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Patrick J. Reid and Paul J. Holman

✓The authors describe a case of osteomyelitis of the craniocervical junction caused by iatrogenic infection of the spine during corticosteroid injection therapy. This 58-year-old diabetic man presented with acute exacerbation of neck pain that had began 4 months prior to admission. He did not experience the associated fever, chills, or sweats, but he did notice transient weakness in the right upper extremity. A computed tomography (CT) scan of the cervical spine demonstrated a destructive process involving the odontoid and the left occipitocervical and atlantoaxial joints that was not present on a CT obtained 2 months earlier, just before trigger-point and left-sided C1–2 facet joint corticosteroid injections. A diagnosis of staphylococcal osteomyelitis was made, and initial treatment with external immobilization and appropriate antibiotic therapy failed to control radiographically demonstrated and clinical progression. The patient was successfully treated using staged anterior decompression and posterior instrumented fusion with prolonged antibiotic therapy.

To the authors' knowledge this case is the first reported instance of iatrogenic pyogenic osteomyelitis of the craniocervical junction successfully treated with anterior decompression and delayed posterior arthrodesis.

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Patrick C. Reid, Simon Morr and Michael G. Kaiser

Lumbar fusion is an accepted and effective technique for the treatment of lumbar degenerative disease. The practice has evolved continually since Albee and Hibbs independently reported the first cases in 1913, and advancements in both technique and patient selection continue through the present day. Clinical and radiological indications for surgery have been tested in trials, and other diagnostic modalities have developed and been studied. Fusion practices have also advanced; instrumentation, surgical approaches, biologics, and more recently, operative planning, have undergone stark changes at a seemingly increasing pace over the last decade. As the general population ages, treatment of degenerative lumbar disease will become a more prevalent—and costlier—issue for surgeons as well as the healthcare system overall. This review will cover the evolution of indications and techniques for fusion in degenerative lumbar disease, with emphasis on the evidence for current practices.

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Martin H. Pham, Joshua Bakhsheshian, Patrick C. Reid, Ian A. Buchanan, Vance L. Fredrickson and John C. Liu

OBJECTIVE

Freehand placement of C2 instrumentation is technically challenging and has a learning curve due the unique anatomy of the region. This study evaluated the accuracy of C2 pedicle screws placed via the freehand technique by neurosurgical resident trainees.

METHODS

The authors retrospectively reviewed all patients treated at the LAC+USC Medical Center undergoing C2 pedicle screw placement in which the freehand technique was used over a 1-year period, from June 2016 to June 2017; all procedures were performed by neurosurgical residents. Measurements of C2 were obtained from preoperative CT scans, and breach rates were determined from coronal reconstructions on postoperative scans. Severity of breaches reflected the percentage of screw diameter beyond the cortical edge (I = < 25%; II = 26%–50%; III = 51%–75%; IV = 76%–100%).

RESULTS

Neurosurgical residents placed 40 C2 pedicle screws in 24 consecutively treated patients. All screws were placed by or under the guidance of Pham, who is a postgraduate year 7 (PGY-7) neurosurgical resident with attending staff privileges, with a PGY-2 to PGY-4 resident assistant. The authors found an average axial pedicle diameter of 5.8 mm, axial angle of 43.1°, sagittal angle of 23.0°, spinal canal diameter of 25.1 mm, and axial transverse foramen diameter of 5.9 mm. There were 17 screws placed by PGY-2 residents, 7 screws placed by PGY-4 residents, and 16 screws placed by the PGY-7 resident. The average screw length was 26.0 mm, with a screw diameter of 3.5 mm or 4.0 mm. There were 7 total breaches (17.5%), of which 4 were superior (10.0%) and 3 were lateral (7.5%). There were no medial breaches. The breaches were classified as grade I in 3 cases (42.9%), II in 3 cases (42.9%), III in 1 case (14.3%), and IV in no cases. There were 3 breaches that occurred via placement by a PGY-2 resident, 3 breaches by a PGY-4 resident, and 1 breach by the PGY-7 resident. There were no clinical sequelae due to these breaches.

CONCLUSIONS

Freehand placement of C2 pedicle screws can be done safely by neurosurgical residents in early training. When breaches occurred, they tended to be superior in location and related to screw length choice, and no breaches were found to be clinically significant. Controlled exposure to this unique anatomy is especially pertinent in the era of work-hour restrictions.

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Darryl Lau, Cecilia L. Dalle Ore, Patrick Reid, Michael M. Safaee, Vedat Deviren, Justin S. Smith, Christopher I. Shaffrey and Christopher P. Ames

OBJECTIVE

The benefits and utility of routine neuromonitoring with motor and somatosensory evoked potentials during lumbar spine surgery remain unclear. This study assesses measures of performance and utility of transcranial motor evoked potentials (MEPs) during lumbar pedicle subtraction osteotomy (PSO).

METHODS

This is a retrospective study of a single-surgeon cohort of consecutive adult spinal deformity (ASD) patients who underwent lumbar PSO from 2006 to 2016. A blinded neurophysiologist reviewed individual cases for MEP changes. Multivariate analysis was performed to determine whether changes correlated with neurological deficits. Measures of performance were calculated.

RESULTS

A total of 242 lumbar PSO cases were included. MEP changes occurred in 38 (15.7%) cases; the changes were transient in 21 cases (55.3%) and permanent in 17 (44.7%). Of the patients with permanent changes, 9 (52.9%) had no recovery and 8 (47.1%) had partial recovery of MEP signals. Changes occurred at a mean time of 8.8 minutes following PSO closure (range: during closure to 55 minutes after closure). The mean percentage of MEP signal loss was 72.9%. The overall complication rate was 25.2%, and the incidence of new neurological deficits was 4.1%. On multivariate analysis, MEP signal loss of at least 50% was not associated with complication (p = 0.495) or able to predict postoperative neurological deficits (p = 0.429). Of the 38 cases in which MEP changes were observed, the observation represented a true-positive finding in only 3 cases. Postoperative neurological deficits without MEP changes occurred in 7 cases. Calculated measures of performance were as follows: sensitivity 30.0%, specificity 84.9%, positive predictive value 7.9%, and negative predictive value 96.6%. Regarding the specific characteristics of the MEP changes, only a signal loss of 80% or greater was significantly associated with a higher rate of neurological deficit (23.0% vs 0.0% for loss of less than 80%, p = 0.021); changes of less than 80% were not associated with postoperative deficits.

CONCLUSIONS

Neuromonitoring has a low positive predictive value and low sensitivity for detecting new neurological deficits. Even when neuromonitoring is unchanged, patients can still have new neurological deficits. The utility of transcranial MEP monitoring for lumbar PSO remains unclear but there may be advantages to its use.