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George J. Kaptain, Jason P. Sheehan and Neal F. Kassell

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George J. Kaptain, Nathan E. Simmons, Robert E. Replogle and Louis Pobereskin

Object. The authors undertook a study to explore the predisposing risk factors, frequency of occurrence, and clinical implications of kyphosis following laminectomy for cervical spondylotic myelopathy (CSM).

Methods. Preoperative radiological studies were available in 46 patients with CSM who had undergone laminectomy. Records were reviewed to obtain demographic data and operative reports. Preoperative radiographs were assessed to determine spinal alignment. In a follow-up interview the authors established clinical outcome and patient satisfaction. Postoperative cervical alignment and mobility was also determined by assessing lateral neutral, flexion, and extension x-ray films.

Preoperatively, the cervical spine was shown to be kyphotic in four (9%) of 46, straight in 20 (43%) of 46, and lordotic in 22 (48%) of 46 patients. Nine (21%) of 42 patients with either straight or lordotic alignment demonstrated in the preoperative period developed kyphosis after surgery. Kyphosis developed in six (30%) of 20 patients in whom straight spinal alignment was demonstrated preoperatively and in only three (14%) of 22 patients in whom lordosis was found preoperatively. Clinically, 13 (29%) of 45 patients improved and 19 (42%) of 45 remained unchanged after an average 4-year follow-up period; 36 (80%) patients believed that their surgery was successful (one patient, who was mentally retarded, could not respond to the follow-up questionnaire). Spinal alignment was not predictive of outcome; cervical mobility as demonstrated on flexion and extension, however, correlated with improved functional performance (p = 0.005).

Conclusions. Kyphosis may develop in up to 21% of patients who have undergone laminectomy for CSM. Progression of the deformity appears to be more than twice as likely if preoperative radiological studies demonstrate a straight spine. In this study, clinical outcome did not correlate with either pre- or postoperative sagittal alignment.

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W. Jeffrey Elias, Nathan E. Simmons, George J. Kaptain, James B. Chadduck and Richard Whitehill

Object. The authors reviewed their series of patients to quantify clinical and radiographic complications in those who underwent a posterior lumbar interbody fusion (PLIF) procedure in which a threaded interbody cage (TIC) was implanted.

Methods. Sixty-seven patients underwent a posterior lumbar interbody fusion procedure in which a TIC was used. The authors excluded patients who underwent procedures in which other instrumentation was used or a nondorsal approach was performed. Fifteen percent of the cases (10 patients) were complicated by laceration of the dura. In three cases, bilateral implantation could not be performed. The average blood loss was 670 ml for all cases, and blood transfusion was required in 25% of the cases (17 patients). The rate of minor wound complication was 4.5% (three patients). One patient died. The average period of hospitalization was 4.25 days.

Twenty-eight patients (42%) experienced significant low-back pain 3 months postoperatively, and in 10 (15%) of these cases it persisted beyond 1 year. In 10 patients postoperative radiculopathy was demonstrated, and magnetic resonance imaging revealed epidural fibrosis in six patients, arachnoiditis in one, and a recurrent disc herniation in one. One patient incurred a permanent motor deficit with sexual dysfunction. Pseudarthrosis was suggested radiographically with evidence of motion on lateral flexion—extension radiographs (10 cases), lucencies around the implants (seven cases), and posterior migration of the cage (two cases).

Additional procedures (in 14 patients) consisted primarily of transverse process fusion with pedicle screw and plate augmentation for persistent back pain and radiographically demonstrated signs of spinal instability. In two patients with radiculopathy, migration of the TIC required that it be removed. Graft material that extruded from one implant necessitated its removal. In one patient scarectomy was performed.

Conclusions. Our high incidence of TIC-related complications in PLIF is inconsistent with that reported in previous studies.

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K. Michael Webb, George Kaptain, Jonas Sheehan and John A. Jane Sr.

