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Sang Hyun Park, Yoshua Esquenazi, David G. Kline, and Daniel H. Kim

OBJECT

Iatrogenic injuries to the spinal accessory nerve (SAN) are not uncommon during lymph node biopsy of the posterior cervical triangle (PCT). In this study, the authors review the operative techniques and surgical outcomes of 156 surgical repairs of the SAN following iatrogenic injury during lymph node biopsy procedures.

METHODS

This retrospective study examines the authors’ clinical and surgical experience with 156 patients with SAN injury between 1980 and 2012. All patients suffered iatrogenic SAN injuries during lymph node biopsy, with the vast majority (154/156, 98.7%) occurring in Zone I of the PCT. Surgery was performed on the basis of anatomical and electro-physiological findings at the time of the operation. The mean follow-up period was 24 months (range 8–44 months).

RESULTS

Of the 123 patients who underwent graft or suture repair, 107 patients (87%) improved to Grade 3 functionality or higher using the Louisiana State University Health Science Center (LSUHSC) grading system. Neurolysis was performed in 29 patients (19%) when the nerve was found in continuity with recordable nerve action potential (NAP) across the lesion. More than 95% of patients treated by neurolysis with positive NAP recordings recovered to LSUHSC Grade 3 or higher. Forty-one patients (26%) underwent end-to-end repair, while 82 patients (53%) underwent graft repair, and Grade 3 or higher recovery was assessed for 90% and 85% of these patients, respectively. The average graft length used was 3.81 cm. Neurotization was performed in 4 patients, 2 of whom recovered to Grade 2 and 3, respectively.

CONCLUSIONS

SAN injuries present challenges for surgical exploration and repair because of the nerve’s size and location in the PCT. However, through proper and timely intervention, patients with diminished or absent function achieved favorable functional outcomes. Surgeons performing lymph node biopsy procedures in Zone I of the PCT should be aware of the potential risk of injury to the SAN.

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Daniel K. Fahim, Sang Don Kim, Dosang Cho, Sangkook Lee, and Daniel H. Kim

Object

The thoracolumbar junction is frequently accessed through an anterolateral approach with the incision and muscle dissection extending from the lower thoracic region to the lateral border of the rectus abdominis muscle. This approach is frequently associated with the subsequent development of an unsightly and uncomfortable relaxation of the ipsilateral abdominal wall, or flank bulge, caused by denervation injury to the intercostal nerves. However, the etiology of this complication is not widely recognized by spine surgeons. The object of this study was to better define the relevant anatomy and innervation of the anterolateral abdominal wall musculature.

Methods

The authors performed 32 cadaveric dissections and 6 intraoperative electromyography (EMG) evaluations.

Results

The cadaveric dissection studies and intraoperative EMG evaluations provided detailed anatomy of the anterolateral abdominal wall and its innervation. Cadaveric dissections revealed that the most significant intercostal nerve contributions to the anterolateral abdominal wall arise from T11 and T12. Electrophysiological confirmation of these findings was accomplished through intraoperative stimulation in 6 patients undergoing anterolateral retroperitoneal approaches to the thoracolumbar junction. The authors confirmed T11 and T12 innervation of the anterolateral abdominal wall musculature by direct intraoperative EMG recording in all 6 patients.

Conclusions

The authors classified the 3 potential zones of injury that can be affected during an anterolateral approach to the thoracolumbar junction. Modifications to the operative technique are suggested to avoid the complication of flank bulge. The most significant intercostal nerve contributions to the anterolateral abdominal wall arise from T11 and T12.

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Sangkook Lee, Kriangsak Saetia, Suparna Saha, David G. Kline, and Daniel H. Kim

Object

The aim of this retrospective study was to present and investigate axillary nerve injuries associated with sports.

Methods

This study retrospectively reviewed 26 axillary nerve injuries associated with sports between the years 1985 and 2010. Preoperative status of the axillary nerve was evaluated by using the Louisiana State University Health Science Center (LSUHSC) grading system published by the senior authors. Intraoperative nerve action potential recordings were performed to check nerve conduction and assess the possibility of resection. Neurolysis, suture, and nerve grafts were used for the surgical repair of the injured nerves. In 9 patients with partial loss of function and 3 with complete loss, neurolysis based on nerve action potential recordings was the primary treatment. Two patients with complete loss of function were treated with resection and suturing and 12 with resection and nerve grafting. The minimum follow-up period was 16 months (mean 20 months).

