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Jens R. Chapman, Paul A. Anderson, Christopher Pepin, Sean Toomey, David W. Newell and M. Sean Grady

✓ Fractures, tumors, and other causes of instability at the cervicothoracic junction pose diagnostic and treatment challenges. The authors report on 23 patients with instability of the cervicothoracic region, which was treated with posterior plate fixation and fusion between the lower cervical and upper thoracic spine. During operation AO reconstruction plates with 8- or 12-mm hole spacing were affixed to the spine using screws in the cervical lateral masses and the thoracic pedicles. Postoperative immobilization consisted of the patient's wearing a simple external brace for 2 months. The following parameters were analyzed during the pre- and postoperative treatment period: neurological status, spine anatomy and reconstruction, and complications. Follow up consisted of clinical and radiographic examinations (mean duration of follow up, 15.4 months; range, 6–41 months).

No neurovascular or pulmonary complications arose from surgery. All patients achieved a solid arthrodesis based on flexion-extension radiographs. There was no significant change in angulation during the postoperative period, but one patient had an increase in translation that was not clinically significant. There were no hardware complications that required reoperation. One patient requested hardware removal in hopes of reducing postoperative pain in the cervicothoracic region. One postoperative wound infection required debridement but not hardware removal. The authors conclude that posterior plate fixation is a satisfactory method of treatment of cervicothoracic instability.

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Gerald A. Grant, Sohail K. Mirza, Jens R. Chapman, H. Richard Winn, David W. Newell, Dolors T. Jones and M. Sean Grady

Object. The authors retrospectively reviewed 121 patients with traumatic cervical spine injuries to determine the risk of neurological deterioration following early closed reduction.

Methods. After excluding minor fractures and injuries without subluxation, the medical records and imaging studies (computerized tomography and magnetic resonance [MR] images) of 82 patients with bilateral and unilateral locked facet dislocations, burst fractures, extension injuries, or miscellaneous cervical fractures with subluxation were reviewed. Disc injury was defined on MR imaging as the presence of herniation or disruption: a herniation was described as deforming the thecal sac or nerve roots, and a disruption was defined as a disc with high T2-weighted signal characteristics in a widened disc space. Fifty-eight percent of patients presented with complete or incomplete spinal cord injuries. Thirteen percent of patients presented with a cervical radiculopathy, 22% were intact, and 9% had only transient neurological deficits in the field.

Early, rapid closed reduction, using serial plain radiographs or fluoroscopy and Gardner—Wells craniocervical traction, was achieved in 97.6% of patients. In two patients (2.4%) closed reduction failed and they underwent emergency open surgical reduction. The average time to achieve closed reduction was 2.1 ± 0.24 hours (standard error of the mean).

The incidence of disc herniation and disruption in the 80 patients who underwent postreduction MR imaging was 22% and 24%, respectively. However, the presence of disc herniation or disruption did not affect the degree of neurological recovery, as measured by American Spinal Injury Association motor score and the Frankel scale following early closed reduction. Only one (1.3%) of 80 patients deteriorated, but that occurred more than 6 hours following closed reduction.

Conclusions. Although disc herniation and disruption can occur following all types of traumatic cervical fracture subluxations, the incidence of neurological deterioration following closed reduction in these patients is rare. The authors recommend early closed reduction in patients presenting with significant motor deficits without prior MR imaging.

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Charles Kuntz IV, Sohail K. Mirza, Abel D. Jarell, Jens R. Chapman, Christopher I. Shaffrey and David W. Newell

The optimum treatment of Type II odontoid fractures in the geriatric population remains controversial. Coexisting medical conditions encountered in the elderly patient often increase operative risk and make cervical immobilization difficult to tolerate. Previous studies have shown increased morbidity and mortality and decreased fusion rates for Type II odontoid fractures treated with cervical orthoses in the geriatric population, whereas low morbidity and mortality rates with operative management have recently been documented. To investigate the role of surgical and nonsurgical treatment, a retrospective analysis was performed of patients with Type II odontoid fractures who were at least 65 years old and were consecutively admitted to a single medical center from 1994 to 1998. Twenty patients met inclusion criteria. In 12 patients nonsurgical management with a cervical orthosis was attempted. The nonsurgical management failed early in six patients, with one associated death. Eleven patients were treated surgically with either anterior odontoid screw fixation or posterior C1–2 transarticular screw fixation and modified Gallie fusion. Postoperatively one patient required revision of the C1–2 transarticular screws, and there was one death. In conclusion Type II odontoid fractures in this elderly population were associated with early 10% morbidity and 20% mortality rates. Nonsurgical management of Type II odontoid fractures failed early in six (50%) of 12 patients, whereas surgical treatment failed early in one of 11 (9%) patients. Both the nonsurgical and surgical treatments resulted in approximately 10% morbidity and 10% mortality rates.

