Influence of Imidacloprid and Horticultural Oil on Spider Abundance on Eastern Hemlock in the Southern Appalachians.

Hemlock woolly adelgid, Adelges tsugae Annand (Hemiptera: Adelgidae), is an exotic pest of eastern hemlock, Tsuga canadensis (L.) Carrière (Pinales: Pinaceae), in the eastern United States. Two commonly used insecticides to manage adelgid are imidacloprid, a systemic neonicotinoid insecticide, and horticultural oil, a refined petroleum oil foliar spray. We have investigated the influence of imidacloprid and horticultural oil on spider abundance at different canopy strata in eastern hemlock. In total, 2,084 spiders representing 11 families were collected from the canopies of eastern hemlock. In beat-sheet and direct observation samples, the families Theridiidae, Araneidae, Salticidae, and Anyphaenidae were the most abundant. Significantly higher numbers of spiders were recorded on untreated control trees compared with trees treated with imidacloprid using soil drench and soil injection applications. Spider abundance in trees injected with imidacloprid and horticultural oil applications did not significantly differ from control trees. Spider abundance was significantly greater in the top and middle strata of the canopy than in the bottom stratum, where imidacloprid concentrations were the highest. Regression analysis showed that spider abundance was inversely associated with imidacloprid concentration. This research demonstrates that imidacloprid, when applied with selected methods, has the potential to result in reductions of spider densities at different strata. However, slight reductions in spider abundance may be an acceptable short-term ecological impact compared with the loss of an untreated hemlock and all the associated ecological benefits that it provides. Future studies should include investigations of long-term impact of imidacloprid on spiders associated with eastern hemlock.

Optimized, Minimal Specific Absorption Rate MRI for High-Resolution Imaging in Patients with Implanted Deep Brain Stimulation Electrodes.

BACKGROUND AND PURPOSE: Obtaining high-resolution brain MR imaging in patients with a previously implanted deep brain stimulator has been challenging and avoided by many centers due to safety concerns relating to implantable devices. We present our experience with a practical clinical protocol at 1.5T by using 2 magnet systems capable of achieving presurgical quality imaging in patients undergoing bilateral, staged deep brain stimulator insertion. MATERIALS AND METHODS: Protocol optimization was performed to minimize the specific absorption rate while providing image quality necessary for adequate surgical planning of the second electrode placement. We reviewed MR imaging studies performed with a minimal specific absorption rate protocol in patients with a deep brain stimulator in place at our institution between February 1, 2012, and August 1, 2015. Images were reviewed by a neuroradiologist and a functional neurosurgeon. Image quality was qualitatively graded, and the presence of artifacts was noted. RESULTS: Twenty-nine patients (22 with Parkinson disease, 6 with dystonia, 1 with essential tremor) were imaged with at least 1 neuromodulation implant in situ. All patients were imaged under general anesthesia. There were 25 subthalamic and 4 globus pallidus implants. Nineteen patients were preoperative for the second stage of bilateral deep brain stimulator placement; 10 patients had bilateral electrodes in situ and were being imaged for other neurologic indications, including lead positioning. No adverse events occurred during or after imaging. Mild device-related local susceptibility artifacts were present in all studies, but they were not judged to affect overall image quality. Minimal aliasing artifacts were seen in 7, and moderate motion, in 4 cases on T1WI only. All preoperative studies were adequate for guidance of a second deep brain stimulator placement. CONCLUSIONS: An optimized MR imaging protocol that minimizes the specific absorption rate can be used to safely obtain high-quality images in patients with previously implanted deep brain stimulators, and these images are adequate for surgical guidance.

First Report of Geosmithia morbida in North Carolina: The Pathogen Involved in Thousand Cankers Disease of Black Walnut.

