Anterior cervical discectomy and fusion associated complications.

STUDY DESIGN: Retrospective review study with literature review. OBJECTIVE: The goal of our current study is to raise awareness on complications associated with anterior cervical discectomy and fusion (ACDF) and their early detection and proper management. SUMMARY OF BACKGROUND DATA: It is known that ACDF constitutes one of the most commonly performed spinal procedures. Its outcome is quite satisfactory in the majority of cases. However, occasional complications can become troublesome, and in rare circumstances, catastrophic. Although there are several case reports describing such complications, their rate of occurrence is generally underreported, and data regarding their exact incidence in large clinical series are lacking. Meticulous knowledge of potential intraoperative and postoperative ACDF-related complications is of paramount importance so as to avoid them whenever possible, as well as to successfully and safely manage them when they are inevitable. METHODS: In a retrospective study, 1015 patients undergoing first-time ACDF for cervical radiculopathy and/or myelopathy due to degenerative disc disease and/or cervical spondylosis were evaluated. A standard Smith-Robinson approach was used in all our patients, while an autologous or allograft was used, with or without a plate. Operative reports, hospital and outpatient clinic charts, and radiographic studies were reviewed for procedure-related complications. Mean follow-up time was 26.4 months. RESULTS: The mortality rate in our current series was 0.1% (1 of 1015 patients, death occurred secondary to an esophageal perforation). Our overall morbidity rate was 19.3% (196 of 1015 patients). The most common complication was the development of isolated postoperative dysphagia, which observed in 9.5% of our patients. Postoperative hematoma occurred in 5.6%, but required surgical intervention in only 2.4% of our cases. Symptomatic recurrent laryngeal nerve palsy occurred in 3.1% of our cases. Dural penetration occurred in 0.5%, esophageal perforation in 0.3%, worsening of preexisting myelopathy in 0.2%, Horner's syndrome in 0.1%, instrumentation backout in 0.1%, and superficial wound infection in 0.1% of our cases. CONCLUSION: Meticulous knowledge of the ACDF-associated complications allows for their proper management. Postoperative dysphagia, hematoma, and recurrent laryngeal nerve palsy were the most common complications in our series. Management of complications was successful in the vast majority of our cases.

Interobservational variation in determining fusion rates in anterior cervical discectomy and fusion procedures.

The fusion rate represents one of the most commonly used criteria for evaluating the efficacy of spinal surgical techniques and the effectiveness of newly developed instrumentation and spinal implants. Reported fusion rates are not frequently supported by adequate information regarding by whom and how fusion was defined. In our prospective study we examined the fusion rate in patients undergoing first time anterior cervical discectomy and fusion for degenerative disease. Separate, well-defined radiographic fusion criteria were used and the 12-month post-operative X-rays were reviewed independently by a neurosurgeon, a neuroradiologist and an orthopedic surgeon, who were not involved in the patients' management. The observed fusion rates were 77.3, 87.8 and 84.7% respectively. Statistical analysis demonstrated concordance rates of 87.8, 91 and 91.4% and Kappa coefficients of 0.585, 0.620 and 0.723 for each pair of evaluators. Another set of ratings of the same radiographs, by the same interviewers, was obtained 6 weeks after the initial one. The reported fusion rates were 78.2% for the neurosurgeon, 87.4% for the orthopedic surgeon, and 86.1% for the neuroradiologist. Statistical analysis demonstrated intra-observer concordance rates of 98.7, 92.2 and 97.9% respectively, while the Kappa coefficients were 0.963, 0.677 and 0.907 for each reviewer. Our findings confirm the necessity of defining and describing criteria for fusion whenever this rate is reported in clinical series. The lack of widely accepted, well-defined criteria makes comparison of these results difficult. The development of a well organized, prospective clinical study in which fusion and outcome will be assessed by both clinical and radiographic parameters could significantly contribute to a more accurate evaluation of overall outcome of cervical spinal procedures.

Diving injuries of the cervical spine in amateur divers.

BACKGROUND CONTEXT: Diving injuries are the cause of potentially devastating trauma, primarily affecting the cervical spine. PURPOSE: Our purpose was to describe our experience with diving injuries treatment. STUDY DESIGN: Retrospective review. PATIENT SAMPLE: Twenty patients with diving injuries. OUTCOME MEASURES: Using the American Spinal Injury Association (ASIA) impairment scales as the primary outcome measure, the patients' neurological status before and after treatment was assessed. In this way we were able to draw conclusions about neurological improvement or deterioration in response to conservative or operative treatment. METHODS: We retrospectively reviewed 20 patients with diving injuries of the cervical spine who were admitted to our institute over a 34-year period from 1970 until 2004. RESULTS: The typical patient profile was of a young, healthy, athletic male who suffered an injury to the cervical spine after diving into shallow water. The number of cases corresponds to 2.6% of all admitted cervical spine injuries. All injures occurred between May and September. The most commonly fractured vertebrae were C5 and C6. Four patients were treated operatively and 16 conservatively. The indications for surgical treatment were posttraumatic instability and persistent neurological deficit. The mean follow-up of the patients was 17 years. Five patients died within the first month of their hospitalization and 1 patient died 1 year after his injury. Of the 14 patients who were available for follow-up 5 years past injury time, 6 improved neurologically and 8 remained unchanged in relation to their neurology upon admission. Of the 11 patients who were available for follow-up 10 years past injury time, 9 remained neurologically unchanged, 1 deteriorated, and 1 improved in relation to their neurology in the 5-year follow-up. CONCLUSION: Diving injuries of the cervical spine demonstrate high mortality and morbidity rates. Recovery depends on the severity of the initial neurological damage. Conservative treatment is justified in specific patients and can lead to improvement of the initial neurological deficit.

