The Use of Bone Morphogenetic Protein in Pediatric Cervical Spine Fusion Surgery: Case Reports and Review of the Literature.

Study Design Case report. Objective There is a paucity of literature describing the use of bone graft substitutes to achieve fusion in the pediatric cervical spine. The outcomes and complications involving the off-label use of bone morphogenetic protein (BMP)-2 in the pediatric cervical spine are not clearly defined. The purpose of this article is to report successful fusion without complications in two pediatric patients who had instrumented occipitocervical fusion using low-dose BMP-2. Methods A retrospective review of the medical records was performed, and the patients were followed for 5 years. Two patients under 10 years of age with upper cervical instability were treated with occipitocervical instrumented fusion using rigid occipitocervical fixation techniques along with conventionally available low-dose BMP-2. A Medline and PubMed literature search was conducted using the terms "bone morphogenetic protein," "BMP," "rh-BMP2," "bone graft substitutes," and "pediatric cervical spine." Results Solid occipitocervical fusion was achieved in both pediatric patients. There were no reported perioperative or follow-up complications. At 5-year follow-up, radiographs in both patients showed successful occipital cervical fusion without evidence of instrumentation failure or changes in the occipitocervical alignment. To date, there are few published reports on this topic. Complications and the appropriate dosage application in the pediatric posterior cervical spine remain unknown. Conclusions We describe two pediatric patients with upper cervical instability who achieved successful occipital cervical fusion without complication using off-label BMP-2. This report underscores the potential for BMP-2 to achieve successful arthrodesis of the posterior occipitocervical junction in pediatric patients. Use should be judicious as complications and long-term outcomes of pediatric BMP-2 use remain undefined in the existing literature.

Symptomatic Triple-Region Spinal Stenosis Treated with Simultaneous Surgery: Case Report and Review of the Literature.

Study Design Case report. Objectives Symptomatic triple-region spinal stenosis (TRSS), defined as spinal stenosis in three different regions of the spine, is extremely rare. To our knowledge, treatment with simultaneous decompressive surgery is not described in the literature. We report a case of a patient with TRSS who was treated successfully with simultaneous decompressive surgery in three separate regions of the spine. Methods A 50-year-old man presented with combined progressive cervical and thoracic myelopathy along with severe lumbar spinal claudication and radiculopathy. He underwent simultaneous decompressive surgery in all three regions of his spine and concomitant instrumented fusion in the cervical and thoracic regions. Results Estimated blood loss for the procedure was 600 mL total (250 mL cervical, 250 mL thoracic, 100 mL lumbar) and operative time was ∼3.5 hours. No changes were noted on intraoperative monitoring. The postoperative course was uncomplicated. The patient was discharged to inpatient rehabilitation on postoperative day (POD) 7 and discharged home on POD 11. At 6-month follow-up, his gait and motor function was improved and returned to normal in all extremities. He remains partially disabled due to chronic back pain. Conclusions This report is the first of symptomatic TRSS treated with simultaneous surgery in three different regions of the spine. Simultaneous triple region stenosis surgery appears to be an effective treatment option for this rare condition, but may be associated with prolonged hospital stay after surgery.

Nonoperative Management of Craniocervical Ligamentous Distraction Injury: Literature Review.

Study Design Literature review and case report. Objective Review the existing literature and report the successful nonoperative management of a two-level craniocervical ligamentous distraction injury. Methods A PubMed and Medline review revealed only three limited reports involving the nonoperative management of patients with craniocervical distraction injury. This article reviews the existing literature and reports the case of a 27-year-old man who was involved in a motorcycle accident and sustained multiple systemic injuries and ligamentous distraction injuries to both occipitocervical joints and both C1-C2 joints. The patient's traumatic brain injury and bilateral pulmonary contusions precluded safe operative management of the two-level craniocervical distraction injury. Therefore, the patient was placed in a halo immobilization device. Results The literature remains unclear as to the specific indications for nonoperative management of ligamentous craniocervical injuries. Nonoperative management was associated with poor outcomes in the majority of reported patients. We report a patient who was managed for 6 months in a halo device. Posttreatment computed tomography and flexion-extension radiographs demonstrated stable occipitocervical and C1-C2 joints bilaterally. The patient reported minimal neck pain and had excellent functional outcome with a Neck Disability Index score of 2 points at 41 months postoperatively. He returned to preinjury level of employment without restriction. Conclusions Further study is needed to determine which craniocervical injuries may be managed successfully with nonoperative measures.

Vertebral artery anomaly and injury in spinal surgery.

STUDY DESIGN: Systematic review. STUDY RATIONALE: The purpose of this review is to further define the published literature with respect to vertebral artery (VA) anomaly and injury in patients with degenerative cervical spinal conditions. OBJECTIVES: In adult patients with cervical spine or degenerative cervical spine disorders receiving cervical spine surgery, what is the incidence of VA injury, and among resulting VA injuries, which treatments result in a successful outcome and what percent are successfully repaired? MATERIALS AND METHODS: A systematic review of pertinent articles published up to April 2013. Studies involving traumatic onset, fracture, infection, deformity or congenital abnormality, instability, inflammatory spinal diseases, or neoplasms were excluded. Two independent reviewers assessed the level of evidence quality using the Grades of Recommendation Assessment, Development and Evaluation criteria; disagreements were resolved by consensus. RESULTS: From a total of 72 possible citations, the following met our inclusion criteria and formed the basis for this report. Incidence of VA injuries ranged from 0.20 to 1.96%. None of the studies reported using preoperative imaging to identify anomalous or tortuous VA. Primary repair and ligation were the most effective in treating VA injuries. CONCLUSION: The incidence of VA injuries in degenerative cervical spinal surgery might be as high as 1.96% and is likely underreported. Direct surgical repair is the most effective treatment option. The most important preventative technique for VA injuries is preoperative magnetic resonance imaging or computed tomography angiographic imaging to detect VA anomalies. The overall strength of evidence for the conclusions is low.