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Mark E. Oppenlander, Forrest D. Hsu, Patrick Bolton and Nicholas Theodore

Although exceedingly rare, catastrophic neurological decline may result from endotracheal intubation of patients with preexisting cervical spine disease. The authors report on 2 cases of quadriplegia resulting from emergent endotracheal intubation in the intensive care unit.

A 68-year-old man with ankylosing spondylitis became quadriplegic after emergent intubation. A new C6–7 fracturedislocation was identified, and the patient underwent emergent open reduction and C4–T2 posterior fixation and fusion. The patient remained quadriplegic and ultimately died of pneumonia 1 year later. This is the first report with radiographic documentation of a cervical fracture-dislocation resulting from intubation in a patient with ankylosing spondylitis.

A 73-year-old man underwent posterior C6–T1 decompression and fixation for a C6–7 fracture. On postoperative Day 12, emergent intubation for respiratory distress resulted in C6-level quadriplegia. Imaging revealed acute spondyloptosis at C6–7, and the patient underwent emergent open reduction with revision and extension of posterior fusion from C-3 to T-2. He remained quadriplegic and ventilator dependent. Five days after the second operation, care was withdrawn. This is the first report of intubation as a cause of significant neurological decline related to disruption of a recently fixated cervical fracture.

Risk factors are identified and pertinent literature is reviewed for cases of catastrophic neurological complications after emergent endotracheal intubation. Strategies for obtaining airway control in patients with cervical spine pathology are also identified. Awareness of the potential dangers of airway management in patients with cervical spine pathology is critical for all involved subspecialty team members.

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Nicholas C. Bambakidis, Nicholas Theodore, Peter Nakaji, Adrian Harvey, Volker K. H. Sonntag, Mark C. Preul and Robert H. Miller

The continuous regeneration of glial cells arising from endogenous stem cell populations in the central nervous system (CNS) occurs throughout life in mammals. In the ongoing research to apply stem cell therapy to neurological diseases, the capacity to harness the multipotential ability of endogenous stem cell populations has become apparent. Such cell populations proliferate in response to a variety of injury states in the CNS, but in the absence of a supportive microenvironment they contribute little to any significant behavioral recovery. In the authors' laboratory and elsewhere, recent research on the regenerative potential of these stem cells in disease states such as spinal cord injury has demonstrated that the cells' proliferative potential may be greatly upregulated in response to appropriate growth signals and exogenously applied trophic factors. Further understanding of the potential of such multipotent cells and the mechanisms responsible for creating a favorable microenvironment for them may lead to additional therapeutic alternatives in the setting of neurological diseases. These therapies would require no exogenous stem cell sources and thus would avoid the ethical and moral considerations regarding their use. In this review the authors provide a brief overview of the enhancement of endogenous stem cell proliferation following neurological insult.

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Tsinsue Chen, Karam Moon, Daphne E. deMello, Iman Feiz-Erfan, Nicholas Theodore and Ratan D. Bhardwaj

A 13-year-old boy presented with fever and neck pain and stiffness, which was initially misdiagnosed as culture-negative meningitis. Magnetic resonance images of the brain and cervical spine demonstrated what appeared to be an intradural extramedullary mass at the C1–3 level, resulting in moderate cord compression, and a Chiari Type I malformation. The patient underwent a suboccipital craniectomy and a C1–3 laminectomy with intradural exploration for excisional biopsy and resection. The lesion containing the parasite was extradural, extending laterally through the C2–3 foramina. Inflammatory tissue secondary to Onchocerca lupi infection was identified, and treatment with steroids and doxycycline was initiated. At the 6-month follow-up, the patient remained asymptomatic, with MR images demonstrating a significant reduction in lesional size. However, 10 weeks postoperatively, the infection recurred, necessitating a second operation. The patient was treated with an additional course of doxycycline and is currently maintained on ivermectin therapy. This is the second reported case of cervical O. lupi infection in a human. In the authors' experience, oral doxycycline alone was insufficient in controlling the disease, and the addition of ivermectin therapy was necessary.