In the past decade, black walnut (Juglans nigra) trees throughout western North America have suffered from widespread branch dieback and canopy loss, causing substantial tree mortality (2,3). The fungus, Geosmithia morbida, vectored by the walnut twig beetle (WTB), Pityophthorus juglandis, has been associated with this devastating disease known as Thousand Cankers Disease (TCD) (2,3). In August of 2012, branch samples from TCD symptomatic black walnut trees (5 to 10 cm in diameter and 15 to 30 cm long) were collected on the North Carolina side of the Great Smoky Mountain National Park (GRSM) in Cataloochee Cove (35°37.023' N, 83°07.351' W) and near the Big Creek Campground (35°45.290' N, 83°06.473' W), in Haywood County. Five symptomatic trees near the Big Creek Campground and three from Cataloochee Cove displayed typical TCD signs including progressive crown thinning, branch flagging, and branch dieback; however, insect holes were not observed. Samples were double bagged in Ziploc plastic bags, sealed in a 19-liter plastic bucket, and transported to the University of Tennessee. Outer bark was removed from the samples and small, elliptical, necrotic cankers were observed. Wood chips (3 to 4 mm2) from cankers were excised and placed on 1/10 strength potato dextrose agar amended with 30 mg/liter streptomycin sulfate and 30 mg/liter chlortetracycline HCL and incubated on a 12-h dark/light cycle at 22°C for 5 to 7 days. Fungal isolates were tentatively identified as G. morbida by using culture morphology, and characteristics of conidiophores and conidia (2). The isolated fungus from the Cataloochee Cove location was grown in 1/10 strength potato dextrose broth at room temperature for 2 weeks. Isolates from Big Creek Campground were contaminated and were not analyzed further. Fungal colonies were tan to light yellow. Conidia were tan, subcylindrical, and catenulate. Conidiophores were multibranched, verticillate, and verrucose. To verify the morphological data, DNA was extracted from fungal mycelia using DNeasy Plant Mini Kit (Qiagen, Valencia, CA) according to the manufacturer's published protocol. Isolates from Cataloochee Cove were characterized using ITS1 and ITS4 universal primers (4). The putative G. morbida isolate (GenBank Accession No. KC461929) had ITS sequences that were 100% identical to the G. morbida type isolate CBS124663 (FN434082.1) (2). Additionally, fungal DNA from Cataloochee Cove was amplified using G. morbida-specific microsatellite loci (GS04, GS27, and GS36) (1). PCR products were analyzed with the QIAxcel Capillary Electrophoresis System (Qiagen) and were similar to those previously published (2). To date, all confirmed cases of TCD in the native range of black walnut have been in urban areas, along rural roadsides and/or fence rows. The report in North Carolina is the first finding of G. morbida, the causal agent of TCD, in a forest setting. References: (1) D. Hadziabdic et al. Conserv. Genet. Resources 4:287, 2012. (2) M. Kolarik et al. Mycologia 103:325, 2011. (3) N. Tisserat et al. Plant Health Progr. doi:10.1094/PHP-2011-0630-01-BR, 2011. (4) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, San Diego, CA, 1990.

Primary hepatocellular neoplasms in a MODY3 family with a novel HNF1A germline mutation.

Maturity onset diabetes of the young type 3 (MODY3) and hepatocellular adenomas (HCAs) are associated with mutations in the HNF1A gene. HNF1A codes for the transcription factor HNF1α, which interacts with DNA as a homodimer or a heterodimer with HNF1ß, to regulate multiple cellular functions including glucidic metabolism, lipidic transport, and detoxication. We report three members of one family with a novel germline in-frame deletion of HNF1A exons 2-3 identified initially using array CGH and direct sequence analysis. All three family members have MODY3 in association with primary liver cell tumours (HCA, liver adenomatosis (LA), and hepatocellular carcinoma (HCC)). Additionally, a high rate of infant mortality was observed in the family. The described family demonstrates a novel HNF1A mutation associated with both benign and malignant primary liver cell tumours and MODY3.

Factors affecting establishment and recovery of Sasajiscymnus tsugae (Coleoptera: Coccinellidae), an introduced predator of hemlock woolly adelgid (Hemiptera: Adelgidae) on eastern hemlock (Pinales: Pinaceae).

