Atypical Hangman's Fractures: An Institutional Study of 51 Patients With Atypical Traumatic Spondylolisthesis of C2.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Atypical hangman's fractures are associated with increased risk for neurologic injury due to involvement of the posterior cortex of the axis body. We present the largest single-center cohort of atypical hangman's fractures with the goal of guiding treatment decisions and outcomes based on fracture classification. METHODS: We performed a retrospective analysis of all patients with atypical hangman's fractures treated at a single Level I trauma center between January 2010 and September 2023. 51 patients met inclusion criteria and demographic, treatment, and radiographic data were recorded and compared across the Type I and II fracture groups. RESULTS: Final treatment modalities varied significantly between the groups (P < 0.01), with hard cervical collar and invasive halo immobilization being the most prevalent treatments for fracture Types I and II respectively. One Type I fracture patient and four Type II fracture patients failed non-operative treatment, requiring surgery. Across both groups, posterior cervical fusion (73%) was the most common surgical approach. Median length of stay varied significantly between the two fracture groups (2.0 (1.0-7.0) vs 5.0 (3.0-8.0) days; P = 0.01). Irrespective of fracture type, longer hospital length of stay was associated with increased patient age (IRR = 1.02; P < 0.01), non-white race (IRR = 2.47; P = 0.01), injury caused by MVC (IRR = 1.93; P < 0.01), and the presence of non-spine orthopedic injuries (IRR = 1.72; P = 0.03). CONCLUSIONS: While atypical Type I hangman's fractures may be managed effectively non-operatively with a hard cervical collar, atypical Type II fractures managed with a hard cervical collar are at greater risk of requiring subsequent surgical intervention.

Social Vulnerability Index Provides Greater Granularity Compared to the Area Deprivation Index When Assessing Outcomes Following Elective Lumbar Fusion.

STUDY DESIGN: Retrospective review of a single institution cohort. OBJECTIVE: To determine whether Area Deprivation Index (ADI) or Social Vulnerability Index (SVI) is more suitable for evaluating minimum clinically important difference (MCID) achievement following elective lumbar fusion as captured by the Patient Reported Outcomes Measurement Information System (PROMIS). SUMMARY OF BACKGROUND DATA: A total of 182 patients who underwent elective one- to two-level posterior lumbar fusion between January 2015 and September 2021. METHODS: ADI and SVI values were calculated from patient-supplied addresses. Patients were grouped into quartiles based on values; higher quartiles represented greater disadvantage. MCID thresholds for Pain Interference (PI) and Physical Function (PF) were determined via a distribution-based method. Multivariable logistic regression was performed to identify factors impacting MCID attainment. Univariate logistic regression was performed to determine which themes comprising SVI values affected MCID achievement. Statistical significance was set at P<0.05. RESULTS: Multivariate logistic regression demonstrated that ADI and SVI quartile assignment significantly impacted achievement of MCID for PI (P=0.04 and P=0.01 respectively) and PF (P=0.03 and P=0.02 respectively). Specifically, assignment to the third ADI and SVI quartiles were significant for PI (OR: 0.39 and 0.23 respectively), and PF (OR: 0.24 and 0.22 respectively). Race was not a significant predictor of MCID for either PI or PF. Univariate logistic regression demonstrated that among SVI themes, the socioeconomic status theme significantly affected achievement of MCID for PI (P=0.01), while the housing type and transportation theme significantly affected achievement of MCID for PF (P=0.01). CONCLUSION: ADI and SVI quartile assignment were predictors of MCID achievement. While ADI and SVI may both identify patients at risk for adverse outcomes following lumbar fusion, SVI offers greater granularity in terms of isolating themes of disadvantage impacting MCID achievement.

Depression State Correlates with Functional Recovery Following Elective Lumbar Spine Fusion.