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Laura A. Snyder, Harry Shufflebarger, Michael F. O'Brien, Harjot Thind, Nicholas Theodore and Udaya K. Kakarla

Object

Isthmic spondylolysis can significantly decrease functional abilities, especially in adolescent athletes. Although treatment can range from observation to surgery, direct screw placement through the fractured pars, or Buck's procedure, may be a more minimally invasive procedure than the more common pedicle screw-hook construct.

Methods

Review of surgical databases identified 16 consecutive patients treated with Buck's procedure from 2004 to 2010. Twelve patients were treated at Miami Children's Hospital and 4 at Barrow Neurological Institute. Demographics and clinical and radiographic outcomes were recorded and analyzed retrospectively.

Results

The 16 patients had a median age of 16 years, and 14 were 20 years or younger at the time of treatment. Symptoms included axial back pain in 100% of patients with concomitant radiculopathy in 38%. Pars defects were bilateral in 81% and unilateral in 19% for a total of 29 pars defects treated using Buck's procedure. Autograft or allograft augmented with recombinant human bone morphogenetic protein as well as postoperative bracing was used in all cases. Postoperatively, symptoms resolved completely or partially in 15 patients (94%). Of 29 pars defects, healing was observed in 26 (89.6%) prior to 1 revision surgery, and an overall fusion rate of 97% was observed at last radiological follow-up. There were no implant failures. All 8 athletes in this group had returned to play at last follow-up.

Conclusions

Direct screw repair of the pars interarticularis defect as described in this series may provide a more minimally invasive treatment of adolescent patients with satisfactory clinical and radiological outcomes, including return to play of adolescent athletes.

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Eduardo Martinez-del-Campo, Leonardo Rangel-Castilla, Hector Soriano-Baron and Nicholas Theodore

Object

Performance of MR imaging in patients with gunshot wounds at or near the lumbar spinal canal is controversial. The authors reviewed the literature on the use of MR imaging in gunshot wounds to the spine. They discuss the results from in vitro and clinical studies, analyze the physical properties of common projectiles, and evaluate the safety and indications for MR imaging when metallic fragments are located near the spinal canal.

Methods

A review of the English-language literature was performed. Data from 25 articles were analyzed, including 5 in vitro studies of the interaction between 95 projectiles and the MR system's magnetic fields, and the clinical outcomes in 22 patients with metallic fragments at or near the spinal canal who underwent MR imaging.

Results

Properties of 95 civilian and military projectiles were analyzed at a magnet strength of 1, 1.5, 3, and 7 T. The most common projectiles were bullets with a core of lead, either with a copper jacket or unjacketed (73 [76.8%] of 95). Steel-containing (core or jacket) projectiles comprised 14.7%. No field interaction was evident in 78 (96.3%) of the 81 nonsteel projectiles. All steel projectiles showed at least positive deflection forces, longitudinal migration, or rotation. Heating of the projectiles was clinically insignificant. Image artifact was significant in all 9 steel bullets tested, but was not significant in 39 (88.6%) of the 44 nonsteel bullets tested. Overall, 22 patients with complete (82%) and incomplete (14%) spinal cord injury secondary to a projectile lodged inside the spinal canal underwent MR imaging. Discomfort and further physical or neurological deficits were not reported by any patient. Two patients with spinal cord injuries underwent MR imaging studies before surgical decompression and had subsequent, significant neurological improvement.

Conclusions

Metallic implants near or at the spinal canal are a relative contraindication for MR imaging. However, safe MR imaging might be feasible when a projectile's properties and a patient's individualized clinical presentation are considered.

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Seref Dogan, Sam Safavi-Abbasi, Nicholas Theodore, Eric Horn, Harold L. Rekate and Volker K. H. Sonntag

Object

In this study the authors evaluated the mechanisms and patterns of injury and the factors affecting management and outcome of pediatric subaxial cervical spine injuries (C3–7).

