John A. Jane Sr.
Jason P. Sheehan, Jonas M. Sheehan, M. Beatriz Lopes and John A. Jane Sr.
✓ Diastematomyelia is a rare entity in which some portion of the spinal cord is split into two by a midline septum. Most cases occur in childhood, but some develop in adulthood. A variety of concurrent spinal anomalies may be found in patients with diastematomyelia.
The authors describe a 38-year-old right-handed woman who presented with a 7-month history of lower-extremity pain and weakness on the right side. She denied recent trauma or illness. Sensorimotor deficits, hyperreflexia, and a positive Babinski reflex in the right lower extremity were demonstrated on examination.
Neuroimaging revealed diastematomyelia extending from T-1 to T-3, an expanded right hemicord from T-2 to T-4, and a C6–7 syrinx. The patient underwent T1–3 total laminectomies, resection of the septum, untethering of the cord, and excision of the hemicord lesion. The hemicord mass was determined to be an intramedullary epidermoid cyst; on microscopic evaluation the diastematomyelia cleft was shown to contain fibroadipose connective tissue with nerve twigs and ganglion cells. Postoperatively, the right lower-extremity pain, weakness, and sensory deficits improved.
Diastematomyelia can present after a long, relatively asymptomatic period and should be kept in the differential diagnosis for radiculopathy, myelopathy, tethered cord syndrome, or cauda equina syndrome. Numerous spinal lesions can be found in conjunction with diastematomyelia. To the authors' knowledge, this is the first case in which a thoracic epidermoid cyst and cervical syrinx occurred concurrently with an upper thoracic diastematomyelia. Thorough neuraxis radiographic evaluation and surgical treatment are usually indicated.
Jay Jagannathan, Jonathan H. Sherman, Tom Szabo, Christopher I. Shaffrey and John A. Jane Sr.
This study details long-term clinical and radiographic outcomes following single-level posterior cervical foraminotomy for degenerative disc or osteophyte disease.
The authors conducted a retrospective review of 162 cases involving patients treated by a single surgeon using a posterior cervical foraminotomy. Inclusion criteria were a minimum of 5 years' clinical and radiographic follow-up and unilateral single-level posterior cervical foraminotomy for degenerative disease between C-3 and C-7. Patients who had undergone previous operations, those who underwent bilateral procedures, and those who underwent foraminotomy as part of a larger laminectomy were excluded. The Neck Disability Index (NDI) was used for clinical follow-up, and radiographic follow-up was performed using static and dynamic lateral radiographs to compare focal and segmental alignment and changes in disc-space height.
The mean presenting NDI score was 18 (range 2–39). The most common presenting symptoms were radiculopathy (110 patients [68%]), neck pain (85 patients [52%]), and subjective weakness (91 patients [56%]). The mean preoperative focal angulation at the surgically treated level was 4.2° (median 4.1°, range 7.3–15.3°), and the mean preoperative segmental curvature between C-2 and C-7 was 18.0° (median 19.3°, range −22.1 to 39.3°). The mean postoperative NDI score was 8 (range 0–39). Improvement in NDI scores was seen in 150 patients (93%). Resolution of radiculopathy was experienced by 104 patients (95% of patients with radiculopathy). The mean radiographic follow-up was 77.3 months (range 60–177 months). No statistically significant changes in focal or segmental kyphosis or disc-space height were seen among the overall cohort with time (Cox proportional hazards analysis and Student t-test, p > 0.05). The mean postoperative focal angulation was 4.1° (median 3.9°, range −9.9° to 15.1°) and mean postoperative segmental angulation was 17.6° (median 15.4°, range −40.2 to 35.3°). Postoperative instability on dynamic imaging was present in 8 patients (4.9%); 7 of these patients were clinically asymptomatic and were treated conservatively, and 1 required cervical fusion. Postoperative loss of lordosis (defined as segmental Cobb angle < 10°) was seen in 30 patients (20%), 9 of whom had clinical symptoms and 4 of whom required further surgical correction. Factors associated with worsening sagittal alignment (Cox proportional hazards analysis, p < 0.05) included age > 60 at initial surgery, the presence of preoperative cervical lordosis of < 10°, and the need for posterior surgery after the initial foraminotomy
The posterior cervical foraminotomy is highly effective in treating patients with cervical radiculopathy and results in long-lasting pain relief and improved quality-of-life outcomes in most patients. Long-term radiographic follow-up shows no significant trend toward kyphosis, although select patient subsets (patients older than 60 years, patients who had previous posterior surgery, and patients with < 10° of lordosis preoperatively) appear to be at higher risk and require closer follow-up.