OBJECTIVE: To determine how depression state impacts postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores and achievement of minimum clinically important difference (MCID) following lumbar fusion. Depression has been shown to negatively impact outcomes following numerous orthopedic surgeries. Situational and major clinical depression can differentially affect postoperative outcomes. METHODS: Adult patients undergoing elective 1-3 level lumbar fusion were reviewed. Patients with a formal diagnosis of major depression were classified as "clinically depressed" whereas patients with at least "mild" PROMIS Depression scores in the absence of formal depression diagnosis were deemed "situationally depressed." analysis of variance testing was used to assess differences within and between groups. Multivariate regression was used to identify features associated with the achievement of MCID. RESULTS: Two hundred patients were included. The average age was 65.9 ± 12.2 years. 75 patients (37.5%) were nondepressed, 66 patients (33.0%) were clinically depressed, and 59 patients (29.5%) were situationally depressed. Situationally depressed patients had worse preoperative physical function (PF) and pain interference (PI) scores and were more likely to have severe symptoms (P = 0.001, P = 0.001). All groups improved significantly from preoperative baseline scores. All groups met MCID PF at different rates, with highest proportion of situationally depressed reaching this metric (P = 0.03). Rates of achieving MCID PI were not significantly different between groups (P = 0.47). Situational depression was predictive of achieving MCID PF (P = 0.002) but not MCID PI. CONCLUSIONS: Our study investigated the relationship between depression and postoperative PROMIS scores and identified situationally depressed patients as having the worst preoperative impairment. Despite this, the situationally depressed cohort had the highest likelihood of achieving MCID PF, suggestive of a bidirectional relationship between lumbar degenerative disease and subclinical, situational depression. These findings may help guide preoperative counseling on expectations, and patient selection.

Socioeconomic disadvantage is correlated with worse PROMIS outcomes following lumbar fusion.

BACKGROUND CONTEXT: Socioeconomic status (SES) has been associated with differential healthcare outcomes and may be proxied using the area-deprivation index (ADI). Few studies to date have investigated the role of ADI on patient-reported outcomes and clinically meaningful improvement following lumbar spine fusion surgery. PURPOSE: The purpose of this study is to investigate the role of SES on lumbar fusion outcomes using Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. STUDY DESIGN/SETTING: Retrospective review of a single institution cohort. PATIENT SAMPLE: About 205 patients who underwent elective one-to-three level posterior lumbar spine fusion. OUTCOME MEASURES: Change in PROMIS scores and achievement of minimum clinically important difference (MCID). METHODS: Patients 18 years or older undergoing elective one-to-three level lumbar spine fusion secondary to spinal degeneration from January 2015 to September 2021 with minimum one year follow-up were reviewed. ADI was calculated using patient-supplied addresses and patients were grouped into quartiles. Higher ADI values represent worse deprivation. Minimum clinically important difference (MCID) thresholds were calculated using distribution-based methods. Analysis of variance testing was used to assess differences within and between the quartile cohorts. Multivariable regression was used to identify features associated with the achievement of MCID. RESULTS: About 205 patients met inclusion and exclusion criteria. The average age of our cohort was 66±12 years. The average time to final follow-up was 23±8 months (range 12-36 months). No differences were observed between preoperative baseline scores amongst the four quartiles. All ADI cohorts showed significant improvement for pain interference (PI) at final follow-up (p<.05), with patients who had the lowest socioeconomic status having the lowest absolute improvement from preoperative baseline physical function (PF) and PI (p=.01). Only those patients who were in the lowest socioeconomic quartile failed to significantly improve for PF at final follow-up (p=.19). There was a significant negative correlation between socioeconomic level and the absolute proportion of patients reaching MCID for PI (p=.04) and PF (p=.03). However, while ADI was a significant predictor of achieving MCID for PI (p=.02), it was nonsignificant for achieving MCID for PF. CONCLUSIONS: Our study investigated the influence of ADI on postoperative PROMIS scores and identified a negative correlation between ADI quartile and the proportion of patients reaching MCID. Patients in the worse ADI quartile had lower chances of reaching clinically meaningful improvement in PI. Policies focused on alleviating geographical deprivation may augment clinical outcomes following lumbar surgery.

