Introduction: the value of peripheral nerve surgery.

If a single picture is worth a thousand words, then a video, by logical extension, would be priceless. This edition showcases peripheral nerve surgery in all its grandeur and preserves it for posterity. Classic and novel surgical techniques are shown related to tumor biopsy or resection; nerve decompression for entrapment; and nerve reconstruction with direct repair or nerve transfer. Akin to a nautical chart filled with detailed maps for sailors, this Neurosurgical Focus Video Atlas provides navigational tools for neurosurgeons. The shared underlying message is that a sound knowledge of anatomy can lead to innovation (i.e., creative approaches or solutions) and excellence (i.e., improved patient outcomes).

Sacral fractures.

Sacral fractures are uncommon lesions and most often the result of high-energy trauma. Depending on the fracture location, neurological injury may be present in over 50% of cases. In this article, the authors conducted a comprehensive literature review on the epidemiology of sacral fractures, relevant anatomy of the sacral and pelvic region, common sacral injuries and fractures, classification systems of sacral fractures, and current management strategies. Due to the complex nature of these injuries, surgical management remains a challenge for the attending surgeon. Few large-scale studies have addressed postoperative complications or long-term results, but current evidence suggests that although fusion rates are high, long-term morbidity, such as residual pain and neurological deficits, persists for many patients.

Comparison of perioperative oral multimodal analgesia versus IV PCA for spine surgery.

STUDY DESIGN: A preintervention and postintervention design was used to examine a total of 200 patients. OBJECTIVE: After successful implementation at our institution of a perioperative oral multimodal analgesia protocol in major joint arthroplasty, a modified regimen was provided to patients undergoing spine procedures. SUMMARY OF BACKGROUND DATA: A proactive, multimodal approach is currently recommended for the management of acute postoperative pain. Inadequate postoperative analgesia can negatively influence surgical outcome and duration of rehabilitation. Routine use of intravenous patient controlled analgesia (IV PCA) after surgery can result in substantial functional interference, side effects, and lead to untoward events as a result of programming errors. METHODS: A preintervention and postintervention design was used to compare a historical control group of spine surgery patients who received conventional IV PCA (N=100) with a prospective group who received some form of perioperative oral multimodal analgesia (N=100). The new regimen included preoperative and postoperative scheduled extended-release oxycodone, gabapentin, and acetaminophen, intraoperative dolasetron and as-needed postoperative short-acting oral oxycodone. Patient surveys and chart audits were used to measure pain intensity, functional interference from pain, opioid consumption, analgesic-related side effects, and patient satisfaction over the first 24 hours postoperatively. RESULTS: Patients who received the new perioperative multimodal oral regimen had significantly less opioid consumption (P<0.001), lower ratings of Least Pain (P<0.01), and experienced less nausea (P<.001), drowsiness (P<0.05), interference with walking (P=0.05), and coughing and deep breathing (P<0.05) compared with the IV PCA group. CONCLUSIONS: This quality improvement study shows some safety and significant advantages of a multimodal perioperative oral analgesic regimen compared with standard IV PCA after spine surgery.

Transient anesthetic-induced worsening of existing left-sided weakness in a patient undergoing elective anterior cervical discectomy.

The differential diagnosis of new or worsening focal neurologic deficits on emergence from anesthesia is broad. Cerebral ischemia or hemorrhage, focal seizures, and acute metabolic abnormalities can all result in similar neurologic findings. Intravenously administered anesthetic agents also have been reported to cause new or worsening focal neurologic deficits in patients with a history of preexisting deficits. A patient who suffered such a reversible deficit related to anesthesia is presented.

Use of ventral plates for cervical arthrodesis.

OBJECTIVE: Ventral cervical plates are used to increase the immediate postoperative rigidity of the spine after decompressive and reconstructive procedures. The evidence supporting this practice is reviewed. METHODS: A computerized literature search of the database of the National Library of Medicine was conducted using PubMed. All relevant articles were reviewed and a critique was performed to explore the utility of ventral cervical plating. RESULTS: Several randomized controlled trials of ventral cervical discectomy versus ventral cervical discectomy and fusion were identified. Three randomized controlled trials that included a differentiation between anterior cervical decompression and fusion, with and without plating, were identified. Many retrospective series, technical reports, and topical reviews were also identified. CONCLUSION: There is little support in the literature for the medical usefulness of ventral cervical plates after single-level cervical fusion. There may, however, be a cost-benefit advantage to the use of such devices. In multilevel procedures and in the setting of traumatic instability, there seems to be an advantage to the use of cervical plates.

Cervical spondylosis: ventral or dorsal surgery.

