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John K. Houten and Louis A. Noce


The Hoffmann sign is commonly used in clinical practice to assess cervical spine disease. It is whether the sign correlates with the severity of myelopathy, and no consensus exists regarding the significance a positive sign in asymptomatic individuals.


In a retrospective review of cervical spine surgeries for myelopathy due to cervical spondylosis, fication of the posterior longitudinal ligament, or disc herniation performed at a tertiary center, the authors data on the presence of hyperreflexia, the Hoffmann and Babinski signs, and modified Japanese Orthopaedic ciation (mJOA) scale scores. Then, in a prospective evaluation, new patients with lumbar spine complaints examined for the presence of a Hoffmann sign, and, if present, a cervical MR imaging study was assessed for compression.


Of the 225 surgically treated patients, a Hoffmann sign occurred in 68%, hyperreflexia in 60%, and Babinski sign in 33%. In patients with milder disability (mJOA Scores 14–16), the Hoffmann sign was present 46%, whereas a Babinski sign occurred in 10%; in those with severe myelopathy and mJOA scores of ≤ 10, Hoffmann sign was present in 81% and the Babinski sign in 83%. Of 290 patients presenting exclusively with bar spine–related complaints, 36 (12%) had a positive Hoffmann sign. Magnetic resonance imaging demonstrated spinal cord compression in 91% when the sign was present bilaterally and 50% when positive unilaterally.


In patients surgically treated for cervical myelopathy, the Hoffmann sign is more prevalent more likely to be seen in individuals with less severe neurological deficits than the Babinski sign. In patients lumbar symptoms, a bilateral Hoffmann sign was a highly sensitive marker for occult cervical cord compression, whereas a unilateral Hoffmann sign correlated with similar disease in about one-half of patients.

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John K. Houten, Scott P. Sanderson and Paul R. Cooper

✓ Synovial cysts emanating from the lumbar facet joints may compromise the spinal canal and produce symptoms of radiculopathy or stenosis. Good results have been reported after excision of the symptomatic lesions. There are limited data, however, on the natural history involving nonoperative management and little information to suggest that these lesions ever regress spontaneously. The authors report on three patients in whom symptomatic lumbar synovial cysts spontaneously resolved and review the relevant literature.

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Mark Chwajol and John K. Houten

✓Congenital kyphosis Type I results from failure of formation of the vertebral body (VB). The clinical course is characterized by progressive deformity and neurological dysfunction unless the patient undergoes fusion. It has been postulated that failure of VB formation may be secondary to anomalies of the segmental arteries arising from the aorta. There is limited clinical evidence in the literature, however, to support this hypothesis. The authors report on the case of an adult patient with congenital kyphosis Type I in whom spinal angiography correlated vascular with vertebral anomalies.

This 32-year-old man presented with back pain, lower-extremity paresthesias, and incomplete voiding, which had progressed over several years. Imaging revealed that the L-1 and L-2 vertebrae had not fully formed, causing kyphotic deformity such that the anterior portion of T-12 nearly articulated with that of L-3; this anomaly produced significant mobility in flexion and extension. Magnetic resonance imaging revealed distal spinal cord atrophy and signal change on T2-weighted images.

Spinal angiography showed that the right and left segmental arteries at both L-1 and L-2 arose from a common trunk from the aorta. This was confirmed during subsequent T12–L3 anterior–posterior fusion. Postoperatively the patient experienced relief of pain and remained neurologically stable throughout a 3-year follow-up period.

The presence of corresponding anomalies of the segmental arteries and vertebrae in this case of congenital kyphosis Type I indicates that a relationship may exist in the genesis of aberrant spinal vertebral and vascular structures.

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John K. Houten, Lucien C. Alexandre, Rani Nasser and Adam L. Wollowick

A lateral transpsoas approach to achieve interbody fusion in the lumbar spine using either the extreme lateral interbody fusion or direct lateral interbody fusion technique is an increasingly popular method to treat spinal disease. Dissection and dilation through the iliopsoas muscle places the lumbosacral plexus at risk for injury, but there is very limited information in the published literature about adverse clinical events resulting in postoperative motor deficits or reports of failure of electrophysiological monitoring to detect nerve injury. The authors present 2 cases of postoperative motor deficits following the transpsoas approach not detected by intraoperative monitoring, review the medical literature, and discuss strategies for complication avoidance.

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Rani Nasser, Kimberly Ashayeri, Alan D. Legatt and John K. Houten

The authors describe the case of a 48-year-old man found to have the first reported intramedullary spinal cord spindle cell hemangioma. Previous research indicates that spindle cell hemangiomas are rarely found in the spine. Only 3 previous cases exist, all in the intradural, extramedullary space. In the present case, gross-total resection of the tumor was possible with no loss of function from baseline. This report presents the successful resection of the first reported intramedullary spindle cell hemangioma and reports 4-month follow-up, demonstrating the biological behavior of this rare tumor.

