✓ Decisions regarding the return of injured athletes to contact sports after spinal surgery can be complicated. The authors offer a brief overview of the return-to-play guidelines used successfully at their institution for the past two decades when caring for professional and amateur athletes after spinal surgery.
Mark G. Burnett and Volker K. H. Sonntag
Richard M. Westmark, Kaye D. Westmark, and Volker K. H. Sonntag
The authors report the case of a 48-year-old woman who experienced spontaneous resolution of a large herniated disc at C6-7. Spontaneous resolution of a herniated lumbar disc was first documented by computerized tomography. This case is another example of a rare spontaneous resolution of a cervical disc herniation documented by magnetic resonance imaging.
Curtis A. Dickman and Volker K. H. Sonntag
✓ Sixteen patients referred for atlantoaxial fixation failures were treated surgically with revision procedures during the past decade. Of these 16 patients, atlantoaxial instability occurred because of rheumatoid arthritis in five, os odontoideum in seven, transverse ligament disruption in two, and odontoid fracture nonunion in two. The 16 individuals (10 men, six women; mean age 43.7 years; age range 20–77 years) had undergone a total of 20 C1–2 internal fixation procedures that failed.
Surgical strategies for definitive revision of the nonunions in these 16 subjects included 10 rigid internal fixations with transarticular screws, three revised C1–2 fixations with autogenous bone struts and wire or cables, and three extended fixations with occipitocervical instrumentation. Autogenous grafts were used in all revisions. A postoperative halo brace was used in five individuals with osteoporotic bone; all patients wore a restrictive postoperative cervical orthosis.
Postoperatively, 15 patients (94%) had a stable construct (mean follow up 35 months; range 12–79 months), which included 13 osseous unions and two stable fibrous unions. One patient had nonunion; he fractured his anterior C1–2 transarticular screws 2 years postoperatively. He had occipital radicular pain without myelopathy but refused further surgery.
Atlantoaxial pseudarthroses were effectively treated by addressing the pathological, biomechanical, and technical reasons for failed fusion. Successful fusion after reoperation was improved by using autologous bone grafts, adequately controlling atlantoaxial motion (with rigid transarticular screws internally or externally with a halo vest), compressing the bone grafts between the arches of C-1 and C-2 with wire cables, meticulously preparing the fusion bed, and by optimizing the pharmacological and clinical parameters to promote bone healing.
A summary of seven cases
Mark N. Hadley, Volker K. H. Sonntag, and Hal W. Pittman
✓ The suprascapular nerve, formed from the upper trunk of the brachial plexus, can be entrapped at the suprascapular notch and result in significant patient morbidity. Seven patients with suprascapular nerve palsy are presented, and their evaluation, treatment, and outcome over a mean follow-up period of 24 months are described. Six of these patients were treated surgically and one medically; all experienced good results. In a review of the relevant literature, this entity is distinguished from other causes of shoulder pain, the typical presenting signs and symptoms are outlined, and the appropriate management of these patients is addressed.
Stephen M. Papadopoulos, Curtis A. Dickman, and Volker K. H. Sonntag
✓ Atlantoaxial subluxation in patients with rheumatoid arthritis is common. Operative stabilization is clearly indicated when signs and symptoms of spinal cord compression occur. However, many recommend early operative fusion before evidence of appreciable neural compression occurs because 1) the myelopathy in these patients may be irreversible; 2) the overall prognosis is poor once symptoms of cord compression are present; and 3) the risk of sudden death associated with atlantoaxial subluxation is increased even in asymptomatic patients. The authors believe that rheumatoid arthritis patients in relatively good health without advanced multisystem disease and less than 65 years of age should be considered for operative stabilization if mobile atlantoaxial subluxation is greater than 6 mm. Seventeen patients with severe rheumatoid arthritis and atlantoaxial subluxation treated with a posterior arthrodesis are presented. A new method of fusion, devised by the senior author (V.K.H.S.), was utilized in all cases. Indications for operative therapy in these patients included evidence of spinal cord compression in 11 patients (65%) and mobile atlantoaxial subluxation greater than 6 mm but no signs or symptoms of cord compression in six patients (35%). Thirteen patients developed a stable osseous fusion, two patients a well-aligned fibrous union, one patient a malaligned fibrous union, and one patient died prior to evaluation of fusion stability.