Cervical spondylosis is a result of degenerative changes of the cervical spine. Neurological symptoms of myelopathy result from the narrowing of the spinal canal, causing spinal cord compression. Surgical management of cervical stenosis requires an understanding of the interplay between multiple pathological and biomechanical factors contributing to this disease process. Surgical decompression can be addressed from a ventral, dorsal, or combined approach. The authors discuss the technical aspects of the surgical decision making process regarding the decision to approach the spine from a ventral or dorsal orientation.

Anterior cervical plates: a historical perspective.

The development of anterior cervical plates (ACPs) represents a rapidly changing aspect of spine surgery. This paper focuses on a historical overview of ACPs. The authors discuss the disadvantages of earlier generations of plates and demonstrate how current plates have been designed to overcome the presumed shortcomings of their predecessors. This historical review begins with the earliest plates--unrestricted backout plates--and moves on to newer plates--restricted backout plates and their different subcategories. Virtually all modern ACPs work equally well in cervical stabilization; however, there are differences in design that warrant future studies to understand the long-term performances of different plates.

Recurrent lumbar disc herniation.

Recurrent lumbar disc herniation is a common disease process. It has been noted to occur in 5 to 15% of cases surgically treated for primary lumbar disc herniation. Outcomes in one series approached those after the initial operations, although this is not the case in the experience of most surgeons. The removal of recurrent lumbar disc herniations requires meticulous surgical technique. Great care is taken to identify the osseous margins of the previous surgical site. Identification and dissection of scar from the dura mater is greatly aided with the use of a microscope.

Anatomic suitability of the C1-C2 complex for pedicle screw fixation.

STUDY DESIGN AND OBJECTIVES: A computed tomography (CT) study of 60 consecutive patients (120 sides) was performed to assess suitability for either transarticular or pedicle screw fixation. SUMMARY OF BACKGROUND DATA: A C1 lateral mass and C2 pedicle screw fixation with a rigid cantilever beam system has been described. The anatomic constraints relevant for this technique have not. METHODS: Fifty consecutive patients underwent standard CT of the cervical spine. Pedicle and transarticular screw trajectories were plotted, and the maximum safe diameter for screw placement was determined for each trajectory. Also, trajectories were plotted in 10 additional patients with known craniocervical junction abnormalities using three-dimensional (3-D) imaging and computer-aided navigation tools. Screw placement was considered feasible if a 4-mm diameter trajectory could be plotted without impingement on neural or vascular structures. RESULTS: Four-millimeter diameter pedicle screws could be placed in 91 of 100 C2 pedicles in the CT studies and in 20 of 20 pedicles in the 3-D studies. Four-millimeter diameter C1-C2 transarticular screws could be placed in 94 of 100 sides in the CT study and in 19 of 20 sides in the 3-D study. Four sides could tolerate a C2 pedicle screw and not a transarticular screw; the opposite situation existed in five sides. Placement of screws into C1 was not an issue in any patient. The mean maximum diameter of potential transarticular screws was 6.5 mm, and the mean maximum diameter of the pedicle screws was 5.3 mm (P < 0.01). CONCLUSIONS: C1-C2 pedicle screw fixation is a technique that appears to be widely applicable and may represent an alternative fixation technique in selected patients.

Unilateral calf hypertrophy seen in lumbosacral stenosis: case report and review of the literature.

STUDY DESIGN: A case report of a patient with neurogenic unilateral calf hypertrophy and review of the literature are reported. OBJECTIVES: To provide further evidence that S1 radiculopathy is predisposed to develop neurogenic muscle hypertrophy. SUMMARY OF BACKGROUND DATA: Calf hypertrophy, specifically hypertrophy of the gastrocnemius muscle, is a rare but recognized presentation of S1 and less commonly L5 radiculopathies. The pathophysiology of this is incompletely understood. METHODS: We present a 59-year-old patient with painless progressive distal right leg weakness and calf enlargement. Electrodiagnostic studies and MAGNETIC RESONANCE IMAGING scanning were performed to evaluate the extent and cause of radicular damage as the etiology for unilateral calf hypertrophy. RESULTS: Examination and electrodiagnostic studies revealed right L5, right S1, and left L5 radiculopathies. Imaging studies demonstrated lumbar stenosis at L3-L4, L4-L5, and L5-S1 vertebral levels as well as L4-L5 and L5-S1 foraminal stenosis. After decompressive surgery the progressive nature of the patient's symptomatology halted, and he had partial resolution of his deficits. CONCLUSION: Although the patient had bilateral L5 radiculopathies, he only had hypertrophy in the distribution of his right S1 radiculopathy. This supports the hypothesis that dysfunction of the S1 nerve root or its distribution is a predisposing factor to develop neurogenic muscle hypertrophy. Furthermore, patients presenting with unilateral calf hypertrophy need a careful diagnostic evaluation for S1 radiculopathy as well as to exclude asymmetric presentation of systemic neuromuscular conditions.