An Analysis of Patient and Fracture Characteristics and Clinical Outcomes in Patients With Hyperostotic Spine Fractures.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate outcomes and complications following operative and nonoperative management of hyperostotic spine fractures. METHODS: Patients presenting between 2008 and 2017 to a single level 1 trauma center with hyperostotic spine fractures had their information and fracture characteristics reviewed. Bivariate analyses were conducted to compare patients across a number of characteristics and outcomes. Multivariate logistic regression models for complication and mortality were done in a stepwise fashion. RESULTS: Sixty-five ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH) patients with a spine fracture met our inclusion criteria. DISH was slightly more prevalent (55% vs 45%). Overall delayed diagnosis, reoperation, mortality (at 1 year), and complication rates were high at 32%, 13%, 23%, and 57%, respectively. In multivariate logistic regression models, patients undergoing operative management had significantly increased odds of having a complication (odds ratio [OR] = 23.03, 95% confidence interval [CI] = 2.24-236.45, P = .008), while increasing age was associated with increased odds of death (OR = 1.18, 95% CI = 1.06-1.31, P = .003). CONCLUSIONS: Patients with AS or DISH who fracture their spine are at high risk of complication and death. However, neither operative nor nonoperative treatment increases the odds of mortality. This study helps add to a growing, but still limited, body of literature on the characteristics of patients with spine fractures in the setting of AS or DISH.

Predictors of 30-Day Unplanned Readmissions, Complications, and Mortality Following Operative Management of C2 Fractures.

STUDY DESIGN: Retrospective database review. OBJECTIVES: To determine factors associated with unplanned readmission, complications, and mortality in patients undergoing operative management for C2 fractures. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (ACS NSQIP) was queried between 2007 and 2014. Unplanned readmission, any complication, and mortality were the outcomes of interest. Bivariate statistics were calculated, and multivariate regression models were estimated. RESULTS: A total of 285 patients were enrolled. Readmission data was available for 199 patients and 11 patients (5.5% of 199 patients) had an unplanned readmission. Overall, 60 patients (21% of 285 patients) had at least 1 complication and 15 patients (5.3% of 285 patients) died. Five factors were associated with complications: transferred from another facility (odds ratio [OR] 3.00, 95% confidence interval [CI]1.51-5.98; P < .01); operative time ≥180 minutes (OR 2.43, 95% CI 1.11-5.36; P = .03); at least 1 patient comorbidity (OR 2.50, 95% CI 1.01-6.18; P < .05); American Society of Anesthesiologists (ASA) class 3 (OR 4.86, 95% CI 1.19-19.88; P = .03); and ASA class 4 (OR 7.24, 95% CI 1.66-31.66; P = .01). The only factor associated with unplanned readmission was having at least one postoperative complication (OR 7.10, 95% CI 1.04-48.59; P < .05), while patients who were partially or totally dependent from a functional standpoint were at increased odds of death (OR 3.98, 95% CI 1.12-14.08; P = .03). CONCLUSIONS: Patients with functional limitations have increased odds of death, while patients with postoperative complications have increased odds of unplanned readmission. Being transferred from an outside facility, having an operative time ≥180 minutes, having at least one comorbidity, and being classified as ASA class 3 or 4 increase patient odds of complication.

Comparison of adult spinal deformity patients with and without rheumatoid arthritis undergoing primary non-cervical spinal fusion surgery: a nationwide analysis of 52,818 patients.

BACKGROUND CONTEXT: Numerous studies have analyzed the impact of rheumatoid arthritis (RA) on the cervical spine and its related surgical interventions. However, there is a paucity of literature available conducting the same analyses in patients with non-cervical spine involvement. PURPOSE: The objective of this study was to compare patient characteristics, comorbidities, and complications in patients with and without RA undergoing primary non-cervical spinal fusions. STUDY DESIGN/SETTING: This is a retrospective national database review. PATIENT SAMPLE: A total of 52,818 patients with adult spinal deformity undergoing non-cervical spinal fusions (1,814 patients with RA and 51,004 patients without RA). OUTCOME MEASURES: The outcome measures in the study include patient characteristics, as well as complication and mortality rates. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample from 2003 to 2014, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes were used to identify patients aged ≥18 years old with and without RA undergoing primary non-cervical spinal fusions. Univariate analysis was used to determine patient characteristics, comorbidities, and complication values for each group. Bivariate analysis was used to compare the two groups. Significance was set at p<.05. RESULTS: Patients with RA were older (p<.001), were more likely to be women (p<.001), had increased rates of osteoporosis (p<.001), had a greater percentage of their surgeries reimbursed by Medicare (p<.001), and more often had weekend admissions (p=.014). There was no difference in all the other characteristics. Patients with RA had higher rates of iron deficiency anemia, congestive heart failure, chronic pulmonary disease, depression, and fluid and electrolyte disorders (all, p<.001). Patients without RA had higher rates of alcohol abuse (p=.027). There was no difference in all the other complications. There was no difference in mortality rate (p=.99). Total complications were greater in patients with RA (p<.001). Patients with RA had higher rates of infection (p=.032), implant-related complications (p=.010), incidental durotomies (p=.001), and urinary tract infections (p<.001). No difference existed among the other complications. CONCLUSIONS: Patients with RA have an increased number of comorbidities and complication rates compared with patients without RA. Such knowledge can help surgeons and patients with RA have beneficial preoperative discussions regarding outcomes.

