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Editorial. Benefits of robotic spine surgery: the future is bright

Daniel Lubelski and Nicholas Theodore

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Basilar artery thrombosis after reduction of cervical spondyloptosis: a cautionary report

Case report

Luis M. Tumialán and Nicholas Theodore

Traumatic cervical spondyloptosis is a rare clinical entity typically associated with complete neurological deficit. The inherent mechanics of this fracture-dislocation pattern contorts the vertebral arteries in such a way that it may result in dissection or compromised flow through those vessels. Thus, intimal injury or thrombus from stasis of flow may result. Reduction of the spondyloptosis restores flow to the vertebral arteries, but it also may mobilize thrombus or propagate an intimal dissection within the previously contorted vessel.

The authors review their experience in the care of a 43-year-old man who sustained C4–5 spondyloptosis while riding an all-terrain vehicle. On arrival, the patient demonstrated no motor function below C-4 but had sensation to the nipple line (American Spinal Injury Association Spinal Cord Injury Classification B). The patient's cranial nerve examination was unremarkable. Computed tomography of the cervical spine demonstrated complete spondyloptosis at C4–5. The patient was immediately placed in cervical traction and taken to the operating room for open reduction of the fracture dislocation, decompression of the spinal cord, and stabilization with an interbody graft and cervical plate. Preoperative cervical traction was successful in only partial reduction of the fracture dislocation. Open reduction was achieved with exposure of the C-4 and C-5 bodies and sequential distraction. After anatomical alignment was achieved, an interbody graft was placed and a cervical plate secured. A subsequent decline in the patient's level of consciousness prompted CT of the head, which showed evidence of a basilar artery thrombosis. A CT angiographic study demonstrated patency of the vertebral arteries, but a mid–basilar artery thrombosis. The patient progressed to brain death 24 hours after reduction of the fracture dislocation.

The degree of contortion of the vertebral arteries in cervical spondyloptosis in the upper cervical spine may result in stasis of flow with subsequent formation of thrombus or intimal injury. After anatomical reduction, restoration of flow within the vertebral arteries may mobilize the thrombus or propagate an intimal dissection and result in subsequent embolic events. Endovascular evaluation may be warranted immediately after anatomical reduction of a high cervical spondyloptosis for evaluation of the vertebral arteries and possible thrombus dissolution or retrieval.

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Shaken Baby Syndrome

Ronald H. Uscinski

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Introduction: the rise of the robots in spinal surgery

Nicholas Theodore, Paul M. Arnold, and Ankit I. Mehta

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Calcitonin and Spinal Fusion

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Daniel Ruge: the first neurosurgeon to serve as physician to the president

A. Karim Ahmed, Eduardo Martinez-del-Campo, and Nicholas Theodore

The role of chief White House physician has traditionally been held by an individual with a background in a broad medical field, such as emergency medicine, family medicine, or internal medicine. Dr. Daniel Ruge, who served as the director of the Spinal Cord Injury Service for the Veterans Administration and was appointed during President Ronald Reagan’s first term, was the first neurosurgeon to become the chief White House physician. Aside from being the first neurosurgeon to serve in this capacity, Dr. Ruge also stands apart from others who have held this esteemed position because of how he handled Reagan’s care after an attempt was made on the then-president’s life. Instead of calling upon leading medical authorities of the time to care for the president, Dr. Ruge instead decided that Reagan should be treated as any trauma patient would be treated. Dr. Ruge’s actions after the assassination attempt on President Reagan resulted in the rapid, smooth recovery of the then-president. Daniel Ruge’s background, his high-profile roles and heavy responsibilities, and his critical decision-making are characteristics that make his role in the history of medicine and of neurosurgery unique.

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Delayed subarachnoid hemorrhage following failed odontoid screw fixation

Case report

David A. Wilson, David J. Fusco, and Nicholas Theodore

Iatrogenic vascular injury is a rare but potentially devastating complication of cervical spine instrumentation. The authors report on a patient who developed an anterior spinal artery pseudoaneurysm associated with delayed subarachnoid hemorrhage after undergoing odontoid screw placement 14 months earlier. This 86-year-old man presented with spontaneous subarachnoid hemorrhage (Fisher Grade 4) and full motor strength on neurological examination. Imaging demonstrated pseudarthrosis of the odontoid process, extension of the odontoid screw beyond the posterior cortex of the dens, and a pseudoaneurysm arising from an adjacent branch of the anterior spinal artery. Due to the aneurysm's location and lack of active extravasation, endovascular treatment was not attempted. Posterior C1–2 fusion was performed to treat radiographic and clinical instability of the C1–2 joint. Postoperatively, the patient's motor function remained intact. Almost all cases of vascular injury related to cervical spine instrumentation are recognized at surgery. To the authors' knowledge, this is the first report of delayed vascular injury following an uncomplicated cervical fixation. This case further suggests that the risk of this phenomenon may be elevated in cases of failed fusion.