To reduce populations of hemlock woolly adelgid, Adelges tsugae Annand (Hemiptera: Adelgidae), >500,000 Sasajiscymnus tsugae (Sasaji and McClure) (Coleoptera: Coccinellidae) have been released in the Great Smoky Mountains National Park since 2002. To determine factors affecting establishment and recovery of these predatory beetles, 65 single release sites were sampled using beat sheets from 2008 to 2012. Several abiotic and biotic factors were evaluated for their association with establishment and recovery of S. tsugae. Information on predatory beetle releases (location, year of release, number released, and season of release), topographic features (elevation, slope, Beers transformed aspect, and topographic relative moisture index), and temperature data (minimum and maximum temperatures 1 d after release and average minimum and maximum temperatures 7 d after release) were obtained from Great Smoky Mountains National Park personnel. These factors were evaluated using stepwise logistic regression and Pearson correlation. S. tsugae was recovered from 13 sites 2 to 10 yr after release, and the greatest number was recovered from 2002 release sites. Regression indicated establishment and recovery was negatively associated with year of release and positively associated with the average maximum temperature 7 d after release and elevation (generally, recovery increased as temperatures increased). Several significant correlations were found between presence and number of S. tsugae and year of release, season of release, and temperature variables. These results indicate that releases of S. tsugae should be made in warmer (≍10-25°C) temperatures and monitored for at least 5 yr after releases to enhance establishment and recovery efforts.

High-resolution human cervical spinal cord imaging at 7 T.

We present high-resolution anatomical imaging of the cervical spinal cord in healthy volunteers at the ultrahigh field of 7 T with a prototype four-channel radiofrequency coil array, in comparison with 3-T imaging of the same subjects. Signal-to-noise ratios at both field strengths were estimated using the rigorous Kellman method. Spinal cord cross-sectional area measurements were performed, including whole-cord measurements at both fields and gray matter segmentation at 7 T. The 7-T array coil showed reduced sagittal coverage, comparable axial coverage and the expected significantly higher signal-to-noise ratio compared with equivalent 3-T protocols. In the cervical spinal cord, the signal-to-noise ratio was found by the Kellman method to be higher by a factor of 3.5 with the 7-T coil than with standard 3-T coils. Cervical spine imaging in healthy volunteers at 7 T revealed not only detailed white/gray matter differentiation, but also structures not visualized at lower fields, such as denticulate ligaments, nerve roots and rostral-caudal blood vessels. Whole-cord cross-sectional area measurements showed good agreement at both field strengths. The measurable gray/white matter cross-sectional areas at 7 T were found to be comparable with reports from histology. These pilot data demonstrate the use of higher signal-to-noise ratios at the ultrahigh field of 7 T for significant improvement in anatomical resolution of the cervical spinal cord, allowing the visualization of structures not seen at lower field strength, particularly for axial imaging.

Host utilization of field-caged native and introduced thistle species by Rhinocyllus conicus.

Rhinocyllus conicus Fröelich was introduced from Europe into North America as a biological control agent of the exotic weed Carduus nutans L. Concern exists over the feeding of this weevil on at least 25 species of native Cirsium thistles. Beginning in 2008, cage studies isolating adults of R. conicus on buds and flower heads of all eight thistle species (native and introduced) recorded from Tennessee were conducted to test if R. conicus could use these species for reproduction and what impacts larval feeding of R. conicus may have on seed production. Larvae of R. conicus completed development in heads of the native species C. carolinianum (Walter) Fernald and Schubert. and C. horridulum Michaux, and significant reductions in seed numbers of both species occurred during 2008. Rhinocyllus conicus oviposited on both C. carolinianum and C. horridulum at significantly greater levels than the introduced species C. arvense (L.) Scopoli and C. vulgare (Savi) Tenore. Infested heads of C. carolinianum contained numbers of R. conicus per centimeter of plant head width similar to Ca. nutans in 2008, and both native species contained numbers of R. conicus per centimeter of plant head width similar to C. arvense and C. vulgare in 2009. Body length was similar between R. conicus reared on native thistles and its target host Ca. nutans. This report is the first documentation of R. conicus feeding and reproducing on C. carolinianum and C. horridulum. Although R. conicus has been observed only on introduced thistles in naturally occurring populations in this region, the utilization of C. carolinianum and C. horridulum as host species in controlled conditions warrants continued monitoring of field populations and further investigation into factors that may influence nontarget feeding in the future.

Spatial prediction of habitat overlap of introduced and native thistles to identify potential areas of nontarget activity of biological control agents.