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James M. Schuster, Anthony M. Avellino, Frederick A. Mann, Allain A. Girouard, M. Sean Grady, David W. Newell, H. Richard Winn, Jens R. Chapman and Sohail K. Mirza

Object. The use of structural allografts in spinal osteomyelitis remains controversial because of the perceived risk of persistent infection related to a devitalized graft and spinal hardware. The authors have identified 47 patients over the last 3.5 years who underwent a surgical decompression and stabilization procedure in which fresh-frozen allografts were used after aggressive removal of infected and devitalized tissue. The patients subsequently underwent 6 weeks of postoperative antibiotic therapy (12 months for those with tuberculosis [TB]).

Methods. Follow-up data included results of serial clinical examinations, radiography, laboratory analysis (erythrocyte sedimentation rate and white blood cell count), and clinical outcome questionnaires. Of the original 47 patients (14 women and 33 men, aged 14–83 years), 39 were available for follow up. The average follow-up period at the time this article was submitted was 17 ± 9 months (median 14 months, range 6–45 months). In the majority of cases (57%), a Staphylococcus species was the infectious organism. Predisposing risk factors included intravenous drug abuse (IVDA), previous surgery, diabetes, TB, and concurrent infections. During the follow-up period only two patients suffered recurrent infection at a contiguous level; both had a history of IVDA and one also had a chronic excoriating skin condition. No other recurrent infections have been identified, and no patient has required reoperation for persistent infection or allograft/hardware failure.

Conclusions. It is the authors' opinion that the use of structural allografts in combination with aggressive tissue debridement and adjuvant antibiotic therapy provide a safe and effective therapy in cases of spinal osteomyelitis requiring surgery.

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Gregory C. Wiggins, Sohail Mirza, Carlo Bellabarba, G. Alex West, Jens R. Chapman and Christopher I. Shaffrey

Object

Anterior decompression and stabilization for thoracic spinal tumors often involves a thoracotomy and can be associated with surgical approach–related complications. An alternative to thoracotomy is surgery via a costotransversectomy exposure.

To delineate the risks of surgery, the authors reviewed their prospective database for patients who had undergone surgery via either of these approaches for thoracic or thoracolumbar tumors. The complications were recorded and graded based on severity and risk of impact on patient outcome.

Methods

Between September 1995 and April 2001, the authors performed 29 costotransversectomies (Group 1) and 18 thoracolumbar or combined (Group 2) approaches as initial operations for thoracic neoplasms. The age, sex, pre-operative motor score, and preoperative Frankel grade did not significantly differ between the groups. In the costotransversectomy group there were greater numbers of metastases, upper thoracic procedures, and affected vertebral levels; additionally, the comorbidity rate based on Charlson score, was higher. The mean Frankel grades at discharge were not significantly different whereas the discharge motor and last follow-up motor scores were better in Group 2. There were 11 Group 1 and seven Group 2 patients who suffered at least one complication. The number or patients with complications, the mean number of complications, and severity of complications did not differ between the groups.

Conclusions

Compared with anterior or combined approaches, the incidence and severity of perioperative complications in the surgical treatment of thoracic and thoracolumbar spinal tumors is similar in patients who undergo costotransversectomy. Costotransversectomy may be the preferred operation in patients with significant medical comorbidity or tumors involving more than one thoracic vertebra.

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Saadi Ghatan, David W. Newell, M. Sean Grady, Sohail K. Mirza, Jens R. Chapman, Frederick A. Mann and Richard G. Ellenbogen

✓ Children younger than 3 years of age represent a distinct subpopulation of patients at particular risk for high cervical and craniovertebral injuries. There are few descriptions of survivors of severe craniocervical trauma among the very young, and scarce data exist regarding management after initial emergency stabilization.

The authors describe three children, age 1 to 32 months, who presented with craniocervical junction injuries. Variable neurological findings were observed at presentation (cranial nerve deficits, obtundation, and moderate-to-severe quadriparesis). All three were treated with prolonged immobilization and have recovered with minimal to no neurological deficit.

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Carlo Bellabarba, Sohail K. Mirza, G. Alexander West, Frederick A. Mann, Andrew T. Dailey, David W. Newell and Jens R. Chapman

Object

Craniocervical dissociation (CCD) is a highly unstable and usually fatal injury resulting from osseoligamentous disruption between the occiput and C-2. The purpose of this study was to elucidate systematic factors associated with delays in diagnosing and treating this life-threatening condition and to introduce an injury-severity classification with therapeutic implications.

