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Allan D. O. Levi, Curtis A. Dickman and Volker K. H. Sonntag

fixation must also be appreciated by spinal surgeons; these include, among others, hardware failure and neurological injury. Infections may develop after any surgical procedure, and the management of this complication in the setting of spinal instrumentation is critical in providing appropriate postoperative care to these patients. The incidence of wound infection after spinal surgery without instrumentation is relatively low. In an era in which antibiotic prophylaxis before spine surgery has become relatively routine, the incidence of infection after lumbar discectomy

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Allan D. O. Levi, Curtis A. Dickman and Volker K. H. Sonntag

The authors retrospectively reviewed 452 consecutively treated patients who underwent a spinal instrumentation procedure at a single institution to establish which patients and which surgical approaches might be associated with an increased risk of developing deep wound infections and to determine the efficacy with which the institution's current treatment strategy eradicates these infections. Wound infections occurred in 17 patients (10 men and seven women) with spinal instrumentation (incidence 3.8%). All infections occurred after posterior spinal instrumentation procedures (7.2%); there were no infections after anterior instrumentation procedures regardless of the level. Each patient was assigned an infection risk factor (RF) score depending on the number of RFs identified in an individual patient preoperatively. The mean RF score of patients who developed infections was 2.18, whereas the mean RF score for a procedure-matched, infection-free control group was 0.71. The mean number of days from surgery to clinical presentation was 27.6 days (range 4-120 days), and the mean increase in hospitalization time for the subset of patients who developed infections was 16.6 days. The most common organism isolated from wound cultures was Staphylococcus aureus (nine of 17 cases). Of the 17 patients, five had infections involving multiple organisms. All patients were infection free at a minimum of 8 months follow-up review. The current treatment regimen advocated at this institution consists of operative debridement of the infected wound, a course of intravenous followed by oral antibiotic medications, insertion of an antibiotic-containing irrigation-suction system for a mean of 5 days, and maintenance of the instrumentation system within the infected wound.

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Curtis A. Dickman and Volker K. H. Sonntag

permanent sequelae from any perioperative complications. There were 11 complications in eight patients related to the revision surgery. Three patients had intraoperative dural tears that were repaired with sutures; one developed a postoperative cerebrospinal fluid (CSF) leak from his neck wound that required a temporary external lumbar drain; the CSF leak ceased without sequelae. Three individuals developed wound infections: there were two superficial infections involving the neck wound and one iliac crest—graft site wound. All the wound infections resolved with local

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Volker K. H. Sonntag and Bennett M. Stein

demonstrable occlusion of the cerebral arteries ( Fig. 1 right ). These “punched-out” narrowings of the intracranial arteries resembled arteritis or thrombosis rather than spasm. In two cases the process was self-limited, and in the other death intervened. None of these patients had clinical or laboratory evidence of cardiac myxomas, collagen vascular disorders, bacterial infection, or other systemic disease processes. This small number of cases is presented to alert other surgeons to the possibility of complications from EACA treatment and to encourage the use of follow

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Udaya K. Kakarla, M. Yashar S. Kalani, Giriraj K. Sharma, Volker K. H. Sonntag and Nicholas Theodore

C occidioides immitis is a dimorphic fungus endemic to arid regions of the southwestern US, northern Mexico, Central America, and South America. 10 An estimated 100,000 infections occur annually in the US, of which 34% are symptomatic. 10 The incidence of coccidioidal infection in Arizona has increased from 12 new cases per 100,000 people in 1995 to 58.2 new cases per 100,000 in 2005. 12 The primary clinical manifestation is acute respiratory infection caused by inhalation of airborne arthroconidia, which are deposited in the terminal bronchioles. In

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Roberto Masferrer, Carlos H. Gomez, Dean G. Karahalios and Volker K. H. Sonntag

prone on a radiolucent operating room table. Fluoroscopy with a C-arm image intensifier was used in all cases to permit anteroposterior and lateral views of the spine. All patients underwent somatosensory evoked potential monitoring transoperatively. A course of prophylactic antibiotics was given in all patients transoperatively and for 48 hours postoperatively. With the exception of patients with neoplasms or infections, a cell-saver unit was used to reduce the need for postoperative blood transfusions. A standard posterior approach was used in all cases

