Traumatic Atlantoaxial Lateral Subluxation With Chronic Type II Odontoid Fracture: A Case Report.

BACKGROUND: We report a case of an elderly patient who was diagnosed with lateral atlantoaxial subluxation with type II odontoid fracture, an extremely uncommon upper cervical spine injury that has not been previously reported in the literature to the knowledge of the authors. METHODS: An 87-year-old male reported to the emergency room following a syncopal episode after sustaining a fall. He complained of dizziness, fatigue, disruption of vision and audition, and worsening neck pain. Computed tomographic scans were positive of partial dislocation of the C1 relative to C2 and chronic fracture of dens classified as type II according to the Anderson and D'Alonzo classification system. Magnetic resonance imaging further revealed large fracture pannus tissue at the level of the dens, reducing the space in the spinal cord. There was no evidence of spinal cord injury. Atlas-axis fusion with instrumentation was performed to manage the injury. A review of the classification, occurrence, and management of upper cervical spine surgeries was performed. RESULTS: An acute injury to a previously unrecognized type II odontoid fracture with partial C1-C2 dislocation was identified as a rare upper cervical spine injury and classified based on the Anderson and D'Alonzo and Fielding and Hawkins classification systems. The decision was made to perform instrumented spinal fusion by inserting mass screws into C1, pars screws into C2, and locking rods to realign the vertebral bodies and address the atlantoaxial instability. Follow-up scans indicated good postsurgical reduction and fixation, including resolution of the pannus overgrowth without direct intervention. CONCLUSIONS: Lateral atlantoaxial subluxation with chronic type II fracture of the dens constitutes a rare injury of the upper cervical vertebrae. Posterior instrumented spinal fusion was used to effectively manage the injury, leading to reabsorption of retro-odontoid pannus tissue.

Addition of Intrathecal Morphine for Postoperative Pain Management in Pediatric Spine Surgery: A Meta-analysis.

STUDY DESIGN: Meta-analysis. OBJECTIVE: The objective of this study was to determine whether adjunctive intrathecal morphine (ITM) reduces postoperative analgesic consumption following pediatric spine surgery. SUMMARY OF BACKGROUND DATA: Previous studies that have tested supplemental ITM to manage pain after pediatric spine surgery have been limited by small sample sizes. METHODS: A comprehensive search of PubMed, Web of Science, Clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials was performed for clinical trials and observational studies. Time to first analgesic demand, postoperative analgesic use, pain scores, and complication data were abstracted from each study. Mean difference (MD) and 95% confidence interval (CI) were used to compare continuous outcomes and odds ratios (OR) and 95% CI were used for dichotomous outcomes. RESULTS: A total of 5 studies, including 3 randomized controlled trials and 2 retrospective chart reviews, containing 636 subjects, were incorporated into meta-analysis. Subjects that were administered ITM in addition to postoperative analgesics (ITM group) were compared with those receiving postoperative analgesics only (control group). In the ITM group, time to first analgesic demand was longer (MD, 8.79; 95% CI, 4.20-13.37; P<0.001), cumulative analgesic consumption was reduced at 24 hours (MD, -0.40; 95% CI, -0.56 to -0.24; P<0.001), and cumulative analgesic consumption was reduced at 48 hours (MD, -0.43; 95% CI, -0.59 to -0.27; P<0.001). Neither postoperative pain scores at 24 hours (P=0.16) nor 48 hours (P=0.18) were significantly different between ITM and control groups. Rates of respiratory depression, nausea, vomiting, and pruritus were not different between groups (all Ps>0.05). CONCLUSIONS: Addition of ITM in pediatric spine surgery produced a potent analgesic effect in the immediate postoperative period. Patients administered ITM did not request opiates as early as control and consumed fewer opiates by the second postoperative day. Furthermore, use of ITM did not increase complications such as respiratory depression, nausea, vomiting, or pruritus.

Complications associated with intrathecal morphine in spine surgery: a retrospective study.

BACKGROUND: Supplemental intrathecal morphine (ITM) represents an option to manage postoperative pain after spine surgery due to ease of administration and ability to confer effective short-term analgesia at low dosages. However, whether ITM increases risk of surgical site infections (SSI), cerebrospinal fluid (CSF) leak, and incidental dural tears (IDT) has not been investigated. Therefore, this study was performed to determine the rates of SSI, CSF leak, and IDT in patients that received ITM. METHODS: Patients that underwent posterior instrumented fusion from January 2010 to 2016 that received ITM were compared to controls with respect to demographic, medical, surgical, and outcome data. Fisher's exact test was used to compare rates of SSI, CSF leak, and IDT between groups. Poisson regression was used to analyze complication rates after adjusting for the influence of covariates and potential confounders. RESULTS: A total of 512 records were analyzed. ITM was administered to 78 patients prior to wound closure. The remaining 434 patients compromised the control group. IDT was significantly more common among patients receiving ITM (P=0.009). Differences in rates of CSF leak and SSI were not statistically significant (P=0.373 and P=0.564, respectively). After compensating for additional variables, Poisson regression revealed a significant increase in rates of IDT (P=0.007) according to ITM injection and advanced age (P=0.014). There was no significant difference in rates of CSF leak or SSI after accounting for the additional variables (P>0.05). CONCLUSIONS: ITM for pain control in posterior instrumented spinal fusion surgery was linked to increased likelihood of IDT but not CSF leaks or SSI. Age was also noted to be a significant predictor of IDT. Spine surgeons should weigh potential risks against benefits when deciding whether to administer ITM for postoperative pain management following spine surgery.

View of U.S. spine surgeons regarding cost reduction measures.

BACKGROUND: This is a cross-sectional study. Our objective is to survey spine surgeons' views of responsibility to reduce healthcare costs, enthusiasm for cost reduction strategies, and agreement regarding roles in cost containment. The rising cost of healthcare has spurred debate about reducing expenditures. Previous studies have found that attitudes of anesthesiologists are predominantly in alignment with those of American physicians, but less is known about the views of spine surgeons. METHODS: After obtaining institutional approval, an electronic survey was disseminated to active members of AO Spine North America (AOSNA) via email. Respondents were asked eight questions about their age, gender, years in practice, practice facility, political views and opinions regarding management of healthcare costs. RESULTS: From 91 respondents, most were under the age of 60 years (87%), male (96%), and in practice for less than 30 years (91%), practiced at university hospitals (47%) and held politically conservative views (47%). Most responsibility was allocated to hospital and health systems, health insurance companies, pharmaceutical companies, and device manufacturers. Respondents were most enthusiastic about rooting out fraud and abuse and aware of their role in managing the cost of healthcare. Spine surgeons who were in practice for longer were more enthusiastic about reducing cost by reducing overall physician reimbursement via bundled payments, Medicare payment reduction, ending fee-for-service, penalizing surgeons for patient readmissions, and lowering compensation to individual spine surgeons. CONCLUSIONS: Spine surgeons allocated responsibility to reduce healthcare costs to healthcare systems, were most enthusiastic about eliminating wasteful spending, and were in agreement regarding their responsibility to control the costs of healthcare. Compared to US physicians of various specialties and anesthesiologists, spine surgeons assigned less responsibility to trials lawyers and expressed markedly less enthusiasm for limiting access to expensive treatments.