Adult paravertebral pleomorphic rhabdomyosarcoma infiltrating diffusely the whole spinal axis. Case report.

The authors report a unique case of diffuse spinal metastatic disease due to a pleomorphic rhabdomyosarcoma (RMS) in an adult. In addition to its overall rarity, peculiar characteristics of the particular tumor included its site of origin, demonstrated radiologically as the lumbar paravertebral musculature (psoas muscle) and the transcanalicular spread into the vertebral canal, resulting in thecal compression at multiple levels. The salient clinicopathological characteristics of RMS, as they related particularly to the spine, are subsequently discussed and a short review of the major therapeutic modalities for these tumors is offered.

Results of long-term follow-up in patients undergoing anterior screw fixation for type II and rostral type III odontoid fractures.

STUDY DESIGN: Retrospective analysis of the fusion rate of a group of 38 patients having undergone anterior screw fixation for type II and "shallow" type III odontoid fractures. OBJECTIVE.: To determine primarily the long-term fusion rate after anterior screw fixation and to study the clinical characteristics of patients that have a statistically significant or nonsignificant influence on successful outcome. SUMMARY OF BACKGROUND DATA: Long-term outcome of anterior screw fixation for odontoid fractures has been evaluated in very few studies. This information should be critical for further establishing this technique as a major therapeutic strategy for these cases. METHODS: Thirty-eight patients, 25 males and 13 females (with mean age 48.4 +/- 0.4 years), with type II and rostral type III odontoid fractures, underwent anterior cannulated screw fixation during a 62-month period. Radiologic examination of the cervical spine with plain radiographs was performed at 6 weeks, and 2, 6, 12, and 24 months, while computerized tomography of the upper cervical spine (C1-C3) was obtained at 6 months after surgery. Follow-up was available for 31 patients, and the follow-up time ranged from 39 to 87 months (mean 58.4). RESULTS: Radiographic evaluation of the follow-up group showed satisfactory bony fusion and no evidence of abnormal movement at the fracture site in 27 (87.1%) patients. Pseudarthrosis developed in 4 (12.9%) patients; however, 3 (9.6%) of them without instability and 1 (3.2%) with instability. One (3.2%) patient had an instrumentation failure without instability. CONCLUSIONS: In our series, anterior odontoid screw fixation comprised a safe therapeutic modality with high stability and low mechanical failure rates during short-term and long-term follow-up.

Immediate and early postoperative pain relief after kyphoplasty without significant restoration of vertebral body height in acute osteoporotic vertebral fractures.

OBJECT: Painful osteoporotic vertebral compression fractures (VCFs) are a significant cause of disability in the elderly population. Kyphoplasty, a recently developed minimally invasive procedure, has been advocated for the successful management of these fractures in terms of immediate pain relief, and also for restoration of the premorbid level of daily activities. In this retrospective study the authors report on their experience with the early management of VCFs with kyphoplasty. METHODS: A retrospective analysis was conducted in 13 patients (seven women and six men) whose ages ranged from 48 to 87 years (mean age 71.5 +/- 11 years [mean +/- standard deviation]). The interval between onset of symptoms and surgical intervention ranged from 4 to 9 weeks. Twenty levels (12 thoracic, eight lumbar) were treated in this cohort. Immediate and early postoperative (1-month follow-up visit) visual analog scale (VAS) pain scores, activity levels, and restoration of vertebral body (VB) height were assessed. The mean preoperative VAS score was 8 +/- 1, whereas the immediate and early postoperative scores were 1 +/- 1. These findings reflected a resolution of 90 to 100% of preoperative pain. All patients resumed routine activities within hours of the procedure, although improvement in VB height was not accomplished in this cohort. No major complications were encountered in this clinical series. CONCLUSIONS: Kyphoplasty is a safe and effective method for the treatment of osteoporotic VCFs. Failure to restore VB height does not seem to interfere with the excellent pain management and good functional outcome provided by this procedure.

Primary spinal cord oligodendroglioma: case report and review of the literature.

OBJECTS: The objectives were to present a case of pediatric spinal oligodendroglioma and review the existing literature written in English on the subject of human spinal oligodendrogliomas. A comparison of the clinical, radiologic, and pathologic characteristics, as they relate to those already described in similar cases, was also attempted. METHODS: Thorough evaluation of the patient's clinical course was undertaken. Presenting symptoms and signs are reported. The perioperative radiologic features of the case are presented and the intraoperative details as well as the pathologoanatomic findings and follow-up history are provided. We subsequently performed a thorough search in the literature focusing on the number, characteristics, treatment modalities, and prognosis of patients with spinal cord oligodendrogliomas. CONCLUSIONS: Spinal oligodendrogliomas are a distinctly rare type of nervous system tumor, especially in the pediatric population. An international registry addressing all of their clinical and pathobiological characteristics would be of great benefit to patients harboring these rare tumors.