Nontarget feeding of Rhinocyllus conicus Fröelich and Trichosirocalus horridus (Panzer) on native North American thistles in the genus Cirsium has been documented. Some species of these native thistles have shown greater infestation levels of R. conicus in populations that are in close proximity to the target plant species, Carduus nutans L. In 2005 a study was initiated to identify areas of potential nontarget feeding by R. conicus and T. horridus on thistle species by predicting habitats of two known introduced hosts [C. nutans and Cirsium vulgare (Savi) Tenore] and two native species [Cirsium carolinianum (Walter) Fernald and Schubert and C. discolor (Muhlenberg ex Willdenow) Sprengel] using Mahalanobis distance (D(2)). Cumulative frequency graphs showed that the D(2) models for all four plant species effectively identified site conditions that contribute to the presence of the respective species. Poisson regression showed an association between D(2) values and plant counts at field-test sites for C. nutans and C. carolinianum. However, negative binomial regression detected no association between D(2) values and plant counts for C. discolor or C. vulgare. Chi-square analysis indicated associations between both weevil species and sites where C. vulgare and Carduus nutans were found, but not between the weevil and native thistle species. Habitats of C. nutans and Cirsium carolinianum overlapped in ≈12% of the study area. Data-based habitat models may provide a powerful tool for land managers and scientists to monitor native plant populations for nontarget feeding by introduced biological control agents.

32-channel 3 Tesla receive-only phased-array head coil with soccer-ball element geometry.

A 32-channel 3T receive-only phased-array head coil was developed for human brain imaging. The helmet-shaped array was designed to closely fit the head with individual overlapping circular elements arranged in patterns of hexagonal and pentagonal symmetry similar to that of a soccer ball. The signal-to-noise ratio (SNR) and noise amplification (g-factor) in accelerated imaging applications were quantitatively evaluated in phantom and human images and compared with commercially available head coils. The 32-channel coil showed SNR gains of up to 3.5-fold in the cortex and 1.4-fold in the corpus callosum compared to a (larger) commercial eight-channel head coil. The experimentally measured g-factor performance of the helmet array showed significant improvement compared to the eight-channel array (peak g-factor 59% and 26% of the eight-channel values for four- and fivefold acceleration). The performance of the arrays is demonstrated in high-resolution and highly accelerated brain images.

3T phased array MRI improves the presurgical evaluation in focal epilepsies: a prospective study.

BACKGROUND: Although detection of concordant lesions on MRI significantly improves postsurgical outcomes in focal epilepsy (FE), many conventional MR studies remain negative. The authors evaluated the role of phased array surface coil studies performed at 3 Tesla (3T PA MRI). METHODS: Forty patients with medically intractable focal epilepsies were prospectively imaged with 3T PA-MRI including high matrix TSE T2, fluid attenuated inversion recovery, and magnetization prepared rapid gradient echo. All patients were considered candidates for epilepsy surgery. 3T PA-MRIs were reviewed by a neuroradiologist experienced in epilepsy imaging with access to clinical information. Findings were compared to reports of prior standard 1.5T MRI epilepsy studies performed at tertiary care centers. RESULTS: Experienced, unblinded review of 3T PA-MRI studies yielded additional diagnostic information in 48% (19/40) compared to routine clinical reads at 1.5T. In 37.5% (15/40), this additional information motivated a change in clinical management. In the subgroup of patients with prior 1.5T MRIs interpreted as normal, 3T PA-MRI resulted in the detection of a new lesion in 65% (15/23). In the subgroup of 15 patients with known lesions, 3T PA-MRI better defined the lesion in 33% (5/15). CONCLUSION: Phased array surface coil studies performed at 3 Tesla read by an experienced unblinded neuroradiologist can improve the presurgical evaluation of patients with focal epilepsy when compared to routine clinical 1.5T studies read at tertiary care centers.

Eight-channel phased array coil and detunable TEM volume coil for 7 T brain imaging.

An eight-channel receive-only brain coil and table-top detunable volume transmit coil were developed and tested at 7 T for human imaging. Optimization of this device required attention to sources of interaction between the array elements, between the transmit and receive coils and minimization of common mode currents on the coaxial cables. Circular receive coils (85 mm dia.) were designed on a flexible former to fit tightly around the head and within a 270-mm diameter TEM transmit volume coil. In the near cortex, the array provided a fivefold increase in SNR compared to a TEM transmit-receive coil, a gain larger than that seen in comparable coils at 3 T. The higher SNR gain is likely due to strong dielectric effects, which cause the volume coil to perform poorly in the cortex compared to centrally. The sensitivity and coverage of the array is demonstrated with high-resolution images of the brain cortex.

