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Khalil Salame, Georges E. R. Ouaknine, Nissim Razon, and Semion Rochkind


Cage devices were introduced in spinal fusion to overcome the shortcomings of autograft, allograft, and biocompatible implants. The aim of this study was to assess the short-term results of anterior cervical discectomy and fusion (ACDF) in which an interbody carbon fiber cage (CFC) and local osteophyte–derived bone graft were implanted.


A retrospective review was conducted of 100 consecutive patients treated by ACDF in which a CFC was packed with bone fragments obtained from osteophytes at the surgical site. Plain radiographs with dynamic lateral views obtained 1 year postoperatively were used to assess bone fusion, alignment of the cervical spine, and stability. Dynamic radiographs were also obtained at last follow up to determine whether loss of cervical alignment or collapse at the fused disc had occurred.

The mean follow-up period was 25 months. In all cases the cervical lordosis was maintained or corrected to different extents and disc height was restored. Solid fusion was achieved in 98% of the cases. There were no cage-related complications and no cases of cage failure.


The authors conclude that application of the CFC for ACDF is safe, effective, and technically feasible. Osteophytes resected during surgery may be a good alternative material for bone grafting in cage-assisted cervical interbody fusion.

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Khalil Salame, Yoram Segev, Dan M. Fliss, and Georges E. Ouaknine

Posttraumatic cranio-orbital cerebrospinal fluid (CSF) fistula is very rare. Diagnosis of these fistulas may be difficult, and it is possible that this complication of craniofacial injury is underdiagnosed. Early recognition and adequate treatment is of paramount importance to prevent hazardous complications. The authors report the case of a 20-year-old woman in whom a CSF leak developed through the medial canthus area of her eye after she sustained a mild sports-related injury. Clinical examination and chemical analysis of the fluid led to the correct diagnosis, and the leak was stopped with conservative treatment. It is proposed that a CSF leak through the eye be termed “oculorrhea” as compared with otorrhea and rhinorrhea. The mechanism of the fistula in this patient is discussed, as is the pertinent radiologically demonstrated anatomy and the mechanism of injury. Management and controversies are also discussed.

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Eyal Behrbalk, Khalil Salame, Gilad J. Regev, Ory Keynan, Bronek Boszczyk, and Zvi Lidar


A retrospective study analyzing medical files of patients who had undergone surgical management for cervical spondylotic myelopathy (CSM) at a single tertiary hospital was performed to determine the time needed by community care physicians to reach a diagnosis of CSM in patients presenting with typical myelopathic signs and symptoms, and to establish the reasons for the delayed diagnosis when present.

Previous studies have documented that early diagnosis and surgical treatment of CSM may improve patients' neurological as well as general outcome. However, patients complaining of symptoms compatible with CSM may undergo lengthy medical investigations and treatments by community-based physicians before a correct diagnosis is made. The authors have found no published data on the process and time frame involved in attaining a diagnosis of CSM in the community setting.


The medical records of 42 patients were retrospectively reviewed for demographic data, symptoms, time to diagnosis, physician specialty, number of visits involved in the diagnostic process, and neurological status prior to surgery.


The mean time delay from initiation of symptoms to diagnosis of CSM was 2.2 ± 2.3 years. The majority of symptomatic patients (90.4%) initially presented to a family practitioner (69%) or an orthopedic surgeon (21.4%), with fewer patients (9.6%) referring to other disciplines (for example, the emergency department) for initial care. In contrast, the diagnosis of CSM was most often made by neurosurgeons (38.1%) and neurologists (28.6%), and less frequently by orthopedic surgeons (19%) or family physicians (4.8%).


The diagnosis of CSM in the community is frequently delayed, leading to late referral for surgery. A higher index of suspicion for this debilitating entity is required from family practitioners and community-based orthopedic surgeons to prevent neurological sequelae.

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Khalil Salame, Shimon Maimon, Gilad J. Regev, Tali Jonas Kimchi, Akiva Korn, Laurence Mangel, and Zvi Lidar


Preoperative embolization is performed before spine tumor surgery when significant intraoperative hemorrhage is anticipated. Occlusion of radicular and segmental arteries may result in spinal ischemia. The goal of this study was to check whether neurophysiological monitoring during preoperative angiography in patients scheduled for total en bloc spondylectomy (TES) of spine tumors improves the safety of vessel occlusion.


This was a case series study of patients who underwent tumor embolization under somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring in preparation for TES in treating spine tumors. The angiography findings, the embolized vessels, and the results are presented.


Five patients whose ages ranged from 33 to 75 years and who had thoracic spine tumors are reported. Four patients suffered from primary tumor and 1 patient had a metastatic tumor. Radicular arteries at the tumor level, 1 level above, and 1 level below were permanently occluded when SSEPs and MEPs were preserved during temporary occlusion. No complications were encountered during or after the angiography procedure and embolization.


Temporary occlusion with electrophysiological monitoring during preoperative angiography may improve the safety of permanent radicular artery occlusion, including the artery of Adamkiewicz in patients undergoing TES for the treatment of spine tumors.