attractive alternative. The lack of artifact on postoperative imaging studies and the ability to load share across fusion sites in a time-dependent manner can lead to more accurate fusion assessment and increased fusion rates. The preliminary data from small, short-term studies are promising. However, larger studies with long-term follow-up are lacking. The theoretic advantages of bioabsorbable materials must be tempered by the lack of long-term clinical evidence of their benefit. Until the results of more studies in human spinal applications become available, the precise indications for the use of bioabsorbable interbody spacers will continue to evolve.

Anatomic mapping and evaluation of the esophagus in relation to the cervical vertebral body.

The relationship of the esophagus to the cervical vertebral body (CVB), disc space and longus colli (LC) muscles, to our knowledge, has not been previously studied. The purpose of this study was to quantify the relationship of the esophagus to the CVB, disc space and LC. 30 patients were selected for a retrospective review of computed tomography (CT) scans. Measurements between the esophagus and the C5, C6, and C7 vertebral bodies as well as the C5/6 and C6/7 disc spaces were performed in the midline, 3 mm right and left of midline, and at the edge of the LC on both sides. The closest distance of the esophagus to the CVB and disc space occurs at the midline (range 1.02-1.31 mm at each level). The furthest distance occurred at the edge of the right LC (range 2.67-3.30 mm at each level). The mean distance from the edge of the right LC to the midline was significantly greater (P < 0.01) than mean distance from the edge of the left LC to the midline. No statistical significant differences were observed when comparing measurements at the individual vertebral bodies and disc spaces. The results of the study demonstrate that the esophagus lies in closest proximity to the CVB and disc space in the midline. A larger potential space exists between the esophagus and the CVB and disc space at the edge of the LC. These results may provide insight into a potential cause of post-operative dysphagia. Furthermore, it may help guide the future design of cervical plates to better utilize the potential space between the esophagus and the CVB and disc space at the edge of the LC.

The use of bioabsorbable implants in spine surgery.

The use of bioabsorbable implants in spine surgery is expanding at a rapid pace. These implants are mimicking the roles of traditional metallic devices and are demonstrating similar efficacy in terms of maintaining stability and acting as carriers for grafting substances. Biomechanical studies have demonstrated their ability to stabilize effectively a degenerative cervical and lumbar motion segment. In numerous animal models, researchers have illustrated the ability of bioabsorbable implants to function satisfactorily as an interbody spacer and to achieve satisfactory bone fusion. Investigators have explored various opportunities for these implants to replace their metallic counterparts in clinical studies conducted in humans. The gradual resorption of these implants appears effectively to transfer gradual loads to the grafting substances promoting the biological mechanisms of fusion. Novel uses of bioabsorbable technology are constantly evolving. Their future as a carrier of biological agents such as bone morphogenetic proteins and bone graft extenders, their radiolucency, and their eventual resorption make them an ideal implant for use in spinal degenerative disease.

Early findings in a pilot study of anterior cervical fusion in which bioabsorbable interbody spacers were used in the treatment of cervical degenerative disease.

OBJECT: In this pilot study the authors assessed the efficacy of bioabsorbable interbody spacers in the treatment of cervical degenerative disease. Metallic cages or interbody spacers have been widely used in the treatment of degenerative and traumatic cervical disease. Bioabsorbable technology has been used to develop a resorbable cage that can eliminate the complications and drawbacks seen with the use of traditional metallic implants. In general clinical practice bioabsorbable implants have shown the ability to degrade safely while demonstrating optimal imaging characteristics as a result of their radiolucency, and these devices eliminate stress shielding by their gradual dissolution. METHODS: This study is a retrospective evaluation of charts and x-ray films obtained in the first eight patients who underwent an anterior cervical decompression and fusion procedure with placement of a bioabsorbable interbody spacer and anterior cervical plate. All patients were treated in one surgeon's practice and had a minimum follow-up period of at least 6 months. At a follow-up interval of approximately 7 months, five patients exhibited an excellent result and three had a good result; no patient was noted to have a satisfactory or poor outcome according to the Odom criteria at their most recent follow-up visit. Seventeen (94%) of 18 grafted levels appeared to be solidly fused. One patient experienced a perisurgical complication consisting of a symptomatic hematoma, which was successfully drained. CONCLUSIONS: Bioabsorbable interbody spacers appear to be a safe and effective interbody implant in terms of clinical outcome and radiographically confirmed healing.

Spinal applications of bioabsorbable implants.

With the increasing use of bioabsorbable implants in a variety of clinical conditions, potential advantages in selected spinal applications are now being realized. Newer polymers with biomechanical properties relevant to the requirements of specific spinal implants and resorption rates appropriate for specific spinal applications are being developed. These new materials offer the necessary biomechanical stability of conventional spinal implants without the sequelae associated with metallic implants such as long-term loosening, implant migration, and imaging interference. At this time, the majority of clinical applications for these new polymers have involved tension band plating in the lumbar and anterior cervical spine, anterior spinal interbody reconstruction, posterior bone graft containment, and bone graft harvest site reconstruction.

Early halo immobilization of displaced traumatic spondylolisthesis of the axis.

STUDY DESIGN: A retrospective study evaluating early halo immobilization of Types II and IIA hangman's fractures. OBJECTIVE: To determine the treatment efficacy of early halo immobilization of Type II and IIA hangman's fractures. SUMMARY OF BACKGROUND DATA: The treatment of hangman's fractures with traction reduction is well established, but the time required in traction before the institution of halo-vest immobilization is controversial. METHODS: A retrospective review of all patients admitted to a level one spinal cord injury center between 1986 and 1999 with either a Type II or IIA hangman's fracture was performed. Initial and final radiographs were measured for translation and angulation. The need for reapplication of traction was also recorded. RESULTS: There were a total of 27 Type II and four Type IIA fractures. Of the Type II fractures, 21 went onto union after early halo immobilization. Six patients required reapplication of traction reduction because of fracture displacement. The Type IIA fractures all progressed to union. The discerning factor between the failure group and the success group was the initial degree of angulation on lateral cervical radiography. The patients requiring reapplication of traction had an initial fracture angulation of 12 degrees or greater. CONCLUSIONS: Early halo immobilization after traction reduction of Type II and IIA hangman's fractures is an effective method of management. Type II fractures with an angulation of greater than or equal to 12 degrees may require an extended period of traction to ensure adequate long-term fracture alignment.

Spinal applications of bioabsorbable implants.

With the increasing use of bioabsorbable implants in a variety of clinical conditions, potential advantages in select spinal applications are now being realized. Newer polymers with biomechanical properties relevant to the requirements of specific spinal implants and resorption rates appropriate for specific spinal applications are being developed. These new materials offer the necessary biomechanical stability of conventional spinal implants without the sequelae associated with metallic implants such as long-term loosening, implant migration, and imaging interference. At this time, the majority of clinical applications for these new polymers have involved tension band plating in the lumbar and anterior cervical spine, anterior spinal interbody reconstruction, posterior bone graft containment, and bone graft harvest site reconstruction.