Large Compressive Pseudomeningocele Causing Early Major Neurologic Deficit After Spinal Surgery.

STUDY DESIGN: Retrospective review. OBJECTIVES: Large compressive pseudomeningocele causing a major neurologic deficit is a very rare complication that is not well described in the existing literature. METHODS: Institutional review board consent was obtained to study 2552 consecutive extradural spinal surgical cases performed by a single senior spinal surgeon during a 10-year period. The surgeon's database for the decade was retrospectively reviewed and 3 cases involving postoperative major neurologic deficits caused by large compressive pseudomeningocele were identified. RESULTS: The incidence of postoperative compressive pseudomeningocele causing major neurologic deficit was 0.12% (3/2552) per decade of spinal surgery with approximately 1.3% of cases incurring incidental durotomy. Average age of the patients was 57 years (range 45-78). One patient had posterior cervical spine surgery, and 2 patients had posterior lumbar surgery. All 3 patients had intraoperative incidental durotomy repaired during their index procedure. Large compressive pseudomeningocele causing major neurologic deficit occurred in the early 2-week postoperative period in all patients and was clearly identified on postoperative magnetic resonance imaging. All 3 patients were treated with emergent decompression and repair of the dural defect. All patients recovered neurologic function after revision surgery. CONCLUSIONS: Incidental durotomy and repair causing a large compressive pseudomeningocele after spine surgery is a rare and potentially devastating event. Early postoperative magnetic resonance imaging assists in the diagnosis. Emergent decompression combined with revision dural repair surgery may result in improved outcomes. Surgeons should be cognizant of this rare cause of early postoperative major neurologic deficit in patients who had previous dural repair.

Complications and Readmission After Cervical Spine Surgery in Elderly Patients: An Analysis of 1786 Patients.

OBJECTIVE: To investigate risk factors and complications of cervical spine surgery in elderly patients. METHODS: A retrospective study was performed using data from the American College of Surgeons National Surgical Quality Improvement Program. Patients ≥65 years old who underwent cervical spine surgery from 2005 to 2013 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and Current Procedural Terminology codes. Outcome data were classified as major complication, minor complication, readmission, or mortality. RESULTS: Of 1786 patients ≥65 years old undergoing cervical spine surgery identified, 175 (9.80%) patients experienced at least 1 complication or death. Patients ≥75 years old were at higher risk of developing a complication or death (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.13-2.61). Patients with increased operative times (OR 3.54, 95% CI 2.27-5.53), patients who were partially or totally dependent (OR 3.01, 95% CI 1.79-5.07), and patients listed as American Society of Anesthesiologists class III/IV/V (OR 1.87, 95% CI 1.20-2.94) had increased risks of perioperative complications. Patients 70-74 years old (OR 1.94, 95% CI 1.03-3.65) and patients with at least 1 postoperative complication (OR 9.59, 95% CI 5.17-17.80) had increased risks of unplanned readmissions. Patients ≥75 years old undergoing a laminectomy/laminotomy were at higher risk of complications (OR 3.20, 95% CI 1.33-7.70), whereas there was no difference in risk of complications based on age for elderly patients undergoing a fusion. CONCLUSIONS: Patient comorbidities and clinical factors, such as longer operating time and emergency cases, impact risk of adverse events. Patients 70-74 years old and patients with at least 1 postoperative complication had an increased risk of unplanned readmission.

Complications and readmission after lumbar spine surgery in elderly patients: an analysis of 2,320 patients.

