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Jonathan S. Hott, Jeffrey S. Henn and Volker K. H. Sonntag

✓ The authors describe a unique retraction device adapted for anterior odontoid screw placement. A rigidly fixed tubular retractor system obviates the need for dissecting the longus colli muscles as well as for excessive retraction of the trachea, esophagus, and recurrent laryngeal nerve. The proper trajectory for screw placement can be determined by fine manipulation of the retractor as determined by biplanar fluoroscopy. The retractor is then rigidly fixed in position. The tubular corridor permits the odontoid screw to be placed in the usual fashion.

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Jonathan S. Hott, Jeffrey S. Henn and Volker K. H. Sonntag

✓ The authors describe a unique retraction device adapted for anterior odontoid screw placement. A rigidly fixed tubular retractor system obviates the need for dissecting the longus colli muscles as well as for excessive retraction of the trachea, esophagus, and recurrent laryngeal nerve. The proper trajectory for screw placement can be determined by fine manipulation of the retractor as determined by biplanar fluoroscopy. The retractor is then rigidly fixed in position. The tubular corridor permits the odontoid screw to be placed in the usual fashion.

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Jonathan S. Hott, Vivek R. Deshmukh, Stephen M. Papadopoulos and Robert F. Spetzler

✓The authors describe a unique headholder device adapted to facilitate the placement of anterior odontoid screws. The patient’s head is affixed in the headholder equipped with an articulating arm that can be placed in a paramedian fashion. This configuration rigidly fixates the head and provides an unencumbered open-mouth view of the odontoid using radiographic images, thus making screw placement easier.

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Jonathan S. Hott, Iman Feiz-Erfan, Louis J. Kim, Harold L. Rekate and Volker K. H. Sonntag

✓ Cervical spine injuries in the pediatric population typically affect the upper cervical region. The authors present the first reported case of a subaxial C6–7 unilateral locked facet joint in a neurologically intact 10-month-old infant. To date, this patient's nonoperative treatment has been successful. The proposed biomechanical mechanism of this injury and the treatment paradigm are discussed.

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Jonathan S. Hott, Iman Feiz-Erfan, Kathy Kenny and Curtis A. Dickman

Object. The authors evaluated the clinical and surgical outcomes obtained in patients with giant herniated thoracic discs (HTDs), defined as occupying more than 40% of the spinal canal. Surgery-related considerations and functional outcomes in patients with small- and medium-sized HTDs were compared.

Methods. The authors reviewed 140 cases of surgically treated HTDs, 20 (14%) of which were giant. Before and after surgery, all patients underwent computerized tomography myelography, magnetic resonance imaging, or both. Functional outcomes were assessed using the Frankel grading system preoperatively, immediately after surgery, and at long-term follow-up examination. The results observed in patients with giant HTDs were compared with those with small- and medium-sized HTDs. The mean overall follow-up period was 2.6 years.

Sixty-six patients (47%) presented with myelopathy, including 19 (95%) with a giant HTD. Of the latter, 16 (80%) underwent anterior, eight thoracoscopic, and eight open thoracotomy approaches. Four patients (20%) with laterally oriented giant HTDs within the spinal canal underwent surgery via a posterolateral approach.

Based on analysis of long-term follow-up data, 53% of patients with giant HTDs improved neurologically by one Frankel grade. Progression of myelopathy was arrested in 42%, and in 5% the Frankel grade worsened by one. In patients with small- and medium-sized HTDs, the Frankel grade improved by one in 77%, stabilized in 23%, and worsened in 0%. Patients with giant HTDs who underwent thoracoscopic surgery had worse short- and long-term functional outcomes than those in whom open thoracotomy was performed.

Conclusions. Patients with giant HTDs presented more frequently with myelopathy and experienced worse functional outcomes than those with smaller HTDs. Based on their experience, the authors recommend open thoracotomy rather than thoracoscopy for the treatment of midline giant HTDs.

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Jonathan S. Hott, James J. Lynch, Robert H. Chamberlain, Volker K. H. Sonntag and Neil R. Crawford

Object. In a nondestructive, repeated-measures in vitro flexibility experiment, the authors compared the acute stability of C1–2 after placement of C-1 lateral mass and C-2 pars interarticularis (LC1—PC2) instrumentation with that of C1–2 transarticular screw fixation.

