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Gabriel C. Tender

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Clifford L. Crutcher II, David G. Kline, and Gabriel C. Tender

The traditional posterior subscapular approach offers excellent exposure of the lower brachial plexus and has been successfully used in patients with recurrent thoracic outlet syndrome after an anterior operation, brachial plexus tumors involving the proximal roots, and postirradiation brachial plexopathy, among others. However, this approach also carries some morbidity, mostly related to the extensive muscle dissection of the trapezius, rhomboids, and levator scapulae. In this article, the authors present the surgical technique and video illustration of a modified, less invasive posterior subscapular approach, using a small, self-retaining retractor and only a partial trapezius and rhomboid minor muscle dissection. This approach is likely to result in decreased postoperative morbidity and a shorter hospital stay.

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Gabriel C. Tender, Alexander O. Vortmeyer, and Edward H. Oldfield

✓ Intradural spinal arteriovenous fistulas (AVFs), a subtype of spinal arteriovenous malformation in which there is a direct communication between a spinal artery and a vein on the cord surface or in the subarachnoid space, are generally considered to be congenital lesions caused by maldevelopment of the embryonic vascular system. The authors present the cases of two patients with acquired AVFs of the terminal filum. In each patient an AVF between the distal segment of the anterior spinal artery and its accompanying vein on the terminal filum developed within 1 year of repeated lumbar myelography that had demonstrated no evidence of abnormal vascularity. In both patients spinal arteriography demonstrated the absence of medullary venous drainage in the thoracolumbar region, which, combined with the arterialized venous input from the AVF, permitted the development of venous congestion and myelopathy. The involved segment of the terminal filum was excised; in vitro microarteriography and the histopathological examination demonstrated a single, simple arteriovenous connection in both patients.

The findings in these cases indicate that intradural AVF can spontaneously arise in later life. The development of these lesions and/or their clinical manifestation may require not only the presence of the AVF, but also deficiency of medullary spinal venous drainage. The epidemiology and anatomy of intradural AVFs are compatible with an acquired origin in many cases.

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Gabriel C. Tender, Richard V. Baratta, and Rand M. Voorhies

Object. Lumbar radiculopathy secondary to foraminal entrapment can be treated by unilateral removal of the overlying pars interarticularis. The authors prospectively evaluated the outcome after this procedure.

Methods. Thirty-six consecutive patients underwent unilateral resection of the pars interarticularis between August 1999 and July 2002. In 18 patients acute foraminal disc herniations compressed the nerve root against the superior pedicle; in the other 18 foraminal stenosis was secondary to degenerative changes. All patients, at each visit, completed the following questionnaires: visual analog scale for overall, leg, and back pain; the Prolo Functional Economic Rating scale; and the Pain Rating Index (PRI) of the Short-Form McGill Pain Questionnaire.

At 1 year, leg pain improved in 33 patients (91%). Low-back pain appeared or worsened in eight patients (22%; one in the acute herniation group and seven in the chronic degenerative group). Only one patient required lumbar fusion for pain. The Prolo economic and function scores improved in 21 (58%) and 27 (75%) patients, respectively. The PRI scores improved in 30 cases (83%). No spondylolisthesis was observed at any level at which resection had been performed.

Conclusions. Unilateral removal of the pars interarticularis is effective in relieving lumbar radicular symptoms in patients with intraforaminal entrapment. The incidence of low-back pain in patients with acute foraminal disc herniations does not increase as a result of this procedure. In patients with degenerative foraminal stenosis, unilateral resection of the pars interarticularis may be a better alternative to facetectomy and segmental fusion. This procedure may be a useful tool in spine surgery.

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Gabriel C. Tender, Scott Kutz, Deepak Awasthi, and Peter Rigby

✓ The surgical treatment for cerebral spinal fluid (CSF) fistulas provides closure of the bone and dural defects and prevents the recurrence of brain herniation and CSF fistula. The two main approaches used are the transmastoid and middle fossa ones. The authors review the results of performing a modified middle fossa approach with a vascularized temporalis muscle flap to create a barrier between the repaired dural and bone defects.

