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Arteriopathic complications during treatment of subarachnoid hemorrhage with epsilon-aminocaproic acid

Volker K. H. Sonntag and Bennett M. Stein

✓ A review of arteriopathic complications in three of seven patients receiving epsilon-aminocaproic acid (EACA) is presented. All seven patients with subarachnoid hemorrhage due to ruptured aneurysm were receiving EACA in the presurgical treatment period. Each of the three patients showed cerebral arteriographic changes resembling arteritis or intravascular thrombosis, and a deteriorating clinical course.

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Return to contact sports after spinal surgery

Mark G. Burnett and Volker K. H. Sonntag

✓ 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.

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Surgical management of atlantoaxial nonunions

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.

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Titanium dural clip testing

Technical note

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.

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Cervical corpectomy and plate fixation for postlaminectomy kyphosis

James M. Herman and Volker K. H. Sonntag

✓ Between 1987 and 1991, 20 patients with symptomatic postlaminectomy kyphosis were treated with anterior decompression, bone graft, and anterior cervical plate. The patients were predominantly male (14:6) with a mean age of 58 years. The initial laminectomy was performed for either spondylosis (80%) or spinal tumor (20%). All patients had anterior compressive pathology, which was associated with instability (45%), neck pain (75%), myeloradiculopathy (90%), or severe neck deformity (30%). The mean degree of kyphosis was 38°. Treatment consisted of a trial of cervical traction (75%), anterior corpectomy (95%), intersegmental decompression (5%), bone fusion (100%), and fixation with either Caspar (85%) or Synthes (15%) anterior plating at a mean of 3.8 levels. Halo fixation was used in 10% of patients. Postoperative complications included vocal cord paresis (15%), pneumonia (10%), wound dehiscence (5%), and screw pull-out (5%). At follow-up evaluation, a mean of 28 months after treatment, all patients had a solid fusion and a mean curvature improvement to 16° residual kyphosis. Neurologically, 10% were cured, 55% were improved and returned to premorbid function, 30% were stable, and 5% had late progression. These data suggest that immediate fixation with anterior plating facilitates solid fusion, maintains spinal curvature, and promotes neurological improvement.

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Efficacy of pedicle screw fixation in the treatment of spinal instability and failed back surgery: a 5-year review

Roberto Masferrer, Carlos H. Gomez, Dean G. Karahalios, and Volker K. H. Sonntag

Object

The goal of this study was to review retrospectively the outcome of 95 patients with various disorders leading to instability of the thoracolumbar and lumbar spine who were treated consecutively via a posterior surgical approach with pedicle screw fixation in which the Texas Scottish Rite Hospital system was used.

Methods

All cases were managed according to the same protocol. Follow-up review averaged 29.6 months. Radiographic evidence of osseous union and the patient's current status were analyzed. Four screws were malpositioned, and there were two dural lacerations of a nerve root and one pedicle fracture. Deep wound infections developed in five patients (5.2%) and three patients had postoperative radicular pain. In one case, the rods disengaged from the screws; in four cases, hardware was removed but there were no broken screws. Neurological deficits improved in 85% of the patients and no patient was worse neurologically after surgery. The rate of osseous union was 96.8%. Three patients developed pseudarthrosis, one of whom was asymptomatic. Back pain improved in 80 patients (85%). A solid bone fusion, however, was not necessarily associated with decreased back pain.

Conclusions

These results support the use of pedicle screw fixation as an effective and safe procedure for fusion of the thoracolumbar and lumbar spine and support the finding that complications can be minimal when a meticulous surgical technique is used. The proper selection of patients for surgery is probably the most important factor associated with good outcomes.

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Efficacy of pedicle screw fixation in the treatment of spinal instability and failed back surgery: a 5-year review

Roberto Masferrer, Carlos H. Gomez, Dean G. Karahalios, and Volker K. H. Sonntag

Object. The goal of this study was to review retrospectively the outcome of 95 patients with various disorders leading to instability of the thoracolumbar and lumbar spine who were treated consecutively via a posterior surgical approach with pedicle screw fixation in which the Texas Scottish Rite Hospital system was used.

Methods. All cases were managed according to the same protocol. Follow-up review averaged 29.6 months. Radiographic evidence of osseous union and the patient's current status were analyzed. Four screws were malpositioned, and there were two dural lacerations of a nerve root and one pedicle fracture. Deep wound infections developed in five patients (5.2%), and three patients had postoperative radicular pain. In one case, the rods disengaged from the screws; in four cases, hardware was removed but there were no broken screws. Neurological deficits improved in 85% of the surviving patients, and no patient was worse neurologically after surgery. The rate of osseous union was 96.8%. Three patients developed pseudarthrosis, one of whom was asymptomatic. Back pain improved in 80 patients. A solid bone fusion, however, was not necessarily associated with decreased back pain.

Conclusions. These results support the use of pedicle screw fixation as an effective and safe procedure for fusion of the thoracolumbar and lumbar spine and support the finding that complications can be minimal when a meticulous surgical technique is used. The proper selection of patients for surgery is probably the most important factor associated with good outcomes.

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Cervical Corpectomy

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Triple anterior screw fixation of an acute combination atlas—axis fracture

Case report

Paul J. Apostolides, Nicholas Theodore, Dean G. Karahalios, and Volker K. H. Sonntag

✓ The authors report the successful treatment of an acute combination atlas—axis fracture in an 85-year-old man using anterior odontoid and C1–2 transarticular facet screw fixation and a Philadelphia collar. Treatment with halo brace immobilization failed, and the patient experienced recurrent episodes of oxygen desaturation when placed partially prone for chest physiotherapy. If a posterior approach is not feasible, an anterior odontoid and C1–2 transarticular facet screw fixation can be considered as a salvage procedure for patients with acute combination atlas—axis fractures.

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Spinal Instability