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Mohammed A. Eleraky, Carlos Llanos and Volker K. H. Sonntag

Methods Between 1987 and 1998 at our institution, 185 patients (126 men and 59 women) underwent anterior decompressive cervical corpectomy (performed by the senior author) for the treatment of degenerative spondylosis, ossification of the posterior longitudinal ligament (OPLL), tumors, trauma, and infections ( Table 1 ). Their mean age was 48.2 years (range 9–74 years). Twenty-eight of the patients had undergone a previous anterior cervical reoperation. After graft placement, 179 of the 185 patients also had an anterior plate placed. TABLE 1 Diagnosis in 185

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Paul W. Detwiler, Frederick F. Marciano, Randall W. Porter and Volker K. H. Sonntag

Although the efficacy of posterior decompression for symptomatic lumbar stenosis that is recalcitrant to conservative therapy is well proven, uniform agreement on the need for simultaneous arthrodesis is lacking. The variability in the rate of lumbar fusion with and without instrumentation has been attributed to a number of factors: advances in surgical technique; rapid development of instrumentation; radiographic advances in the diagnosis of disease entities of the lumbar spine; evolution in our understanding of bone healing; improved pre- and postoperative care; aggressive rehabilitation; patient compensation; hospital and surgeon reimbursement; better education of residents, fellows, and practicing neurosurgeons; and, most important, the lack of clear indications based on defined diagnostic categories. Based on review of the literature and their experience at the Barrow Neurological Institute, the authors have attempted to define indications for lumbar fusion with or without instrumentation based on defined diagnostic categories. Clear indications for fusion include trauma, tumor, or infection with two- or three-column injury, iatrogenic instability, and isthmic spondylolisthesis. Relative indications for fusion include degenerative spondylolisthesis, radiographically proven dynamic instability with pain or neurological findings, adult scoliosis, and mechanical back pain. Fusion is rarely indicated with discectomy, abnormal radiographs without appropriate findings (such as degenerative disc disease), facet joint syndrome, failed back surgery, or stable spinal stenosis.

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Roberto Masferrer, Carlos H. Gomez, Dean G. Karahalios and Volker K. H. Sonntag

Object

The goal of this study was to review retrospectively the outcome of 95 patients with various disorders leading to instability of the thoracolumbar and lumbar spine who were treated consecutively via a posterior surgical approach with pedicle screw fixation in which the Texas Scottish Rite Hospital system was used.

Methods

All cases were managed according to the same protocol. Follow-up review averaged 29.6 months. Radiographic evidence of osseous union and the patient's current status were analyzed. Four screws were malpositioned, and there were two dural lacerations of a nerve root and one pedicle fracture. Deep wound infections developed in five patients (5.2%) and three patients had postoperative radicular pain. In one case, the rods disengaged from the screws; in four cases, hardware was removed but there were no broken screws. Neurological deficits improved in 85% of the patients and no patient was worse neurologically after surgery. The rate of osseous union was 96.8%. Three patients developed pseudarthrosis, one of whom was asymptomatic. Back pain improved in 80 patients (85%). A solid bone fusion, however, was not necessarily associated with decreased back pain.

Conclusions

These results support the use of pedicle screw fixation as an effective and safe procedure for fusion of the thoracolumbar and lumbar spine and support the finding that complications can be minimal when a meticulous surgical technique is used. The proper selection of patients for surgery is probably the most important factor associated with good outcomes.

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Curtis A. Dickman, Joseph M. Zabramski, Volker K. H. Sonntag and Stephen Coons

epidural varicose veins are uncommon and may present with sciatica, urinary dysfunction, or, in rare cases, myelopathy. There may be an association with spinal dysraphism in some patients. Symptoms may result from thrombosis and progressive venous distention. Spinal AVM's, neoplasms, infections, and inflammatory processes should be considered in the differential diagnosis and workup of these patients. Radiographic studies are nonspecific. Surgery may offer the only means of achieving a definitive diagnosis and treatment of this disorder. References 1