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James S. Harrop and Gregory J. Przybylski

Odontoid fractures can be successfully treated with anterior screw fixation. Odontoid fractures commonly occur in older patients who may have significant osteopenia. The authors examined the use of a bone substitute to overcome limitations encountered during a procedure in which anterior odontoid screw fixation is performed.

Two elderly patients with displaced, reducible acute odontoid fractures underwent anterior odontoid screw fixation. The intraoperative failure of the anterior vertebral cortex from osteopenic bone and failure to achieve complete contact between the dens and axis were encountered. The defects were supplemented by using the osteoconductive agent Norian. Outcome was evaluated to determine the utility of this method.

Occasional intraoperative failure of anterior odontoid screw fixation may be encountered. Supplementation of bone defects with this osteoconductive agent may facilitate successful bone union in selected patients.

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Daniel R. Fassett, James S. Harrop and Alexander R. Vaccaro

✓The authors describe a rare case of Brown–Séquard syndrome as a result of indirect, concussive trauma to the spinal cord from a gunshot wound (GSW) and present the magnetic resonance (MR) imaging evidence obtained in this interesting case. The patient was shot in the anterior neck and the bullet passed through the lateral aspect of the C-7 lateral mass and transverse process. Bone fragments from the lateral aspect of C-7 were displaced posteriorly into the soft tissues, but no abnormalities were noted within the spinal canal except for high-intensity signal on T2-weighted MR imaging within the right side of the spinal cord. This is the first reported case to provide MR imaging evidence of a Brown–Séquard spinal cord injury as a result of indirect trauma (concussive injury) from a GSW.

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Pascal Jabbour, Michael Fehlings, Alexander R. Vaccaro and James S. Harrop

In this paper the authors review spine trauma and spinal cord injury (SCI) in the geriatric population. The information in this study was compiled through a literature review of clinical presentation and management of SCI in the elderly population. This was done to define, identify, and specify treatment algorithms and management strategies in this unique patient population.

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Gregory J. Przybylski, James S. Harrop and Alexander R. Vaccaro

Object

Acute respiratory failure has been observed in patients after external immobilization for displaced odontoid fractures. The authors studied the frequency of respiratory deterioration in the acute management of displaced Type II odontoid fractures to identify patients at risk for respiratory failure.

Methods

The authors conducted a retrospective review of a consecutive series of 89 patients with odontoid fractures who were treated over a 5-year period to identify 53 patients with displaced Type II odontoid fractures. Patient demographics, degree of displacement, respiratory status, treatment method, and outcome were examined. Of the 32 patients with posteriorly displaced fractures, 13 experienced acute respiratory compromise, whereas only one of 21 patients with anteriorly displaced fractures had respiratory difficulties (p = 0.0032). The average posterior displacement was 6.9 mm. All 13 were initially managed using flexion traction for reduction of these fractures. Two of these patients died because of failure to emergently secure an airway during closed treatment of the fracture.

Conclusions

Frequent respiratory deterioration during acute closed reduction of posteriorly displaced Type II odontoid fractures was observed, whereas respiratory failure in patients with anteriorly displaced fractures was rare. The use of the flexed cervical position in the setting of retropharyngeal edema rather than the direction of the displacement may substantially increase the risk of respiratory failure. This may prompt early elective nasotracheal intubation during closed reduction of posteriorly displaced Type II odontoid fractures that require a flexed posture.

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James S. Harrop, Ashwini D. Sharan and Gregory J. Przybylski

Object

Cervical spinal cord injury (SCI) after odontoid fracture is unusual. To identify predisposing factors, the authors evaluated a consecutive series of patients who sustained SCI from odontoid fractures.

Methods

A consecutive series of 5096 admissions to the Delaware Valley Regional Spinal Cord Injury Center were reviewed, and 126 patients with neurological impairment at the C1–3 levels were identified. Seventeen patients had acute closed odontoid fractures with neurological deficit. Various parameters including demographics, mechanisms of injury, associated injuries, fracture types/displacements, and radiographic cervical canal dimensions were compared between “complete” and “incomplete” spinal cord injured–patients as well as with neurologically intact patients who had suffered odontoid fractures. There were similar demographics, mechanisms of injury, associated injuries, fracture type/displacement, and canal dimensions in patients with complete and incomplete SCIs. However, only patients with complete injury were ventilator dependent. In comparison with patients with intact spinal cords, spinal cord–injured patients were more commonly males (p = 0.011) who had sustained higher velocity injuries (p = 0.027). The computerized tomography scans of 11 of 17 neurologically impaired patients were compared with those of a random sample of 11 patients with intact spinal cords. Although the anteroposterior diameter (p = 0.028) and cross-sectional area (p = 0.0004) of the cervical spinal canal at the C–2 level were smaller in impaired patients, the displacement of the fragment was not different.