Methods

Fifty-one pediatric patients (38 boys and 13 girls; mean age 12.4 years, range 10 months–16 years) with subaxial cervical spine injuries were reviewed retrospectively. Motor vehicle accidents (MVAs) were the most common cause of injury. Overall, 12% presented with a dislocation, 63% with a fracture, 19% with a fracture–dislocation, and 6% with a ligamentous injury. The most frequently injured level was C6–7 (33%); C3–4 (6%) was least frequently involved. Sixty-four percent of patients were neurologically intact, 16% had incomplete spinal cord injuries (SCIs), 14% had complete SCIs, and three patients (6%) died after admission and before assessment. Treatment was conservative in 64%: seven (13%) wore a halo vest and 26 (51%) wore a rigid cervical orthosis. Surgery was performed in the other 18 patients (36%), with the breakdown as follows: 15 (30%) underwent an anterior approach, two (4%) had posterior approaches, and one (2%) had a combined approach. Postoperatively, four patients (8%) who had a neurological deficit improved. The overall mortality rate was 8%; all deaths were related to MVAs. There were no surgery-related deaths or complications.

Conclusions

Subaxial cervical spine injuries are common in children 9 to 16 years of age, and occur principally between C-5 and C-7. Multilevel injury is more common in children 8 years of age and older than in younger children and infants. Most patients with subaxial cervical spine injuries can be treated conservatively. Both anterior and posterior approaches are safe and effective.

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Skeletal dysplasia involving the subaxial cervical spine

Report of two cases and review of the literature

Gregory P. Lekovic, Nitin R. Mariwalla, Eric M. Horn, Steven Chang, Harold L. Rekate and Nicholas Theodore

✓ Because skeletal dysplasias are primary disorders of bone, they have not been commonly understood as neurosurgical diseases. Nevertheless, neurosurgical complications are commonly encountered in many cases of dysplasia syndromes. The authors present two cases of skeletal dysplasia that caused overt instability of the cervical spine. One patient with a diagnosis of Gorham disease of the cervical spine was treated with prolonged fixation in a halo brace after an initial attempt at instrumentation with a posterior occiput–C4 fusion. The other patient, who at birth was identified to have camptomelic dysplasia, has been treated conservatively from the outset. Although these two patients presented with different disorders—in one patient adequate mature bone never formed and in the other patient progressive bone loss became apparent after a seemingly normal initial development—these cases demonstrate unequivocally that surgical options for fusion are ultimately limited by the quality of the underlying bone. In patients in whom the bone itself is inadequate for use as a substrate for fusion, there are currently limited treatment options. Future improvements in our understanding of chondrogenesis and ossification may lead to the design of superior methods of encouraging fusion in these patients; however, at the present time, long-term maintenance in a halo brace may, in fact, be the only treatment.

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Michael A. Mooney, Mark E. Oppenlander, U. Kumar Kakarla and Nicholas Theodore

Tumoral calcinosis is characterized by tumor-like deposition of calcium in periarticular soft tissue. Spinal involvement is rare, and perioperative diagnosis of tumoral calcinosis can be difficult because lesions may be confused with bony neoplasms. Symptoms of tumoral calcinosis result from bony involvement and/or direct compression of surrounding anatomical structures, for which treatment with surgical decompression can be highly successful. The craniovertebral junction is rarely affected by tumoral calcinosis, and patients with this condition may present with distinct symptoms. Herein, to their knowledge the authors present the first case of tumoral calcinosis affecting the craniovertebral junction in a patient who presented with severe dysphagia and required transoral decompression. Recognition of tumoral calcinosis by neurosurgeons is essential for facilitating diagnosis and treatment, and the transoral approach is an effective method for decompression in select patients.

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Nicholas Theodore, Paul M. Arnold and Ankit I. Mehta

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Nicholas C. Bambakidis, John Butler, Eric M. Horn, Xukui Wang, Mark C. Preul, Nicholas Theodore, Robert F. Spetzler and Volker K. H. Sonntag

✓ The development of an acute traumatic spinal cord injury (SCI) inevitably leads to a complex cascade of ischemia and inflammation that results in significant scar tissue formation. The development of such scar tissue provides a severe impediment to neural regeneration and healing with restoration of function. A multimodal approach to treatment is required because SCIs occur with differing levels of severity and over different lengths of time. To achieve significant breakthroughs in outcomes, such approaches must combine both neuroprotective and neuroregenerative treatments. Novel techniques modulating endogenous stem cells demonstrate great promise in promoting neuroregeneration and restoring function.