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Paul W. Detwiler, Randall W. Porter, Neil R. Crawford, Paul J. Apostolides and Curtis A. Dickman

The goals of surgery for metastatic disease of the lumbosacral spine are to relieve compression of the thecal sac and nerve roots, to resect malignant tissue, and to create a stable reconstruction of the spine. Reconstruction of the lumbosacral junction, specifically the L-5 vertebral body, is particularly challenging because the biomechanical properties of this level differ from other areas of the spine.

A 40-year-old woman with intraductal breast carcinoma that metastasized to the L-5 vertebral body presented with progressive low-back pain, right-sided L-5 radiculopathy, and weakness. Magnetic resonance imaging revealed a pathological fracture of the L-5 vertebral body with compression of the cauda equina. The L-5 posterior arch, both facet joints and pedicles, and the posterior third of the vertebral body were removed via a posterior approach. A pedicle screw fixation system was applied from L-4 to S-1. The patient was repositioned, and a transabdominal approach was used to resect the anterior two thirds of the L-5 body, which was reconstructed using an allograft bone strut. An interference bone screw was placed through the inferior aspect of the allograft and screwed into the body of S-1 to provide stability for the reconstructive graft.

The patient's clinical recovery was excellent. She was ambulating without difficulty when seen at 19-month follow-up examination.

Complete spondylectomy by using this novel fusion technique was efficacious in the treatment of metastatic disease to the vertebral column.

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Sedat Çagli, Neil R. Crawford, Volker K. H. Sonntag and Curtis A. Dickman

S urgical treatment of Grade I lumbar spondylolisthesis (25% slippage) involves reducing the subluxation and inserting fixation devices and bone grafts to stabilize the spine and promote fusion. Two surgical options are threaded interbody cylinders 9 and pedicle screw/rod fixation. 3, 12 Threaded interbody cylinders are available as metallic cages or as machined cadaveric cortical bone dowels ( Fig. 1 ). The geometrical configurations of threaded titanium cages and threaded cortical bone dowels are similar, although the metallic cages have sharper threads

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L. Fernando Gonzalez, David Fiorella, Neil R. Crawford, Robert C. Wallace, Iman Feiz-Erfan, Denise Drumm, Stephen M. Papadopoulos and Volker K.H. Sonntag

T he C1–2 joint is susceptible to trauma resulting from exaggerated movement in any of the normal intrinsic directions of motion: vertical, anteroposterior, and rotatory. Subluxation of the C1–2 complex in the horizontal plane can be caused by trauma and by various degenerative, inflammatory (for example, rheumatoid arthritis), and congenital (such as, Down syndrome) conditions. 3 Rotatory instability has also been well described. 12 Radiological criteria have been established to identify horizontal and rotatory injuries of the C1–2 articulation, and

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L. Fernando Gonzalez, Jeffrey D. Klopfenstein, Neil R. Crawford, Curtis A. Dickman and Volker K. H. Sonntag

of the ligamentous anatomy of the CVJ. Used with permission from the Barrow Neurological Institute. We hypothesize that during pure axial distraction of the CVJ, different types of injury will manifest depending on where the vertical portion of the cruciate ligament is disrupted ( Fig. 4 ). In both OAD or AAD, the transverse ligament is likely intact because in patients suffering these injuries, evidence of anteroposterior subluxation is seldom shown ( Fig. 5 ). If all vertically compressive ligaments (apical, alar, and tectorial membrane) and articular

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Roger Härtl, Robert H. Chamberlain, Mary S. Fifield, Dean Chou, Volker K. H. Sonntag and Neil R. Crawford

CA , Sonntag VK , Papadopoulos SM , Hadley MN : The interspinous method of posterior atlantoaxial arthrodesis . J Neurosurg 74 : 190 – 198 , 1991 8 Goel A , Laheri V : Plate and screw fixation for atlantoaxial sub-luxation . Acta Neurochir (Wien) 129 : 47 – 53 , 1994 9 Gonzalez LF , Crawford NR , Chamberlain RH , Perez Garza LE , Preul MC , Sonntag VK , : Craniovertebral junction fixation with transarticular screws: biomechanical analysis of a novel technique . J Neurosurg 98 : 2 Suppl 202 – 209 , 2003 10 Gorek

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Rogerio Rocha, Sam Safavi-Abbasi, Cassius Reis, Nicholas Theodore, Nicholas Bambakidis, Evandro De Oliveira, Volker K. H. Sonntag and Neil R. Crawford

Ebraheim NA , Xu R , Ahmad M , Heck B : The quantitative anatomy of the vertebral artery groove of the atlas and its relation to the posterior atlantoaxial approach . Spine 23 : 320 – 323 , 1998 10 Goel A , Desai KI , Muzumdar DP : Atlantoaxial fixation using plate and screw method: a report of 160 treated patients . Neurosurgery 51 : 1351 – 1357 , 2002 11 Goel A , Laheri V : Plate and screw fixation for atlantoaxial subluxation . Acta Neurochir (Wien) 129 : 47 – 53 , 1994 12 Harms J , Melcher RP : Posterior C1-C2 fusion

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Marco Túlio Reis, Eric W. Nottmeier, Phillip M. Reyes, Seungwon Baek and Neil R. Crawford

biomechanical results and high fusion rates (95%–100%). However, complications such as misplaced screws (0%–33%), screw breakage (0%–33%), VA injury (0%–10%), and cranial nerve palsy have been reported. 9 , 10 , 16 , 20 , 27 , 29 Madawi et al. 18 suggested that this technique should be avoided in patients with incomplete reduction of a C1–2 subluxation, with pathological destruction or collapse of C-2, with aberrant VA anatomy or a large VA groove (20% of cases), after a transoral odontoidectomy, and in cases of cranial assimilation of C-1. In 1994, Goel and Laheri 7