Comparison of physiological noise at 1.5 T, 3 T and 7 T and optimization of fMRI acquisition parameters.

Previous studies have shown that under some conditions, noise fluctuations in an fMRI time-course are dominated by physiological modulations of the image intensity with secondary contributions from thermal image noise and that these two sources scale differently with signal intensity, susceptibility weighting (TE) and field strength. The SNR of the fMRI time-course was found to be near its asymptotic limit for moderate spatial resolution measurements at 3 T with only marginal gains expected from acquisition at higher field strengths. In this study, we investigate the amplitude of image intensity fluctuations in the fMRI time-course at magnetic field strengths of 1.5 T, 3 T, and 7 T as a function of image resolution, flip angle and TE. The time-course SNR was a similar function of the image SNR regardless of whether the image SNR was modulated by flip angle, image resolution, or field strength. For spatial resolutions typical of those currently used in fMRI (e.g., 3 x 3 x 3 mm(3)), increases in image SNR obtained from 7 T acquisition produced only modest increases in time-course SNR. At this spatial resolution, the ratio of physiological noise to thermal image noise was 0.61, 0.89, and 2.23 for 1.5 T, 3 T, and 7 T. At a resolution of 1 x 1 x 3 mm(3), however, the physiological to thermal noise ratio was 0.34, 0.57, and 0.91 for 1.5 T, 3 T and 7 T for TE near T2*. Thus, by reducing the signal strength using higher image resolution, the ratio of physiologic to image noise could be reduced to a regime where increased sensitivity afforded by higher field strength still translated to improved SNR in the fMRI time-series.

Perioperative complications with costotransversectomy and anterior approaches to thoracic and thoracolumbar tumors.

OBJECT: Anterior decompression and stabilization for thoracic spinal tumors often involves a thoracotomy and can be associated with surgical approach-related complications. An alternative to thoracotomy is surgery via a costotransversectomy exposure. To delineate the risks of surgery, the authors reviewed their prospective database for patients who had undergone surgery via either of these approaches for thoracic or thoracolumbar tumors. The complications were recorded and graded based on severity and risk of impact on patient outcome. METHODS: Between September 1995 and April 2001, the authors performed 29 costotransversectomies (Group 1) and 18 thoracolumbar or combined (Group 2) approaches as initial operations for thoracic neoplasms. The age, sex, preoperative motor score, and preoperative Frankel grade did not significantly differ between the groups. In the costotransversectomy group there were greater numbers of metastases, upper thoracic procedures, and affected vertebral levels; additionally, the comorbidity rate based on Charlson score, was higher. The mean Frankel grades at discharge were not significantly different whereas the discharge motor and last follow-up motor scores were better in Group 2. There were 11 Group 1 and seven Group 2 patients who suffered at least one complication. The number or patients with complications, the mean number of complications, and severity of complications did not differ between the groups. CONCLUSIONS: Compared with anterior or combined approaches, the incidence and severity of perioperative complications in the surgical treatment of thoracic and thoracolumbar spinal tumors is similar in patients who undergo costotransversectomy. Costotransversectomy may be the preferred operation in patients with significant medical comorbidity or tumors involving more than one thoracic vertebra.

Multilevel thoracic pedicle aplasia causing congenital thoracic kyphosis: case report.

OBJECTIVE AND IMPORTANCE: Congenital thoracic kyphosis is a rare cause of treatable myelopathy. Multilevel thoracic pedicle aplasia as a cause of this deformity has not been previously reported in the literature. We report a case and describe the surgical management and outcome. CLINICAL PRESENTATION: A 14-year-old boy presented to us with a 4-month history of back pain and slowly progressive spastic paraparesis. Radiographic studies revealed thoracic kyphosis and bilateral aplasia of the pedicles of T4-T8. INTERVENTION: The patient underwent surgical treatment via a posterior approach for decompression of T4-T8, followed by arthrodesis from T2 to T12, using a hook claw construct with multiple points of fixation and autologous bone grafting. CONCLUSION: Congenital vertebral anomalies may be clinically occult, and delayed presentation may occur in adolescence or adulthood. Aplasia of multiple thoracic pedicles can produce kyphotic deformities with neurological compromise. A posterior approach with multiple points of segmental instrumentation can be effective in treating kyphotic deformities that are flexible and of moderate severity (<75 degrees).