Methods

In a retrospective evaluation of institutional databases, the authors reviewed medical records and original images obtained in 17 consecutive surviving patients with CCD treated between 1994 and 2002. Images and clinical results of treatment were evaluated, emphasizing the timing of diagnosis, clinical effect of delayed diagnosis, potential clinical or imaging warning signs, and response to treatment.

Craniocervical dissociation was identified or suspected on the initial lateral cervical spine radiograph acquired in two patients (12%) and was diagnosed based on screening computerized tomography findings in two additional patients (12%). A retrospective review of initial lateral x-ray films showed an abnormal dens–basion interval in 16 patients (94%). The 2-day average delay in diagnosis was associated with profound neurological deterioration in five patients (29%). Neurological status declined in one patient after a fixation procedure was performed. There were no cases of craniocervical pseudarthrosis or hardware failure during a mean 26-month follow-up period. The mean American Spinal Injury Association (ASIA) motor score of 50 improved to 79, and the number of patients with useful motor function (ASIA Grade D or E) increased from seven (41%) preoperatively to 13 (76%) postoperatively.

Conclusions

The diagnosis of CCD was frequently delayed, and the delay was associated with an increased likelihood of neurological deterioration. Early diagnosis and spinal stabilization protected against worsening spinal cord injury.

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Richard Bransford, Fangyi Zhang, Carlo Bellabarba, Mark Konodi and Jens R. Chapman

Object

Symptomatic thoracic disc herniations (TDHs) are relatively uncommon and are typically treated with an anterior approach. Various posterior surgical approaches have been developed to treat TDH, but the gold standard remains transthoracic decompression. Certain patients have comorbidities and herniation aspects that are not optimally treated with an anterior approach. A transfacet pedicle-sparing approach was first described in 1995, but outcomes and complications have not been well described. The objective of this study was to assess outcomes and complications in a consecutive series of patients with TDH undergoing posterior transfacet decompression and discectomy with posterior instrumentation and fusion.

Methods

Eighteen consecutive patients undergoing operative management of TDH were identified from a tertiary care referral database. All patients underwent a transfacet pedicle-sparing decompression and segmental instrumentation with interbody fusion. Outcomes and complications were retrospectively assessed in this patient series. Clinical records were scrutinized to assess levels and types of disc herniation; blood loss; pre- and postoperative motor scores, Nurick grades, and visual analog pain scale scores; and complications such as wrong-level surgery, infection, seroma, and neurological changes. Pre- and postoperative imaging studies were reviewed to assess levels and types of herniation, alignment, and accuracy of instrumentation.

Results

Of the 18 patients, 9 had TDHs at multiple levels. The patients presented with symptoms including myelopathy, axial back pain, urinary symptoms, and radiculopathy and radiological evidence of 29 compressive TDHs ranging from T1–2 to T12–L1. Discs were classified as central (10) or paracentral (19). All discs were successfully removed with no incidence of wrong-level surgery or CSF leak. The mean estimated blood loss was 870 ml with no dural tears. Nurick grades improved on average from 2.5 to 1.9. All patients reported improvement in symptoms compared with preoperative status. The mean visual analog scale score improved from 59 to 21. Sixteen of the 18 patients spent an average of 4.2 days in the hospital; the 2 other patients spent 58 and 69 days. The average duration of follow-up was 12.2 months in 14 patients; 4 patients were lost to follow-up. Twelve patients had no complications. Five patients developed postoperative wound infections or seromas requiring additional operative debridement. One patient had a misplaced screw and suboptimally positioned interbody graft requiring revision. One transient neurological deterioration (American Spinal Injury Association [ASIA] D to ASIA B) occurred postoperatively associated with an inferior segment fracture 20 days after surgery. This necessitated extending the fusion caudally; the patient subsequently experienced a full return to better-than-baseline neurological status.

Conclusions

A modified transfacetal pedicle-sparing approach combined with short segmental fusion offers a safe means of achieving concurrent decompression and segmental stabilization and is an option for certain subtypes of TDH. Although 6 patients required additional surgery for postoperative complications, all patients experienced improvement relative to their preoperative status.