Case report and review of the literature
John W. McDonald, Daniel Becker, Cristina L. Sadowsky, John A. Jane Sr., Thomas E. Conturo and Linda M. Schultz
✓ The authors of this prospective, single-case study evaluated the potential for functional recovery from chronic spinal cord injury (SCI). The patient was motor complete with minimal and transient sensory perception in the left hemibody. His condition was classified as C-2 American Spinal Injury Association (ASIA) Grade A and he had experienced no substantial recovery in the first 5 years after traumatic SCI. Clinical experience and evidence from the scientific literature suggest that further recovery would not take place. When the study began in 1999, the patient was tetraplegic and unable to breathe without assisted ventilation; his condition classification persisted as C-2 ASIA Grade A. Magnetic resonance imaging revealed severe injury at the C-2 level that had left a central fluid-filled cyst surrounded by a narrow donutlike rim of white matter. Five years after the injury a program known as “activity-based recovery” was instituted. The hypothesis was that patterned neural activity might stimulate the central nervous system to become more functional, as it does during development. Over a 3-year period (5–8 years after injury), the patient's condition improved from ASIA Grade A to ASIA Grade C, an improvement of two ASIA grades. Motor scores improved from 0/100 to 20/100, and sensory scores rose from 5–7/112 to 58–77/112. Using electromyography, the authors documented voluntary control over important muscle groups, including the right hemidiaphragm (C3–5), extensor carpi radialis (C-6), and vastus medialis (L2–4). Reversal of osteoporosis and an increase in muscle mass was associated with this recovery. Moreover, spasticity decreased, the incidence of medical complications fell dramatically, and the incidence of infections and use of antibiotic medications was reduced by over 90%. These improvements occurred despite the fact that less than 25 mm2 of tissue (approximately 25%) of the outer cord (presumably white matter) had survived at the injury level.
The primary novelty of this report is the demonstration that substantial recovery of function (two ASIA grades) is possible in a patient with severe C-2 ASIA Grade A injury, long after the initial SCI. Less severely injured (lower injury level, clinically incomplete lesions) individuals might achieve even more meaningful recovery. The role of patterned neural activity in regeneration and recovery of function after SCI therefore appears a fruitful area for future investigation.
Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004
John A. Jane Sr., Jonathan H. Sherman, Paul T. Boulos, Craig Luce and Aaron S. Dumont
✓ Although its management continues to evolve, lumbar stenosis remains a common societal problem. The present article is based on an invited lecture at the 2004 Annual Meeting of the Congress of Neurological Surgeons/American Association of Neurological Surgeons Joint Section on Disorders of the Spine and Peripheral Nerves. In it the authors provide a historical overview of lumbar stenosis and describe how the senior author's treatment of this condition has evolved over the past four decades. Within each era of treatment, the reasons for modification of treatment methods and relevant outcome measures are outlined. Additionally, specific subsets of patients with lumbar stenosis are also discussed to emphasize unique characteristics that affect treatment strategies. The authors' present technique for management of lumbar stenosis is also illustrated.
R. Webster Crowley, Rebecca M. Burke, M. Beatriz S. Lopes, D. Kojo Hamilton and John A. Jane Sr.
High-grade spinal cord gliomas are rare and carry a poor prognosis. A number of treatment modalities exist for spinal cord gliomas, but no consensus exists regarding their management. Cordectomy represents a possible option for treating these lesions; however, few cases have been reported in adults, and none have been reported in the pediatric population. The authors describe the use of cordectomy for the treatment of a high-grade spinal glioma in a 9-year-old boy who remains cancer free 14 years following his initial presentation.
Jay Jagannathan, Christopher I. Shaffrey, Rod J. Oskouian, Aaron S. Dumont, Christian Herrold, Charles A. Sansur and John A. Jane Sr.
Although the clinical outcomes following anterior cervical discectomy and fusion (ACDF) surgery are generally good, 2 major complications are graft migration and nonunion. These complications have led some to advocate rigid internal fixation and/or cervical immobilization postoperatively. This paper examines a single-surgeon experience with single-level ACDF without use of plates or hard collars in patients with degenerative spondylosis in whom allograft was used as the fusion material.
The authors conducted a retrospective review of a prospective database of (Cloward-type) ACDF operations performed by the senior author (J.A.J.) between July 1996 and June 2005. Radiographic follow-up included static and flexion/extension radiographs obtained to assess fusion, focal and segmental kyphosis, and change in disc space height. At most recent follow-up, the patients' condition was evaluated by an independent physician examiner. The Odom criteria and Neck Disability Index (NDI) were used to assess outcome.
One hundred seventy patients underwent single-level ACDF for degenerative pathology during the study period. Their most common presenting symptoms were pain, weakness, and radiculopathy; 88% of patients noted ≥ 2 neurological complaints. The mean hospital stay was 1.76 days (range 0–36 days), and 3 patients (2%) had major immediate postoperative complications requiring reoperation. The mean duration of follow-up was 22 months (range 12–124 months). Radiographic evidence of fusion was present in 160 patients (94%). Seven patients (4%) showed radiographic evidence of pseudarthrosis, and graft migration was seen in 3 patients (2%). All patients had increases in focal kyphosis at the operated level on postoperative radiographs (mean −7.4°), although segmental alignment was preserved in 133 patients (78%). Mean change in disc space height was 36.5% (range 28–53%). At most recent clinical follow-up, 122 patients (72%) had no complaints referable to cervical disease and were able to carry out their activities of daily living without impairment. The mean postoperative NDI score was 3.2 (median 3, range 0–31).
Single-level ACDF without intraoperative plate placement or the use of a postoperative collar is an effective treatment for cervical spondylosis. Although there is evidence of focal kyphosis and loss of disc space height, radiographic evidence of fusion is comparable to that attained with plate fixation, and the rate of clinical improvement is high.