Results

The injuries were associated with the following sports: skiing (12 cases), football (5), rugby (2), baseball (2), ice hockey (2), soccer (1), weightlifting (1), and wrestling (1). Functional recovery was excellent. Neurolysis was performed in 9 cases, resulting in an average functional recovery of LSUHSC Grade 4.2. Recovery with graft repairs averaged LSUHSC Grade 3 or better in 11 of 12 cases

Conclusions

Surgical repair can restore useful deltoid function in patients with sports-associated axillary nerve injuries, even in cases of severe stretch–contusion injury.

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Dosang Cho, Kriangsak Saetia, Sangkook Lee, David G. Kline, and Daniel H. Kim

Object

This study analyzes 84 cases of peroneal nerve injuries associated with sports-related knee injuries and their surgical outcome and management.

Methods

The authors retrospectively reviewed the cases of peroneal nerve injury associated with sports between the years 1970 and 2010. Each patient was evaluated for injury mechanism, preoperative neurological status, electrophysiological studies, lesion type, and operative technique (neurolysis and graft repair). Preoperative status of injury was evaluated by using a grading system published by the senior authors. All lesions in continuity had intraoperative nerve action potential recordings.

Results

Eighty-four (approximately 18%) of 448 cases of peroneal nerve injury were found to be sports related, which included skiing (42 cases), football (23 cases), soccer (8 cases), basketball (6 cases), ice hockey (2 cases), track (2 cases) and volleyball (1 case). Of these 84 cases, 48 were identified as not having fracture/dislocation and 36 cases were identified with fracture/dislocation for surgical interventions. Good functional outcomes from graft repair of graft length < 6 cm (70%) and neurolysis (85%) in low-intensity peroneal nerve injuries associated with sports were obtained. Recovery from graft repair of graft length between 6 and 12 cm (43%) was good and measured between Grades 3 and 4. However, recovery from graft repair of graft length between 13 and 24 cm was obtained in only 25% of patients.

Conclusions

Traumatic knee-level peroneal nerve injury due to sports is usually associated with stretch/contusion, which more often requires graft repair. Graft length is the factor to be considered for the prognosis of nerve repair.

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Kriangsak Saetia, Dosang Cho, Sangkook Lee, Daniel H. Kim, and Sang Don Kim

Ossification of the posterior longitudinal ligament (OPLL) is most commonly found in men, the elderly, and Asian patients. There are many diseases associated with OPLL, such as diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, and other spondyloarthropathies. Several factors have been reported to be associated with OPLL formation and progression, including genetic, hormonal, environmental, and lifestyle factors. However, the pathogenesis of OPLL is still unclear. Most symptomatic patients with OPLL present with neurological deficits such as myelopathy, radiculopathy, and/or bowel and bladder symptoms. There are some reports of asymptomatic OPLL. Both static and dynamic factors are related to the development of myelopathy. Plain radiography, CT, and MR imaging are used to evaluate OPLL extension and the area of spinal cord compression. Management of OPLL continues to be controversial. Each surgical technique has some advantages and disadvantages, and the choice of operation should be made case by case, depending on the patient's condition, level of pathology, type of OPLL, and the surgeon's experience. In this paper, the authors attempt to review the incidence, pathology, pathogenesis, natural history, clinical presentation, classification, radiological evaluation, and management of OPLL.

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Benjamin D. Elder, Krishanthan Vigneswaran, Kyriacos A. Athanasiou, and Daniel H. Kim

Object

Tissue engineering appears to be a promising strategy for articular cartilage regeneration as a treatment for facet joint arthritis. Prior to the commencement of tissue engineering approaches, design criteria must be established to determine the required functional properties of the replacement tissue. As characterization of the functional properties of facet joint cartilage has not been performed previously, the objective of this study was to determine the biomechanical, biochemical, and histological properties of facet joint cartilage.