The details of the operative technique and management strategies are presented. Several technical advantages of this method of fusion make this approach particularly useful in patients with rheumatoid arthritis. Because of multisystem involvement of this disease, a high rate of osseous fusion is often difficult to achieve.
Richard M. Westmark, Kaye D. Westmark, and Volker K. H. Sonntag
✓ The authors report the case of a 48-year-old woman who experienced spontaneous resolution of a large herniated disc at C6–7. Spontaneous resolution of a herniated lumbar disc was first documented by computerized tomography. This case is another example of a rare spontaneous resolution of a cervical disc herniation documented by magnetic resonance imaging.
A review of 53 cases of extradural cervicomedullary compression
Mark N. Hadley, Robert F. Spetzler, and Volker K. H. Sonntag
✓ The transoral-transclival surgical approach is the most direct operative approach to pathology ventral to the brain stem and superior spinal cord. In selected patients, this approach is efficacious in the treatment of extradural compressive lesions from the cervicomedullary junction to the C-4 vertebra.
The authors have used the transoral surgical approach in treating 53 patients with lesions compressing the ventral extradural brain stem or the cervical cord. The evaluation, management, and long-term outcome of these patients are described (median follow-up time 24 months). The operative morbidity rate in this series was 6%, and the operative mortality rate was zero. The authors review specific features of the transoral procedure, including methods of retraction, microsurgical techniques, and adjunctive measures to avoid cerebrospinal fluid fistulae, that contributed to these good results.
David I. Levy and Volker K. H. Sonntag
✓ Spinal dural lacerations can be a difficult part of spinal surgery. A dural tear can result in complications that include meningitis and pseudocyst formation. Appropriate treatment for these tears is generally suturing, using 4.0, 5.0, or 6.0 suture. For successful closure of dural lacerations, the authors have collaborated in the design of a titanium clip, which resembles an aneurysm clip in appearance and is applied with standard aneurysm clip appliers. The titanium clip was tested against suture and Weck hemostatic vascular clips and found to have excellent tissue-approximating capacity and a rapid application time. It is believed that this is an appropriate device for the repair of spinal dural lacerations.
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.
Christopher G. Paramore, Curtis A. Dickman, and Volker K. H. Sonntag
✓ Posterior transarticular screw fixation of the C1–2 complex has become an accepted method of rigid internal fixation for patients requiring posterior C1–2 fusion. The principal limitation of this procedure is the location of the vertebral artery, because an anomalous position may prohibit screw placement. In this study, a consecutive series of computerized tomography (CT) scans was reviewed, and the suitability of each patient for transarticular screw fixation was evaluated.
All of the fine-slice axial C1–2 CT scans and reconstructions performed on a spiral scanner over 2 years were reviewed. A novel screw trajectory reconstruction was designed to visualize the potential path of a transarticular screw in the plane of the reconstruction. Scans were reviewed for bone anatomy and the position of the transverse foramen.
Seventeen (18%) of 94 patients had a high-riding transverse foramen on at least one side of the C-2 vertebra that would prohibit the placement of transarticular screws. The left side was involved in nine patients and the right in five. Three patients had bilateral anomalies. The mean age of the group with anomalies (35.9 years, range 10–76) was not significantly different from the overall mean age (35.7 years, range 6–94). An additional five patients (5%) were considered to have anatomy in which screw placement was feasible but risky. On the basis of these data, it is postulated that 18% to 23% of patients may not be suitable candidates for posterior C1–2 transarticular screw fixation on at least one side.