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W. Jeffrey Elias, Patrick Ireland and James B. Chadduck

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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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James B. Chadduck, J. Robert Sneyd and Louis H. Pobereskin

Object. The authors studied the effect of immediate postoperative administration of bupivacaine in patients who underwent a lumbar decompressive procedure.

Methods. In this randomized double-blind trial, 50 patients who underwent elective lumbar decompression after induction of general anesthetic received a postoperative bilateral paravertebral 40-ml intramuscular application of either saline (0.9%) or bupivacaine (0.25%). For delivering morphine, both groups used a patient-controlled analgesia system for 24 hours postsurgery. Pain scores, 10-cm visual analog scale scores, and morphine consumption were similar between groups with no significant differences (p > 0.05).

Conclusions. Results of subgroup analysis suggested strongly that perioperative administration of methylprednisolone in a sustained-release preparation was associated with a reduction in postoperative pain (p < 0.05).

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Bernhard Sutter, Adam Arthur, Jeffrey Laurent, James Chadduck, Gerhard Friehs, Georg Clarici and Gerhard Pendl

Surgical treatment of intrameduallary spinal cord metastases (ISCM) has become increasingly effective in recent years. The advent of new imaging techniques combined with an enhanced understanding of the natural history of these tumors has improved the effectiveness of the available treatment options. The authors present three new cases of ISCM successfully treated with surgery. A review of 129 cases found in the literature is also discussed. Characteristic symptomology and presentation are reviewed with an eye toward improving diagnostic methodology. The natural history of ISCM is divided into three phases. Surgical intervention should be used early in phase 2.

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Charles G. diPierro, Gregory A. Helm, Christopher I. Shaffrey, James B. Chadduck, Scott L. Henson, Jacek M. Malik, Thomas A. Szabo, Nathan E. Simmons and John A. Jane

✓ A new surgical technique for the treatment of lumbar spinal stenosis features extensive unilateral decompression with undercutting of the spinous process and, to preserve stability, uses contralateral autologous bone fusion of the spinous processes, laminae, and facets. The operation was performed in 29 patients over a 19-month period ending in December of 1991. All individuals had been unresponsive to conservative treatment and presented with low-back pain in addition to signs and symptoms consistent with neurogenic claudication or radiculopathy. Nine had undergone previous lumbar decompressive surgery. The minimum and mean postoperative follow-up times were 2 and 2 1/2 years, respectively. The mean patient age was 64 years; only two patients were younger than 50 years of age.

Of the patients with neurogenic claudication, 69% reported complete pain relief at follow-up review. Of those with radicular symptoms, 41% had complete relief and 23% had mild residual pain that was rated 3 or less on a pain—functionality scale of 0 to 10. For the entire sample, this surgery decreased pain from 9.2 to 3.3 (p < 0.0001) on the scale. Sixty-nine percent of patients were satisfied with surgery. Low-back pain was significantly relieved in 62% of all patients (p < 0.0001). Low-back pain relief correlated negatively with number of levels decompressed (p < 0.05). To assess fusion, follow-up flexion/extension radiographs were obtained, and no motion was detected at the surgically treated levels in any patient.

The results suggest that this decompression procedure safely and successfully treats not only the radicular symptoms caused by lateral stenosis but also the neurogenic claudication symptoms associated with central stenosis. In addition, the procedure, by using contralateral autologous bone fusion along the laminae and spinous processes, can preserve stability without instrumentation.

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