Currently the posterior approach undertaken to perform cervical hemilaminectomy and foraminotomy provides sufficient exposure to treat the majority of lateral soft-disc herniations or osteophytes causing radiculopathy. Limitations imposed by the surgical field, however, often necessitate excessive retraction of the nerve root and epidural venous plexus, which may potentially exacerbate a preexisting radiculopathy or increase intraoperative blood loss. Partial resection of the inferior pedicle augments exposure and enlarges the neural foramen, thus facilitating decompression while minimizing manipulation of the nerve root and epidural venous plexus.

With the patient in the prone position, partial hemilaminectomy and foraminotomy are performed using a high-speed 3-mm diamond burr with continuous irrigation. The thecal sac and nerve root are exposed, and the overlying fibroareolar layer is coagulated and incised. With the nerve root protected and under direct vision, the superomedial portion of the inferior pedicle is removed. Nerve root decompression is then performed through this augmented exposure.

Partial excision of the pedicle allows for more expeditious removal of the pathological elements causing cervical radiculopathy and requires minimal manipulation of the nerve root and epidural venous plexus. This procedure results in a potential decrease in transient postoperative radiculopathy and minimization of intraoperative blood loss. In addition, the resulting foraminal enlargement enhances the decompression provided by traditional foraminotomy, even if discectomy is not performed.

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Tord D. Alden, George J. Kaptain, John A. Jane Jr. and John A. Jane Sr.

The use of chymopapain in the treatment of lumbar disc herniation has been widely studied since Smith first described its use in humans in 1963. The authors describe the use of chymopapain intraoperatively in open lumbar microdiscectomy in 63 patients. When combined with the results of a previous study performed at the same institution, the authors found that this technique significantly reduces the rate of recurrent disc herniation when compared with traditional laminotomy with discectomy. This procedure maximizes the benefits of each approach taken separately, allowing for decompression of the nerve root from a free fragment or sequestered disc and preventing recurrence through dissolution of the nucleus pulposus. Overall, outcome was good or excellent immediately postoperatively in 73% of the 63 patients and in 64% at last follow-up evaluation. Additionally, this procedure is safe with no complications noted in the immediate perioperative period or at follow-up evaluation.

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George J. Kaptain, Christopher I. Shaffrey, Tord D. Alden, Jacob N. Young and Richard Whitehill

Although the expectation of monetary compensation has been associated with failures in lumbar discectomy, the issue has not been investigated in patients undergoing cervical disc surgery. The authors analyzed the relationship between economic forms of secondary gain and surgical outcome in a group of patients with a common pay scale, retirement plan, and disability program.

All procedures were performed at the Portsmouth Naval Medical Center between 1993 and 1995; active-duty military servicepersons treated for cervical radiculopathy were prospectively included. Clinical, demographic, and financial factors were analyzed to determine which were predictive of outcome. Financial data were used to create a compensation incentive, which is proportional to the patient's rank, years of service, potential disability, retirement eligibility, and base pay and reflects the monetary incentive of disability. The results of cervical surgery were compared to a previously reported companion population of patients treated for lumbar disc disease. A good outcome was defined as a return to active duty, whereas a referral for disability was considered a poor surgical result. A 100% follow-up rate was obtained for 269 patients who underwent 307 cervical operations. Only 16% (43 of 269) of patients who underwent cervical operation received disability, whereas 24.7% (86 of 348) of patients who underwent lumbar discectomy obtained a poor result (p = 0.0082). Although economic forms of secondary gain were not associated with a poor outcome in cervical disease, both the rank (p = 0.002) and duration (p = 0.03) of an individual's military career were significant factors (p = 0.02). Of the medical variables tested, multilevel surgery (p = 0.03) and revision operations at the same level (p = 0.03) were associated with referral for medical discharge.

Secondary gain in the form of economic compensation influences outcome in lumbar but not cervical disc surgery patients; the increased rate of disability referral in patients who underwent lumbar discectomy may reflect an expectation of economic compensation. Social factors that are independent of the anticipation of economic compensation seem to influence the outcome in cervical disc surgery patients.

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Shreeram Deshpande, George J. Kaptain and Louis H. Pobereskin

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Clival encephalocele

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George J. Kaptain, David A. Vincent, Jason P. Sheehan and Edward R. Laws Jr.

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