Methods

The in vitro testing was conducted using 4 lumbar spinal segments obtained from skeletally mature canines. In each specimen, articular cartilage was obtained from the superior surface of the L3–4 and L4–5 facet joints. Creep indentation was used to determine the compressive biomechanical properties, while uniaxial tensile testing yielded the Young modulus and ultimate tensile strength of the tissue. Additionally, biochemical assessments included determinations of cellularity, glycosaminoglycan (GAG) content, and collagen content, as well as enzymelinked immunosorbent assays for collagen I and II production. Finally, histological characterization included H & E staining, as well as staining for collagen and GAG distributions.

Results

The means ± standard deviation values were determined. There were no differences between the 2 spinal levels for any of the assessed properties. Averaged over both levels, the thickness was 0.49 ± 0.10 mm and the hydration was 74.7 ± 1.7%. Additionally, the cells/wet weight (WW) ratio was 6.26 ± 2.66 × 104 cells/mg and the cells/dry weight (DW) ratio was 2.51 ± 1.21 × 105 cells/mg. The GAG/WW was 0.038 ± 0.013 and the GAG/ DW was 0.149 ± 0.049 mg/mg, while the collagen/WW was 0.168 ± 0.026 and collagen/DW was 0.681 ± 0.154 mg/ mg. Finally, the aggregate modulus was 554 ± 133 kPa, the Young modulus was 10.08 ± 8.07 MPa, and the ultimate tensile strength was 4.44 ± 2.40 MPa.

Conclusions

To the best of the authors' knowledge, this study is the first to provide a functional characterization of facet joint articular cartilage, thus providing design criteria for future tissue engineering studies.

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Ung-Kyu Chang, Daniel H. Kim, Max C. Lee, Rafer Willenberg, Se-Hoon Kim, and Jesse Lim

Object

The authors of previous in vitro investigations have reported an increase in adjacent-level intradiscal pressures (IDPs) and facet joint stresses following cervical spine fusion. This study was performed to compare adjacent-level IDPs and facet force following arthroplasty with the fusion model.

Methods

Eighteen human cadaveric cervical spines were tested in the intact state for different modes of motion (extension, flexion, bending, and rotation) up to 2 Nm. The specimens were then divided into three groups: those involving the ProDisc-C cervical artificial disc, Prestige cervical artificial disc, and cervical fusion. They were load tested after application of instrumentation or surgery at the C6–7 level. During the test, IDPs and facet forces were measured at adjacent levels.

Results

In arthroplasty-treated specimens, the IDP showed little difference from that of the intact spine at both proximal and distal levels. In fusion-treated specimens, the IDP increased at the posterior anulus fibrosus on extension and at the anterior anulus fibrosus on flexion at the proximal level. At the distal level, the IDP change was not significant. The facet force changes were minimal in flexion, bending, and rotation modes in both arthroplasty- and fusion-treated spines. Significant changes were noted in the extension mode only. In extension, arthroplasty models exhibited significant increases of facet force at the treated level. In the fusion model the facet forces decreased at the treated segment and increased at the adjacent segment.

Conclusions

The two artificial discs of the semiconstrained systems maintain adjacent-level IDPs near the preoperative values in all modes of motion, but with respect to facet force pressure tended to increase after arthroplasty.

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Ung-Kyu Chang, Daniel H. Kim, Max C. Lee, Rafer Willenberg, Se-Hoon Kim, and Jesse Lim

Object

Range of motion (ROM) changes were evaluated at the surgically treated and adjacent segments in cadaveric specimens treated with two different cervical artificial discs compared with those measured in intact spine and fusion models.

Methods

Eighteen cadaveric human cervical spines were tested in the intact state for the different modes of motion (extension, flexion, lateral bending, and axial rotation) up to 2 Nm. Three groups of specimens (fitted with either the ProDisc-C or Prestige II cervical artificial disc or submitted to anterior cervical discectomy and fusion [ACDF]) were tested after implantation at C6–7 level. The ROM values were measured at treated and adjacent segments, and these values were then compared with those measured in the intact spine.