Morbidity and infection in combined subdural grid and strip electrode investigation for intractable epilepsy.

The coverage of large surface areas of the brain for electrographic monitoring purposes necessitates a craniotomy to achieve comprehensive sampling. We undertook a review and prospective analysis over 3 years of 38 patients undergoing craniotomy for electrode implantation. The indication for invasive monitoring was to determine candidacy for resective surgery in patients whose seizure focus was not well localized by scalp electroencephalography and other noninvasive testing. Prophylactic cultures from the epidural space were obtained at electrode removal. There were five positive epidural cultures. All five patients went on to seizure-free status. Two positive cultures occurred in patients without obvious infection and who were not treated with antibiotics. Other complications included individual cases of atrial fibrillation, pulmonary edema, postoperative fever, and epidural hematoma. There was no mortality or permanent neurologic morbidity related to craniotomy for electrode placement. There was a 7.9% rate of clinical infection per patient and a 5.7% rate per craniotomy side. This study has identified several factors that significantly correlate with positive epidural culture results: > 100 electrodes, more than ten cables, more than 14 days of implantation, and more than one cable exit site.

Modified open-door laminoplasty for treatment of neurological deficits in younger patients with congenital spinal stenosis: analysis of clinical and radiographic data.

OBJECT: Multilevel anterior cervical decompressive surgery and fusion effectively treats cervical myeloradiculopathy that is caused by severe cervical spinal stenosis, but degenerative changes at adjacent vertebral levels frequently result in long-term morbidity. The authors performed a modified open-door laminoplasty procedure in which allograft bone and titanium miniplates were used to treat cervical myeloradiculopathy in younger patients with congenital canal stenosis while maintaining functional cervical motion segments. Pre- and postoperative magnetic resonance imaging and/or computerized tomography myelography were performed to assess changes in cervical spinal canal dimensions. Pre- and postoperative flexion-extension radiographs were compared to determine the residual motion of the targeted operative segments. METHODS: Twenty younger patients (average age 37.7 years) underwent modified open-door laminoplasty for treatment of myelopathy or myeloradiculopathy related to significant cervical spinal stenosis with or without associated central or lateral disc herniation or foraminal stenosis. These surgeries were performed during a 2-year period and follow-up review remains ongoing (average follow-up period 21.6 months). Reconstructive procedures were performed on an average of 4.1 levels (range three-six). Operative time averaged 186 minutes (range 93-229 minutes). Average blood loss was 305 ml (range 100-650 ml). No cases were complicated by neurological deterioration, infection, wound breakdown, graft displacement, or hardware failure. The patients' Nurick Scale grade improved from a preoperative average of 1.8 to a postoperative average of 0.5. Pre- and postoperative sagittal spinal diameter averaged 11.2 mm (8-14 mm) and 16.6 mm (13-19 mm), respectively. The sagittal compression ratio (sagittal/lateral x 100%) increased from 48% pre- to 72% postoperatively. The spinal canal area increased an average of 55% (range 19-127%). In patients in whom pre- and postoperative flexion-extension radiographs were obtained, 72.7% residual neck motion was maintained. No patient developed increased neck or shoulder pain. Neurological symptoms improved in all patients, with total relief of myelopathy in 50% and partial improvement in 50%. CONCLUSIONS: Modified open-door laminoplasty with allograft bone and titanium miniplates effectively treats neurological deficits in younger patients with congenital and spinal stenosis. Although long-term results are unknown, short-term results are good and there is a low incidence of complications.

Anterior lumbar fusion with titanium threaded and mesh interbody cages.

