Trends and complications in cervical spine surgery: 1989-1993.

In an effort to determine trends in surgery of cervical spine disorders and the incidence of complications resulting from this treatment, a mechanism was established for the collection and analysis of multicenter data on an every-5-year basis. This data collection technique allowed the tracking of trends in the treatment for specific diagnoses and determination of complication rates for individual procedures. We present the results occurring in 4,589 patients operated on by 35 surgeons per year between 1989 and 1993. Principal diagnoses included spondylosis, herniated nucleus pulposus, trauma, rheumatoid arthritis, ankylosing spondylitis, ossification of the posterior longitudinal ligament, and tumor. Surgical procedures included anterior cervical discectomy, anterior cervical discectomy and fusion, corpectomy, laminectomies, posterior arthrodesis, laminoplasty, and cervical plating. Complications reported include: bone graft failure, cerebrospinal fluid leak, recurrent laryngeal nerve injury, root injury, quadriplegia, and death. The yearly percentages of each diagnosis have been roughly stable for each year of the study. However, the operative procedures revealed some interesting trends. There was no overall trend with regard to complications over time, and the overall complication risk was approximately 5%. The present data confirm that cervical spine disease is primarily degenerative or discogenic. However, trauma still remains a major part of the practice, accounting for upwards of 17% of reported cases. Anterior procedures were twice as common as posterior ones. The risk of operative complications remains small yet significant.

Magnetic resonance imaging in cervical spine trauma.

The ability of magnetic resonance imaging (MRI) to diagnose locked facets was examined in a series of six patients with traumatic cervical spine fractures. Plain films, computed tomography, and magnetic resonance scanning were done immediately following injury. Cord edema, contusions, and acute disc herniation were well visualized on magnetic resonance images. Magnetic resonance proved to be equally effective in diagnosing unilateral and bilateral locked facets, and demonstrated the disruption of the posterior longitudinal ligament (PLL) with clarity. The magnetic resonance diagnostic criteria of locked facets, herniation of intervertebral discs, and rupture of the posterior longitudinal ligament are described. Besides permitting direct visualization of the spinal cord, MRI may have a role in the diagnosis and management of acute bony injury to the cervical spine.

Hyperflexion injury of cervical spine and central cord syndrome in a child.

A case of CCS in a 9-year-old boy who sustained a transient subluxation of C5 over C6 following a diving accident is reported. The clinical diagnosis of CCS is supported by a MRI finding of a traumatic lesion in the center of the cord at the level of subluxation. We postulate that hyperflexion injury was responsible for the subluxation, which in turn caused compression injury of the cervical spinal cord. Such compression injury, as shown by McVeigh, results in damage to the center of the cord. Central cord syndrome should be regarded as an entity caused by compression of the spinal cord, irrespective of the mode of injury, be it hyperflexion or hyperextension, from which no age group is exempt.

Complications of fractures of the cervical spine in ankylosing spondylitis.

Five patients with ankylosing spondylitis who suffered severe neurologic complications after fracture of the cervical spine are presented. All developed delayed neurologic complications, ranging from 2 to 35 days after the initial injury (mean, 15.8 days). The diagnosis was delayed in four, and in three this delay contributed to morbidity. All fractures occurred in the lower cervical spine (C5 to C7). In three patients, the fracture was the result of minor trauma. A high index of suspicion, an appreciation of the extreme instability of these fractures, and prompt rigid immobilization with a halo vest or case in the alignment of preexisting kyphosis are all important factors in preventing neurologic complications.

The use of cement forms to control methylmethacrylate in immediate posterior stabilization of the cervical spine. A technical note.

Under certain clinical conditions, posterior stabilization of the cervical spine, supplemented with polymethylmethacrylate (PMMA), is an accepted method of achieving stability. A technique is described in which "cement forms" are used to limit the spread of PMMA and to allow bone graft placement in the lateral paraspinous gutters.