Results

At the surgically treated segment, the ROM increased after arthroplasty compared with the intact spine in extension (54% in the ProDisc-C group, 47% in the Prestige group) and in flexion (27% in the ProDisc-C group, 10% in the Prestige group). In bending and rotation, the postarthroplasty ROMs were greater than those of the intact spine (10% in the ProDisc-C group and 55% in the Prestige group in bending, 17% in the ProDisc-C group and 50% in the Prestige group in rotation). At the adjacent levels the ROMs decreased in all specimens treated with either artificial disc in all modes of motion (< 10%) except for extension at the inferior the level (29% decrease for ProDisc-C implant, 12% decrease for Prestige disc). The ROM for all motion modes in the ACDF-treated spine decreased at the treated level (range 18–44%) but increased at the adjacent levels (range 3–20%).

Conclusions

Both ProDisc-C and Prestige artificial discs were associated with increased ROM at the surgically treated segment compared with the intact spine with or without significance for all modes of testing. In addition, adjacent-level ROM decreased in all modes of motion except extension in specimens fitted with both artificial discs.

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John Gachiani, Daniel H. Kim, Adriane Nelson, and David Kline

Object

The authors present the results of a retrospective review of 37 surgically treated metastases to nerve (malignant peripheral non–neural sheath nerve tumors). Tumor frequencies, presentations, management, and prognosis are discussed.

Methods

Thirty-seven patients who were treated for metastases to nerve between 1969 and 2006 at the Louisiana State University Health Sciences Center were identified in a review of patient records. Notes regarding patient history and physical examination findings were reviewed to provide information on presenting symptoms and signs. Imaging and histopathological examination results were also reviewed. Cases were analyzed depending on the primary tumor and the location of metastasis.

Results

There included 37 surgically treated lesions, 16 of which originated in the breast and 10 of which originated in the lung. In two cases melanomas had metastasized to nerve, and one tumor each had metastasized from the bladder, rectum, skin, head and neck, and thyroid, and from a primary Ewing sarcoma. There was a single lymphoma that had metastasized to the radial nerve and one chordoma and one osteosarcoma, each of which had metastasized to the brachial plexus.

Conclusions

The nervous system is involved in numerous ways by oncological process. Direct involvement of the peripheral nervous system occurs mostly from direct extension, although it occasionally occurs because of distant spread from the primary tumor to nerve. Surgical excision of the metastatic lesion with margins has been useful mostly in the control of pain. Nevertheless, patients eventually succumb to their primary malignancy.

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Alice Cherqui, Daniel H. Kim, Se-Hoon Kim, Hyung-Ki Park, and David G. Kline

Object

The goal of this study was to analyze the results of surgical treatment of paraspinal nerve sheath tumors (NSTs) and review the surgical approaches to paraspinal NSTs.

Methods

A retrospective review of the cases of paraspinal NSTs treated surgically by two senior authors during the period between 1970 and 2006 was undertaken. Surgical approaches that allow minimal disruption of normal anatomy and are aimed at complete resection of paraspinal lesions and preservation of spinal stability are reviewed according to the spinal level.

Results

Eighty-eight paraspinal NSTs were treated surgically during the period: 56 schwannomas, seven solitary neurofibromas, 21 neurofibromas associated with neurofibromatosis Type 1 (NF1), and four malignant peripheral NSTs. Schwannomas tended to occur in the cervical and thoracic areas. Neurofibromas were usually associated with NF1 and tended to occur in the cervical area. Pain (79 patients, 90%) and paresthesia (81 patients, 92%) were the predominant clinical presenting symptoms; others included weakness (28 patients) and myelopathy (12 patients). Total resection of the tumor was achieved in 50 patients (89.3%) with schwannomas and 22 patients (78.6%) with neurofibromas. There was a large reduction of pain in 70 (88.6%) of 79 patients who had preoperative pain, and weakness improved in 18 (64.3%) of 28. Postoperative transient weakness occurred in 12 (42.9% ) of these patients, but in 85% of this group, the symptom improved over a 12-month period. Myelopathy was reduced in eight (66.7%) of 12 patients. The average follow-up period was 18 months.

Conclusions

Paraspinal NSTs present unique surgical challenges given their anatomical relationships to the spine, spinal cord, nerve roots, and major vasculature. The surgical technique should take into account the location of the lesion and its relationship to paraspinal anatomy, the extent of resection, sparing of normal anatomy, and spinal instability.