The authors report their experience with 42 patients in whom anterior lumbar fusion was performed using titanium cages as a versatile adjunct to treat a wide variety of spinal deformity and pathological conditions. These conditions included congenital, degenerative, iatrogenic, infectious, traumatic, and malignant disorders of the thoracolumbar spine. Fusion rates and complications are compared with data previously reported in the literature. Between July 1996 and July 1999 the senior authors (C.I.S., R.P.N., and M.J.R.) treated 42 patients by means of a transabdominal extraperitoneal (13 cases) or an anterolateral extraperitoneal approach (29 cases), 51 vertebral levels were fused using titanium cages packed with autologous bone. All vertebrectomies (27 cases) were reconstructed using a Miami Moss titanium mesh cage and Kaneda instrumentation. Interbody fusion (15 cases) was performed with either the BAK titanium threaded interbody cage (in 13 patients) or a Miami Moss titanium mesh cage (in two patients). The average follow-up period was 14.3 months. Seventeen patients had sustained a thoracolumbar burst fracture, 12 patients presented with degenerative spinal disorders, six with metastatic tumor, four with spinal deformity (one congenital and three iatrogenic), and three patients presented with spinal infections. In five patients anterior lumbar interbody fusion (ALIF) was supplemented with posterior segmental fixation at the time of the initial procedure. Of the 51 vertebral levels treated, solid arthrodesis was achieved in 49, a 96% fusion rate. One case of pseudarthrosis occurred in the group treated with BAK cages; the diagnosis was made based on the patient's continued mechanical back pain after undergoing L4-5 ALIF. The patient was treated with supplemental posterior fixation, and successful fusion occurred uneventfully with resolution of her back pain. In the group in which vertebrectomy was performed there was one case of fusion failure in a patient with metastatic breast cancer who had undergone an L-3 corpectomy with placement of a mesh cage. Although her back pain was immediately resolved, she died of systemic disease 3 months after surgery and before fusion could occur. Complications related to the anterior approach included two vascular injuries (two left common iliac vein lacerations); one injury to the sympathetic plexus; one case of superficial phlebitis; two cases of prolonged ileus (greater than 48 hours postoperatively); one anterior femoral cutaneous nerve palsy; and one superficial wound infection. No deaths were directly related to the surgical procedure. There were no cases of dural laceration and no nerve root injury. There were no cases of deep venous thrombosis, pulmonary embolus, retrograde ejaculation, abdominal hernia, bowel or ureteral injury, or deep wound infection. Fusion-related complications included an iliac crest hematoma and prolonged donor-site pain in one patient. There were no complications related to placement or migration of the cages, but there was one case of screw fracture of the Kaneda device that did not require revision. The authors conclude that anterior lumbar fusion performed using titanium interbody or mesh cages, packed with autologous bone, is an effective, safe method to achieve fusion in a wide variety of pathological conditions of the thoracolumbar spine. The fusion rate of 96% compares favorably with results reported in the literature. The complication rate mirrors the low morbidity rate associated with the anterior approach. A detailed study of clinical outcomes is in progress. Patient selection and strategies for avoiding complication are discussed.

A new technique for the surgical management of unstable thoracolumbar burst fractures: a modification of the anterior approach and an outcome comparison to traditional methods.

This study was conducted to determine the safety, efficacy, and complication rate associated with the anterior approach in the use of a new titanium mesh interbody fusion cage for the treatment of unstable thoracolumbar burst fractures. The experience with this technique is compared with the senior authors' (C.S., R.W., and M.S.) previously published results in the management of patients with unstable thoracolumbar burst fractures. Between 1996 and 1999, 21 patients with unstable thoracolumbar (T12-L3) burst fractures underwent an anterolateral decompressive procedure in which a titanium cage and Kaneda device were used. Eleven of the 21 patients had sustained a neurological deficit, and all patients improved at least one Frankel grade (average 1.2 grades). There was improvement in outcome in terms of blood loss, correction of kyphosis, and pain, as measured on the Denis Pain and Work Scale, in our current group of patients treated via an anterior approach when compared with the results in those who underwent a posterior approach. In our current study the anterior approach was demonstrated to be a safe and effective technique for the management of unstable thoracolumbar burst fractures. It offers superior results compared with the posterior approach. The addition of the new titanium mesh interbody cage to our previous anterior technique allows the patient's own bone to be harvested from the corpectomy site and used as a substrate for fusion, thereby obviating the need for iliac crest harvest. The use of the cage in association with the Kaneda device allows for improved correction of kyphosis and restoration of normal sagittal alignment in addition to improved functional outcomes.