BACKGROUND CONTEXT: There is a paucity of literature describing risk factors for adverse outcomes after geriatric lumbar spinal surgery. As the geriatric population increases, so does the number of lumbar spinal surgeries in this cohort. PURPOSE: The purpose of the study was to determine how safe lumbar surgery is in elderly patients. Does patient selection, type of surgery, length of surgery, and other comorbidities in the elderly patient affect complication and readmission rates after surgery? STUDY DESIGN/SETTING: This is a retrospective cohort study. PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Database was used in the study. OUTCOME MEASURES: The outcome data that were analyzed were minor and major complications, mortality, and readmissions in geriatric patients who underwent lumbar spinal surgery from 2005 to 2015. MATERIALS AND METHODS: A retrospective cohort study was performed using data from the ACS NSQIP database. Patients over the age of 80 years who underwent lumbar spinal surgery from 2005 to 2013 were identified using International Statistical Classification of Diseases and Related Health Problems diagnosis codes and Current Procedural Terminology codes. Outcome data were classified as either a major complication, minor complication, readmission, or mortality. Multivariate logistic regression models were used to determine risks for developing adverse outcomes in the initial 30 postoperative days. RESULTS: A total of 2,320 patients over the age of 80 years who underwent lumbar spine surgery were identified. Overall, 379 (16.34%) patients experienced at least one complication or death. Seventy-five patients (3.23%) experienced a major complication. Three hundred thirty-eight patients (14.57%) experienced a minor complication. Eighty-six patients (6.39%) were readmitted to the hospital within 30 days. Ten deaths (0.43%) were recorded in the initial 30 postoperative days. Increased operative times were strongly associated with perioperative complications (operative time >180 minutes, odds ratio [OR]: 3.07 [95% confidence interval {CI} 2.23-4.22]; operative time 120-180 minutes, OR: 1.77 [95% CI 1.27-2.47]). Instrumentation and fusion procedures were also associated with an increased risk of developing a complication (OR: 2.56 [95% CI 1.66-3.94]). Readmission was strongly associated with patients who were considered underweight (body mass index [BMI] <18.5) and who were functionally debilitated at the time of admission (OR: 4.10 [1.08-15.48] and OR: 2.79 [1.40-5.56], respectively). CONCLUSIONS: Elderly patients undergoing lumbar spinal surgery have high complications and readmission rates. Risk factors for complications include longer operative time and more extensive procedures involving instrumentation and fusion. Higher readmission rates are associated with low baseline patient functional status and low patient BMI.

Louis A. Goldstein, MD: A Pioneer in Spinal Deformity Surgery.

MINI: During the first half of the 20th century interest in spinal deformity grew due to common conditions of that era including polio and tuberculosis. This article will discuss Louis Arnold Goldstein, a visionary leader in spinal deformity surgery from Rochester, New York and one of the founders of the Scoliosis Research Society.During the first half of the 20th century interest in spinal deformity grew due to common conditions of that era including polio and tuberculosis. This article will discuss Louis Arnold Goldstein, a visionary leader in spinal deformity surgery from Rochester, New York and one of the founders of the Scoliosis Research Society. Louis A. Goldstein was a talented surgeon, administrator, and clinician scientist. He also started a spine surgery fellowship program that still bears his name and that continues to train complex spine surgeons.

Bone morphogenetic protein in pediatric spine fusion surgery.

BACKGROUND: There is a paucity of literature describing the use of bone graft substitutes to achieve fusion in the pediatric spine. Outcomes and complications involving the off-label use of bone morphogenetic protein 2 (BMP-2) in the pediatric spine are not clearly defined. The purpose of this study is to review the existing literature with respect to reported outcomes and complications involving the use of low-dose BMP-2 in pediatric patients. METHODS: A Medline and PubMed literature search was conducted using the words bone morphogenetic protein, BMP, rh-BMP-2, bone graft substitutes, and pediatric spine. RESULTS: To date, there are few published reports on this topic. Complications and appropriate BMP-2 dosage application in the pediatric spine remain unknown. CONCLUSIONS: This report describes the potential for BMP-2 to achieve successful arthrodesis of the spine in pediatric patients. Usage should be judicious as complications and long-term outcomes of pediatric BMP-2 usage remain undefined in the existing literature.

Return to Play in Athletes Receiving Cervical Surgery: A Systematic Review.