Abduction splinting of the hip joints in myelodysplastic infants.

Myelodysplastic infants with midlumbar levels of paralysis were treated with abduction hip splinting until age two. The goals of treatment were prevention of secondary adaptive acetabular changes and decrease in the number and complexity of reconstructive hip surgeries before age three. The splinted group had hip stability of greater than 90% and a sharp decrease in femoral and pelvic osteotomies. An unsplinted control group had poor results.

Intraspinal rhizotomy and distal cordectomy in patients with myelomeningocele.

Intraspinal rhizotomy alone or in combination with excision of the scarred conus medullaris distal to the level of the cord anomaly was used in thirteen patients with myelomeningocele at the thoracolumbar level whose care was complicated by recurrent deformity of the lower extremities that was caused by persistent spasticity. When examined at an average follow-up of 5.3 years, all patients were free of spasticity, had manageable lower extremities, and were able to sit in a wheelchair with ease. Twelve patients had no change in the status of the urinary tract, but one patient noted an adverse change in urinary status with increased wetness between intermittent catheterizations. Intraspinal rhizotomy alone or in combination with distal cordectomy should be used only in patients with congenital paraplegia in whom reflex motor activity has caused recurrent deformity of the lower extremities that cannot be controlled by the use of braces or operations on the lower extremities, or both.

Talectomy for equinovarus deformity in myelodysplasia.

Nine patients with myelomeningocele (seventeen involved feet) had talectomy for the correction of equinovarus deformity. The age at surgery ranged from one year and eight months to seven years and four months old. The length of follow-up averaged seven years and four months and ranged from twenty-two months to twelve years. Fifteen feet had a good and two had a poor correction of the deformity of the hind part of the foot, the result being directly related to the intraoperative correction of the equinus deformity. The correction of the fore part of the foot was rated as good in eight, fair in one, and poor in eight feet. Residual deformity of the fore part of the foot compromised the functional result in six feet that had an acceptable correction of the deformity of the hind part.

Valgus deformity of the ankle in myelodysplastic patients. Correction by stapling of the medial part of the distal tibial physis.

Thirteen patients with myelodysplasia and associated valgus deformities of the ankle had stapling of the medial part of the distal tibial physis. The pattern of neural involvement in these patients was responsible for characteristic muscle imbalances across the tibiotalar and subtalar joints which led to the valgus deformities. Stapling was performed in twenty-five ankles, fifteen of which had previously been treated unsuccessfully with various soft-tissue and bone procedures. Twelve of the patients were followed until closure of the physis. The average preoperative valgus deformity at the tibiotalar joint was 10 degrees and the average amount of correction was 16 degrees. There were no major complications in our series. All patients retained the ability to walk postoperatively, and there was no increase in the need for bracing. Stapling of the medial part of the distal tibial epiphysis has proved to be a safe and simple procedure for correction of valgus deformities of the ankle in myelodysplastic patients.

Metastatic tumors involving the cervical vertebrae: surgical palliation.

Pain, weakness, or paralysis from involvement of the spinal cord and nerve roots secondary to invasion of the vertebrae by a malignant tumor often can be avoided or alleviated by stabilization of the spine. Twelve patients with neoplastic infiltration of the cervical vertebrae were so treated. The operation of wiring, augmentation bone-grafting, and decompression of the spinal cord was successful after conservative methods failed. Indications for operation were: (1) unremitting pain in the neck, not relieved by bracing or radiation therapy; (2) a major degree of vertebral destruction with loss, or impending loss, of support for the head; (3) collapse of a vertebral body; or (4) neural deficit from local tumor invasion. A classification of our twelve patients into three groups helped to delineate the surgical procedure needed. The value of obtaining spinal stability and a solid fusion above and below the tumor was evident in eleven patients. For almost all of their survival time, they were comfortable. Surgical treatment may not appreciably extend the lenght of a patient's survival, but it generally improves the patient's quality of life.