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John K. Houten, Nicholas H. Post, Joseph W. Dryer and Thomas J. Errico


Although transforaminal lumbar interbody fusion (TLIF) is an increasingly popular surgical technique, there are a limited number of studies in which investigators have stratified outcome data with respect to surgical indications or documented radiographically proven and clinical results with respect to disc space height (DSH). The authors conducted a study to evaluate the long-term outcomes after TLIF with respect to surgical indication and radiographic/neuroimaging results.


Thirty-three consecutive TLIF-treated patients underwent follow-up investigation for a mean of 37 months. Isthmic spondylolysis was present in eight patients, recurrent disc herniation in 14, and degenerative disc disease (DDD) in 11. The operative technique involved the placement of interbody structural allograft, pedicle screw instrumentation, and morcellized autograft in the anterior interbody space and the contralateral intertransverse gutter. Surgery was performed at L4–5 in 16 patients, L5–S1 in 14, L3–4 in two, and both L4–5 and L5–S1 in one patient.

Preoperative symptoms were back pain (in 91% of cases), leg pain (in 94%), sensory loss (in 67%), and motor deficits (in 30%). Postoperatively, back pain was improved in 67% of the patients, unchanged in 27%, and worsened in 7%. Leg pain improved in 80% of patients, was unchanged in 10%, and worsened in 10%. Outcome, as measured using the Prolo Functional and Economic Scales, improved from a score of 4.9 to 7. In patients with spondylolysis and recurrent disc herniation outcomes were better than in those with DDD only. There was no correlation of outcome with symptom duration, patient age, or level of surgery. In an independent review of pre- and late postoperative radiographs no significant differences in lordosis angles, Cobb angles, or DSHs were found. Fusion occurred in all cases.


The TLIF procedure was associated with good clinical outcomes and a high fusion rate but no change in the DSH. Patients who present with spondylolysis and recurrent herniations experience better outcome than those with degenerative disease alone.

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John K. Houten, Joshua R. Buksbaum and Michael J. Collins


Paresis of the C5 nerve is a well-recognized complication of cervical spine surgery. Numerous studies have investigated its incidence and possible causes, but the specific pattern and character of neurological deficits, time course, and relationship to preoperative cord signal changes remain incompletely understood.


Records of patients undergoing cervical decompressive surgery for spondylosis, disc herniation, or ossification of the longitudinal ligament, including the C4–5 level, were reviewed from a 15-year period, identifying C5 palsy cases. Data collected included age, sex, diabetes and smoking statuses, body mass index, surgical levels, approach, presence of increased cord signal intensity, and modified Japanese Orthopaedic Association (mJOA) scores. Narrative descriptions of the patterns and findings on neurological examination were reviewed, and complications were noted. The minimum follow-up requirement for the study was 12 months.


Of 642 patients who underwent cervical decompressive surgery, 18 developed C5 palsy (2.8%). The incidence was significantly lower following anterior surgery (6 of 441 [1.4%]) compared with that following cervical laminectomy and fusion (12 of 201 [6.0%]) (p < 0.001). There were 10 men and 8 women whose mean age was 66.7 years (range 54–76 years). The mean preoperative mJOA score of 11.4 improved to 15.6 at the latest follow-up examination. There were no differences between those with and without C5 palsy with regard to sex, age, number of levels treated, or pre- or postoperative mJOA score. Fifteen patients with palsy (83%) had signal changes/myelomalacia on preoperative T2-weighted imaging, compared with 436 of 624 (70%) patients without palsy; however, looking specifically at the C4–5 level, signal change/myelomalacia was present in 12 of 18 (67%) patients with C5 palsy, significantly higher than in the 149 of 624 (24%) patients without palsy (p < 0.00003). Paresis was unilateral in 16 (89%) and bilateral in 2 (11%) patients. All had deltoid weakness, but 15 (83%) exhibited new biceps weakness, 8 (44%) had triceps weakness, and 2 (11%) had hand intrinsic muscle weakness. The mean time until onset of palsy was 4.6 days (range 2–14 days). Two patients (11%) complained of shoulder pain preceding weakness; 3 patients (17%) had sensory loss. Recovery to grade 4/5 deltoid strength occurred in 89% of the patients. No patient had intraoperative loss of somatosensory or motor evoked potentials or abnormal intraoperative C5 electromyography activity.


Postoperative C5 nerve root dysfunction appears in a delayed fashion, is predominantly a motor deficit, and weakness is frequently appreciated in the biceps and triceps muscles in addition to the deltoid muscle. Preoperative cord signal change/myelomalacia at C4–5 was a significant risk factor. No patient had a detectable deficit in the immediate postoperative period or changes in intraoperative neuromonitoring status. Neurological recovery to at least that of grade 4/5 occurred in nearly 90% of the patients.