Conclusions

Odontoid fractures are an infrequent cause of SCI. Patients with these injuries typically are males who have smaller spinal canals and have sustained high velocity injuries.

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James S. Harrop, Ashwini D. Sharan, Edward H. Scheid Jr., Alexander R. Vaccaro and Gregory J. Przybylski

Object. The authors sought to identify variables that predispose patients with acute American Spinal Injury Association (ASIA) Grade A cervical spinal cord injury (SCI) to require tracheostomies for ventilator support or airway protection.

Methods. A retrospective analysis was performed of 178 consecutive patients with a cervical ASIA Grade A SCI who were admitted through the Delaware Valley SCI Center at Thomas Jefferson Hospital during a 6-year period. Exclusion criteria included injury occurring more than 48 hours prior to admission, death within 14 days of admission or nontraumatic SCI. Twenty-two patients were excluded based on these criteria. Parameters evaluated in the remaining population (156 patients) included demographics, cervical vertebral ASIA level, tracheostomy placement, pneumonia, premorbid pulmonary disease, smoking history, evidence of direct thoracic/lung trauma, operative intervention, associated appendicular trauma, and preexisting medical comorbidities.

The ASIA classification of the 156 patients included in this analysis were C-2 (eight), C-3 (11), C-4 (64), C-5 (36), C-6 (20), C-7 (13), and C-8 (four). Tracheostomies were performed in 107 of these 156 patients. Statistical analysis revealed a significant relationship between tracheostomy and patient age (p = 0.0048), preexisting medical conditions (p = 0.0417), premorbid lung disease (p = 0.0177), higher cervical ASIA level (p < 0.0001), and the presence of pneumonia (p < 0.0001). No patient with a C-8 ASIA A injury required tracheostomy, whereas all C-2 and C-3 ASIA A—injured patients underwent tracheostomies. Patients older than 45 years of age with ASIA A levels between C-4 and C-7 more commonly required tracheostomy (p < 0.005) than patients younger than 45 years of age.

Conclusions. Several risk factors were identified that corresponded to the frequent tracheostomy placement in the acute injury phase after complete cervical SCI. Early tracheostomy may be considered in patients with multiple risk factors to reduce duration of stay in the intensive care unit and facilitate ventilatory weaning.

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George M. Ghobrial, David W. Cadotte, Kim Williams Jr., Michael G. Fehlings and James S. Harrop

OBJECT

The use of intrawound vancomycin is rapidly being adopted for the prevention of surgical site infection (SSI) in spinal surgery. At operative closure, the placement of vancomycin powder in the wound bed—in addition to standard infection prophylaxis—can provide high concentrations of antibiotics with minimal systemic absorption. However, despite its popularity, to date the majority of studies on intrawound vancomycin are retrospective, and there are no prior reports highlighting the risks of routine treatment.

METHODS

A MEDLINE search for pertinent literature was conducted for studies published between 1966 and May 2015 using the following MeSH search terms: “intrawound vancomycin,” “operative lumbar spine complications,” and “nonoperative lumbar spine complications.” This was supplemented with references and known literature on the topic.

RESULTS

An advanced MEDLINE search conducted on May 6, 2015, using the search string “intrawound vancomycin” found 22 results. After a review of all abstracts for relevance to intrawound vancomycin use in spinal surgery, 10 studies were reviewed in detail. Three meta-analyses were evaluated from the initial search, and 2 clinical studies were identified. After an analysis of all of the identified manuscripts, 3 additional studies were included for a total of 16 studies. Fourteen retrospective studies and 2 prospective studies were identified, resulting in a total of 9721 patients. A total of 6701 (68.9%) patients underwent treatment with intrawound vancomycin. The mean SSI rate among the control and vancomycin-treated patients was 7.47% and 1.36%, respectively. There were a total of 23 adverse events: nephropathy (1 patient), ototoxicity resulting in transient hearing loss (2 patients), systemic absorption resulting in supratherapeutic vancomycin exposure (1 patient), and culture-negative seroma formation (19 patients). The overall adverse event rate for the total number of treated patients was 0.3%.

CONCLUSIONS

Intrawound vancomycin use appears to be safe and effective for reducing postoperative SSIs with a low rate of morbidity. Study disparities and limitations in size, patient populations, designs, and outcomes measures contribute significant bias that could not be fully rectified by this systematic review. Moreover, care should be exercised in the use of intrawound vancomycin due to the lack of well-designed, prospective studies that evaluate the efficacy of vancomycin and include the appropriate systems to capture drug-related complications.

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George M. Ghobrial, Thana Theofanis, Bruce V. Darden, Paul Arnold, Michael G. Fehlings and James S. Harrop

OBJECT

Unintended durotomy is a common occurrence during lumbar spinal surgery, particularly in surgery for degenerative spinal conditions, with the reported incidence rate ranging from 0.3% to 35%. The authors performed a systematic literature review on unintended lumbar spine durotomy, specifically aiming to identify the incidence of durotomy during spinal surgery for lumbar degenerative conditions. In addition, the authors analyzed the incidence of durotomy when minimally invasive surgical approaches were used as compared with that following a traditional midline open approach.