Fifteen consecutive cases of CSF fistulas treated at the authors' institution were retrospectively reviewed. All patients presented with otorrhea. Eleven patients had previously undergone ear surgery. A middle fossa approach was followed in all cases. The authors used a thin but watertight and vascularly preserved temporalis muscle flap that had been dissected from the medial side of the temporalis muscle and was laid intracranially on the floor of the middle fossa, between the repaired dura mater and petrous bone. The median follow-up period was 2.5 years. None of the patients experienced recurrence of otorrhea or meningitis. There was no complication related to the intracranial temporalis muscle flap (for example, seizures or increased intracranial pressure caused by muscle swelling). One patient developed hydrocephalus, which resolved after the placement of a ventriculoperitoneal shunt 2 months later.

The thin, vascularized muscle flap created an excellent barrier against the recurrence of CSF fistulas and also avoided the risk of increased intracranial pressure caused by muscle swelling. This technique is particularly useful in refractory cases.

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Everett G. Robert, Kenneth B. Fallon, and Gabriel C. Tender

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Gabriel C. Tender, Scott Kutz, Richard Baratta, and Rand M. Voorhies

Object. Lumbar radiculopathy secondary to foraminal stenosis can be treated by unilateral removal of the overlying pars interarticularis. The main concern after this procedure is spinal stability. In this study the authors evaluate the biomechanical behavior of the lumbar spine under torsional loading after unilateral progressive alterations, including resection of the pars.

Methods. Six human cadaveric L5—sacrum functional spinal units were tested while intact and then after the following sequential unilateral alterations: excision of the pars, capsulectomy, facetectomy, and discectomy. Specimens were tested in rotation by using a biomechanical testing machine, with an axial load of 280 N and torques of ± 7.5 Nm. The specimens remained in the machine throughout testing, and the angular displacements were recorded after each set of trials.

No statistically significant difference in any of the measured parameters was found between intact spines and those undergoing resection of the pars. For positive displacement (toward the side of the lesion), a significant difference from the intact condition was found after facetectomy and discectomy. For overall displacement (range of motion), spines treated with capsulectomy, facetectomy, and discectomy were significantly different from those in the intact condition.

Conclusions. Unilateral removal of the pars interarticularis does not increase spinal mobility in a statistically significant fashion. The clinical implication is that the spine may not become acutely unstable after unilateral resection of the pars.

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Gabriel C. Tender, John A. Butman, Edward H. Oldfield, and Russell R. Lonser

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Gabriel C. Tender, Caroline Davidson, Jessica Shields, Jared Robichaux, Joe Park, Clifford L. Crutcher, and Anthony M. DiGiorgio


Axial spinal pain generators are difficult to identify using current diagnostic modalities. Merging CT with SPECT (CT-SPECT) scans allows for accurate identification of areas with increased osteoblastic activity, which may reflect pain generators. In this study, the authors aimed to evaluate the degree of pain improvement in patients who underwent surgery, addressing primary pain generators identified by CT-SPECT.


The authors retrospectively reviewed all patients with chronic axial spine pain who underwent diagnostic CT-SPECT at their institution and analyzed pain improvement in those who underwent surgical treatment in order to determine whether CT-SPECT correctly identified the primary pain generator.


A total of 315 patients underwent diagnostic CT-SPECT between January 2014 and August 2018. Forty-eight patients underwent either cervical or lumbar fusion; there were 26 women (16 cervical, 10 lumbar) and 22 men (9 cervical, 13 lumbar). The overall axial spinal pain, as assessed through self-reporting of visual analog scale scores at 6 months postoperatively, improved from 9.04 ± 1.4 to 4.34 ± 2.3 (p = 0.026), with cervical fusion patients improving from 8.8 ± 1.8 to 3.92 ± 2.2 (p = 0.019) and lumbar fusion patients improving from 9.35 ± 0.7 to 4.87 ± 2.3 (p = 0.008).


CT-SPECT may offer a diagnostic advantage over current imaging modalities in identifying the primary pain generator in patients with axial spinal pain.