Study Design Systematic review. Clinical Questions Among athletes who undergo surgery of the cervical spine, (1) What proportion return to play (RTP) after their cervical surgery? (2) Does the proportion of those cleared for RTP depend on the type of surgical procedure (artificial disk replacement, fusion, nonfusion foraminotomies/laminoplasties), number of levels (1, 2, or more levels), or type of sport? (3) Among those who return to their presurgery sport, how long do they continue to play? (4) Among those who return to their presurgery sport, how does their postoperative performance compare with their preoperative performance? Objectives To evaluate the extent and quality of published literature on the topic of return to competitive athletic completion after cervical spinal surgery. Methods Electronic databases and reference lists of key articles published up to August 19, 2015, were searched to identify studies reporting the proportion of athletes who RTP after cervical spine surgery. Results Nine observational, retrospective series consisting of 175 patients were included. Seven reported on professional athletes and two on recreational athletes. Seventy-five percent (76/102) of professional athletes returned to their respective sport following surgery for mostly cervical herniated disks. Seventy-six percent of recreational athletes (51/67) age 10 to 42 years RTP in a variety of sports following surgery for mostly herniated disks. No snowboarder returned to snowboarding (0/6) following surgery for cervical fractures. Most professional football players and baseball pitchers returned to their respective sport at their presurgery performance level. Conclusions RTP decisions after cervical spine surgery remain controversial, and there is a paucity of existing literature on this topic. Successful return to competitive sports is well described after single-level anterior cervical diskectomy and fusion surgery for herniated disk. RTP outcomes involving other cervical spine diagnoses and surgical procedures remain unclear. Additional quality research is needed on this topic.

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 Injury during Routine Posterior Cervical Exposure: Case Reports and Review of Literature.

Study Design Case series. Objective We report the unusual occurrence of vertebral artery injury (VAI) during routine posterior exposure of the cervical spine. The importance of preoperative planning to identify the course of the bilateral vertebral arteries during routine posterior cervical spine surgery is emphasized. Methods VAI is a rare but potentially devastating complication of cervical spinal surgery. Most reports of VAI are related to anterior surgical exposure or screw placement in the posterior cervical spine. VAI incurred during posterior cervical spinal exposure surgery is not adequately addressed in the existing literature. Two cases of VAI that occurred during routine posterior exposure of the cervical spine in the region of C2 are described. Results VAI was incurred unexpectedly in the region of the midportion of the posterior C1-C2 interval during the initial surgical exposure phase of the operation. An aberrant vertebral artery course in the V2 anatomical section in the region between C1 and C2 intervals was identified postoperatively in both patients. A literature review demonstrates a relatively high incidence of vertebral artery anomalies in the upper cervical spine; however, the literature is deficient in reporting vertebral artery injury in this region. Recommendations for preoperative vertebral artery imaging also remain unclear at this time. Conclusions Successful management of this unexpected complication was achieved in both cases. This case report and review of the literature highlights the importance of preoperative vertebral artery imaging and knowledge of the course of the vertebral arteries prior to planned routine posterior exposure of the upper cervical spine. In both cases, aberrancy of the vertebral artery was present and not investigated or detected preoperatively.

Unilateral versus Bilateral Instrumentation in Spinal Surgery: A Systematic Review.

Study Design Systematic review. Clinical Questions (1) What is the comparative efficacy of unilateral instrumentation compared with bilateral instrumentation in spine surgery? (2) What is the safety of unilateral instrumentation compared with bilateral instrumentation in spine surgery? Methods Electronic databases and reference lists of key articles were searched up to September 30, 2014, to identify studies reporting the comparative efficacy and safety of unilateral versus bilateral instrumentation in spine surgery. Studies including recombinant human bone morphogenetic protein 2 as adjunct therapy and those with follow-up of less than 2 years were excluded. Results Ten randomized controlled trials met the inclusion criteria: five compared unilateral with bilateral instrumentation using open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF), one used open posterolateral fusion, and four used minimally invasive TLIF/PLIF. There were no significant differences between unilateral and bilateral screw instrumentation with respect to nonunion, low back or leg pain scores, Oswestry Disability Index, reoperation, or complications. Conclusions The existing literature does not identify significant differences in clinical outcomes, union rates, and complications when unilateral instrumentation is used for degenerative pathologic conditions in the lumbar spine. The majority of published reports involve single-level lumbar unilateral instrumentation.