METHODS

A MEDLINE search using the term “lumbar durotomy” (under the 2015 medical subject heading [MeSH] “cerebrospinal fluid leak”) was conducted on May 13, 2015, for English-language medical literature published in the period from January 1, 2005, to May 13, 2015. The resulting papers were categorized into 3 groups: 1) those that evaluated unintended durotomy rates during open-approach lumbar spinal surgery, 2) those that evaluated unintended durotomy rates during minimally invasive spine surgery (MISS), and 3) those that evaluated durotomy rates in comparable cohorts undergoing MISS versus open-approach lumbar procedures for similar lumbar pathology.

RESULTS

The MEDLINE search yielded 116 results. A review of titles produced 22 potentially relevant studies that described open surgical procedures. After a thorough review of individual papers, 19 studies (comprising 15,965 patients) pertaining to durotomy rates during open-approach lumbar surgery were included for analysis. Using the Oxford Centre for Evidence-Based Medicine (CEBM) ranking criteria, there were 7 Level 3 prospective studies and 12 Level 4 retrospective studies. In addition, the authors also included 6 studies (with a total of 1334 patients) that detailed rates of durotomy during minimally invasive surgery for lumbar degenerative disease. In the MISS analysis, there were 2 prospective and 4 retrospective studies. Finally, the authors included 5 studies (with a total of 1364 patients) that directly compared durotomy rates during open-approach versus minimally invasive procedures. Studies of open-approach surgery for lumbar degenerative disease reported a total of 1031 durotomies across all procedures, for an overall durotomy rate of 8.11% (range 2%–20%). Prospectively designed studies reported a higher rate of durotomy than retrospective studies (9.57% vs 4.32%, p = 0.05). Selected MISS studies reported a total of 93 durotomies for a combined durotomy rate of 6.78%. In studies of matched cohorts comparing open-approach surgery with MISS, the durotomy rates were 7.20% (34 durotomies) and 7.02% (68), respectively, which were not significantly different.

CONCLUSIONS

Spinal surgery for lumbar degenerative disease carries a significant rate of unintended durotomy, regardless of the surgical approach selected by the surgeon. Interpretation of unintended durotomy rates for lumbar surgery is limited by a lack of prospective and cohort-matched controlled studies.

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James S. Harrop, Gregory J. Przybylski, Alexander R. Vaccaro and Kennedy Yalamanchili

Object

Type II odontoid fractures are the most common trauma-related dens fracture. Although Type III odontoid fractures have a high union rate when external immobilization is applied, Type II fractures are associated with high rates of nonunion, particularly in elderly patients and those with posteriorly displaced fractures or fractures displaced by more than 6 mm. Because elderly patients may not also tolerate external immobilization in a halo vest, alternative techniques should be explored to identify a method for managing these higher-risk patients. In this study the authors examine the efficacy of anterior odontoid screw fixation in a high-risk group of 10 elderly patients (> 65 years of age) treated for Type II odontoid fractures.

Methods

A retrospective review of all patients with Type II odontoid fractures treated at two institutions between September 1997 and March 2000 was performed. Demographic data, neurological examination, fracture type and degree of displacement, treatment method, and outcome data were examined at discharge. Ten patients older than 65 years who had sustained a trauma-related odontoid fracture and had undergone an anterior odontoid screw placement procedure were retrospectively reviewed. Fracture displacement (mean 6.6 mm) was observed in all but one patient, and in seven there were posteriorly displaced fractures. Seven were successfully treated with anterior screw fixation and external orthosis alone; in one patient in whom poor intraoperative screw purchase had been observed, the fracture healed after undergoing halo vest therapy. Only one patient was shown to develop a nonunion requiring a subsequent posterior fusion procedure.

Conclusions

Odontoid screw fixation can be safely performed in elderly patients, and frequent bone union is demonstrated. However, osteopenia may preclude adequate screw fixation in some patients.

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James S. Harrop, Gabriel E. Hunt Jr. and Alexander R. Vaccaro

Conus medullaris syndrome (CMS) and cauda equina syndrome (CES) are complex neurological disorders that can be manifested through a variety of symptoms. Patients may present with back pain, unilateral or bilateral leg pain, paresthesias and weakness, perineum or saddle anesthesia, and rectal and/or urinary incontinence or dysfunction. Although patients typically present with acute disc herniations, traumatic injuries at the thoracolumbar junction at the terminal portion of the spinal cord and cauda equina are also common. Unfortunately, a precise understanding of the pathophysiology and optimal treatments, including the best timing of surgery, has yet to be elucidated for either traumatic CES or CMS. In this paper the authors review the current literature on traumatic conus medullaris and cauda equina injuries and available treatment options.