Methods. The effect of C-1 laminectomy and C1–2 interspinous cable/graft fixation on LC1—PC2 stability was studied. Screw pullout strengths were also compared. Seven human cadaveric occiput—C3 specimens were loaded nondestructively with pure moments while measuring nonconstrained atlantoaxial motion. Specimens were tested with graft alone, LC1—PC2 alone, LC1—PC2 combined with C-1 laminectomy, and graft-augmented LC1—PC2. Interspinous cable/graft fixation significantly enhanced LC1—PC2 stability during extension. After C-1 laminectomy, the LC1—PC2 construct allowed increased motion during flexion and extension. There was no significant difference in lax zone or range of motion between LC1—PC2 fixation and transarticular screw fixation, but graft-assisted transarticular screws yielded a significantly smaller stiff zone during extension. The difference in pullout resistance between C-1 lateral mass screws and C-2 pars interarticularis screws was insignificant. The LC1—PC2 region restricted motion to within the normal range during all loading modes. Atlantal laminectomy reduced LC1—PC2 stability during flexion and extension.

Conclusions. The instrumentation-augmented LC1—PC2 construct performed biomechanically similarly to the C1–2 transarticular screw fixation. The LC1—PC2 construct resisted flexion, lateral bending, and axial rotation well. The weakness of the LC1—PC2 fixation in resisting extension can be overcome by adding an interspinous graft to the construct.

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Eric M. Horn, Jonathan S. Hott, Randall W. Porter, Nicholas Theodore, Stephen M. Papadopoulos and Volker K. H. Sonntag

✓ Atlantoaxial stabilization has evolved from simple posterior wiring to transarticular screw fixation. In some patients, however, the course of the vertebral artery (VA) through the axis varies, and therefore transarticular screw placement is not always feasible. For these patients, the authors have developed a novel method of atlantoaxial stabilization that does not require axial screws. In this paper, they describe the use of this technique in the first 10 cases.

Ten consecutive patients underwent the combined C1–3 lateral mass–sublaminar axis cable fixation technique. The mean age of the patients was 62.6 years (range 23–84 years). There were six men and four women. Eight patients were treated after traumatic atlantoaxial instability developed (four had remote trauma and previous nonunion), whereas in the other two atlantoaxial instability was caused by arthritic degeneration. All had VA anatomy unsuitable to traditional transarticular screw fixation.

There were no intraoperative complications in any of the patients. Postoperative computed tomography studies demonstrated excellent screw positioning in each patient. Nine patients were treated postoperatively with the aid of a rigid cervical orthosis. The remaining patient was treated using a halo fixation device. One patient died of respiratory failure 2 months after surgery. Follow-up data (mean follow-up duration 13.1 months) were available for seven of the remaining nine patients and demonstrated a stable construct with fusion in each patient.

The authors present an effective alternative method in which C1–3 lateral mass screw fixation is used to treat patients with unfavorable anatomy for atlantoaxial transarticular screw fixation. In this series of 10 patients, the method was a safe and effective way to provide stabilization in these anatomically difficult patients.

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Jeffrey D. Klopfenstein, Louis J. Kim, Iman Feiz-Erfan, Jonathan S. Hott, Pam Goslar, Joseph M. Zabramski and Robert F. Spetzler

Object

The goal of this study was to compare rapid and gradual weaning from external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage (SAH) in a prospective, randomized trial.

Methods

Between December 2001 and December 2002, 81 patients with aneurysmal SAH in whom external ventricular drains (EVDs) had been placed were enrolled in the study: 41 patients were randomized to the rapidly weaned group and 40 were randomized to the gradually weaned group. The two groups were well matched with respect to age, sex, posterior aneurysm location, Fisher grade, Hunt and Hess grade, intraventricular hemorrhage on admission, and hydrocephalus on admission. Rapid weaning was defined as weaning that occurred within 24 hours with immediate closure of the EVD, whereas gradual weaning took place over a 96-hour period with daily, sequential height elevations of the EVD system followed by drain closure for 24 hours. All patients in whom EVD weaning failed underwent shunt placement. Rates of shunt implantation, days in the intensive care unit (ICU), and overall duration of hospitalization were compared. There was no significant difference in rates of shunt implantation between the rapidly weaned (63.4%) and gradually weaned (62.5%) groups. Nevertheless, patients in the gradually weaned group spent a mean of 2.8 more days in the ICU (p = 0.0002) and 2.4 more days in the hospital (p = 0.0314) than patients in the rapidly weaned group.

Conclusions

Compared with rapid weaning, gradual, multistep EVD weaning provided no advantage to patients with aneurysmal SAH in preventing the need for long-term shunt placement and prolonged ICU and hospital stays.