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Spinal cord ganglioglioma in a child with neurofibromatosis Type 2

Case report and literature review

Paul D. Sawin, Nicholas Theodore, and Harold L. Rekate

✓ Gangliogliomas of the spinal cord are rare disease entities that occur in early childhood. Their occurrence in association with neurofibromatosis Type 2 (NF2) has not been described. The authors describe the unique case of a 2-year-old child with stigmata of NF2 who harbored a spinal cord ganglioglioma that presented as a rapidly growing, exophytic intramedullary mass lesion at the cervicomedullary junction. Treatment consisted of complete surgical resection. Histopathological analysis of the lesion demonstrated a mixed population of neoplastic cells, of both neuronal and glial lineage, that supported the diagnosis of ganglioglioma.

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Fifty years later: the "rule of Spence" is finally ready for retirement

Srujan Kopparapu, Gordon Mao, Brendan F. Judy, and Nicholas Theodore

Determination of the optimal approach to traumatic atlas fractures with or without transverse atlantal ligament (TAL) injury requires a nuanced understanding of the biomechanics of the atlantoaxial complex. The "rule of Spence" (ROS) was created in 1970 in a landmark effort to streamline management of burst-type atlas fractures. The ROS states that radiographic evidence of lateral mass displacement (LMD) (i.e., the distance that the C1 lateral masses extend beyond the C2 superior articular processes) greater than 6.9 mm may indicate both a torn TAL and need for surgical management. Since then, the ROS has become ubiquitous in the spine literature about atlas injuries. However, in the decades since the original paper by Spence et al., modern research efforts and imaging advancements have revealed that the ROS is inaccurate on both fronts: it neither accurately predicts a TAL injury nor does it inform surgical decision-making. The purpose of this review was to delineate the history of the ROS, demonstrate its limitations, present findings in the existing literature on ROS and LMD thresholds, and discuss the current landscape of management techniques for TAL injuries, including parameters such as the atlantodental interval and type of injury according to the Dickman classification system and AO Spine upper cervical injury classification system. The ROS was revolutionary for initially investigating and later propelling the biomechanical and clinical understanding of atlas fractures and TAL injuries; however, it is time to retire its legacy as a rule.

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Delayed CSF lavage for arteriographic and morphological vasospasm after experimental SAH

Eben Alexander III, Peter McL. Black, Theodore M. Liszczak, and Nicholas T. Zervas

✓ Irrigation of the subarachnoid space after aneurysmal subarachnoid hemorrhage (SAH) has been reported to alleviate subsequent arterial vasospasm. The authors have investigated the effect of lavage of the cerebrospinal fluid (CSF) space in the two-hemorrhage canine model of vasospasm. Twelve dogs had basilar cistern lavage with 120 cc of artificial CSF 24 hours after each of two SAH's, and 12 control dogs had two sequential SAH's without intervening lavage of clot. The amount of clot on the ventral brain stem was evaluated at sacrifice and was graded from 0 (no clot) to 4 (maximum clot) to assess the adequacy of clot removal. Dogs that had undergone lavage had a median grade of 1 (range Grade 0 to 2); control dogs had a median grade of 2 (range Grade 1 to 3.5, p < 0.001, Wilcoxon rank sum test), indicating significant reduction of gross clot by lavage. The neurological findings were graded from 0 to 5, based on meningismus, ataxia, paresis, and cranial nerve deficits. No significant differences in neurological grade were found on any day between the two groups.

Satisfactory angiograms were obtained before and 7 days after hemorrhage and were controlled for blood pressure and blood gases; these showed significant spasm in both groups. There was a mean reduction (± standard deviation) of 21.6% ± 16.2% in basilar artery diameter in control dogs, compared to a 28.8% ± 15.1% reduction in dogs with lavage (difference not significant, t-test). There was a strong, but insignificant, trend toward reduction of endothelial desquamation in the basilar and middle cerebral arteries in dogs with lavage compared to control animals (p = 0.06). Corrugation and tearing of the elastica, thickened intima, intimal fibroplasia, vacuolization of the endothelial or smooth-muscle cells, and presence of blood cells in the adventitia occurred similarly in both groups.

It appears that cisternal lavage 24 hours after hemorrhage in this model has no effect on the angiographic, neurological, or most morphological sequelae of SAH, in spite of evidence for removal of clot as seen at sacrifice. Any postulated interaction of clot and vessel resulting in chronic vasospasm must occur before this time. Evaluation of the effect of much earlier lavage (for instance, 1 hour after hemorrhage) may elucidate the point at which vasospasm is instigated after SAH, and help in determining what factors cause vasospasm.