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Michael G. Fehlings, Justin S. Smith, Branko Kopjar, Paul M. Arnold, S. Tim Yoon, Alexander R. Vaccaro, Darrel S. Brodke, Michael E. Janssen, Jens R. Chapman, Rick C. Sasso, Eric J. Woodard, Robert J. Banco, Eric M. Massicotte, Mark B. Dekutoski, Ziya L. Gokaslan, Christopher M. Bono and Christopher I. Shaffrey

Object

Rates of complications associated with the surgical treatment of cervical spondylotic myelopathy (CSM) are not clear. Appreciating these risks is important for patient counseling and quality improvement. The authors sought to assess the rates of and risk factors associated with perioperative and delayed complications associated with the surgical treatment of CSM.

Methods

Data from the AOSpine North America Cervical Spondylotic Myelopathy Study, a prospective, multicenter study, were analyzed. Outcomes data, including adverse events, were collected in a standardized manner and externally monitored. Rates of perioperative complications (within 30 days of surgery) and delayed complications (31 days to 2 years following surgery) were tabulated and stratified based on clinical factors.

Results

The study enrolled 302 patients (mean age 57 years, range 29–86) years. Of 332 reported adverse events, 73 were classified as perioperative complications (25 major and 48 minor) in 47 patients (overall perioperative complication rate of 15.6%). The most common perioperative complications included minor cardiopulmonary events (3.0%), dysphagia (3.0%), and superficial wound infection (2.3%). Perioperative worsening of myelopathy was reported in 4 patients (1.3%). Based on 275 patients who completed 2 years of follow-up, there were 14 delayed complications (8 minor, 6 major) in 12 patients, for an overall delayed complication rate of 4.4%. Of patients treated with anterior-only (n = 176), posterior-only (n = 107), and combined anterior-posterior (n = 19) procedures, 11%, 19%, and 37%, respectively, had 1 or more perioperative complications. Compared with anterior-only approaches, posterior-only approaches had a higher rate of wound infection (0.6% vs 4.7%, p = 0.030). Dysphagia was more common with combined anterior-posterior procedures (21.1%) compared with anterior-only procedures (2.3%) or posterior-only procedures (0.9%) (p < 0.001). The incidence of C-5 radiculopathy was not associated with the surgical approach (p = 0.8). The occurrence of perioperative complications was associated with increased age (p = 0.006), combined anterior-posterior procedures (p = 0.016), increased operative time (p = 0.009), and increased operative blood loss (p = 0.005), but it was not associated with comorbidity score, body mass index, modified Japanese Orthopaedic Association score, smoking status, anterior-only versus posterior-only approach, or specific procedures. Multivariate analysis of factors associated with minor or major complications identified age (OR 1.029, 95% CI 1.002–1.057, p = 0.035) and operative time (OR 1.005, 95% CI 1.002–1.008, p = 0.001). Multivariate analysis of factors associated with major complications identified age (OR 1.054, 95% CI 1.015–1.094, p = 0.006) and combined anterior-posterior procedures (OR 5.297, 95% CI 1.626–17.256, p = 0.006).

Conclusions

For the surgical treatment of CSM, the vast majority of complications were treatable and without long-term impact. Multivariate factors associated with an increased risk of complications include greater age, increased operative time, and use of combined anterior-posterior procedures.

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James S. Harrop, Robin Hashimoto, Dan Norvell, Annie Raich, Bizhan Aarabi, Robert G. Grossman, James D. Guest, Charles H. Tator, Jens Chapman and Michael G. Fehlings

Object

Using a systematic approach, the authors evaluated the current utilization, safety, and effectiveness of cellular therapies for traumatic spinal cord injuries (SCIs) in humans.

Methods

A systematic search and critical review of the literature published through mid-January 2012 was performed. Articles included in the search were restricted to the English language, studies with at least 10 patients, and those analyzing cellular therapies for traumatic SCI. Citations were evaluated for relevance using a priori criteria, and those that met the inclusion criteria were critically reviewed. Each article was then designated a level of evidence that was developed by the Oxford Centre for Evidence-Based Medicine.

Results

The initial literature search identified 651 relevant articles, which decreased to 350 after excluding case reports and reviews. Evaluation of articles at the title/abstract level, and later at the full-text level, limited the final article set to 12 papers. The following cellular therapies employed in humans with SCI are reviewed: bone marrow mesenchymal and hematopoietic stem cells (8 studies), olfactory ensheathing cells (2 studies), Schwann cells (1 study), and fetal neurogenic tissue (1 study). Overall the quality of the literature was very low, with 3 Grade III levels of evidence and 9 Grade IV studies.

Conclusions

Several different cellular-mediated strategies for adult SCI have been reported to be relatively safe with varying degrees of neurological recovery. However, the literature is of low quality and there is a need for improved preclinical studies and prospective, controlled clinical trials.