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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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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.

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The transoral approach to the superior cervical spine

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.

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Mohammed A. Eleraky, Carlos Llanos and Volker K. H. Sonntag

Object. This study was conducted to determine the indications, safety, efficacy, and complication rate associated with performing corpectomy to achieve anterior decompression of neural elements or for removing anterior lesions.

Methods. Between 1987 and 1998, 185 patients underwent cervical corpectomy for the treatment of degenerative spondylitic disease (81 cases), ossification of posterior longitudinal ligament (16 cases), correction of postoperative kyphosis (31 cases), trauma (39 cases), tumor (10 cases), and infection (eight cases). Ninety-nine patients presented with myelopathy, 48 with radiculomyelopathy, 24 with radicular pain, and 14 with neck muscle pain. Eighty-seven patients underwent a one-level corpectomy; 45 of these patients underwent a discectomy at a different level. Seventy patients underwent a two-level corpectomy; 27 of these patients underwent a discectomy at a different level. Twenty-eight patients underwent a three-level corpectomy. Autograft (iliac crest) was used in 141 cases and allograft (fibula) in 44 cases. All but six patients underwent fixation with an anterior plate-screw system. There were no operative deaths. During the procedure the vertebral artery was injured in four patients and preserved in two of them. No neurological sequelae were encountered. Postoperative hoarseness, transient dysphagia, and pain at the graft site were transitory and successfully managed. The fusion rate was 98.8%. Six patients experienced transient deterioration after surgery but they improved. No patient experienced permanent neurological deterioration and 160 (86.5%) improved.

Conclusions. Corpectomy has an important role in the management of various degenerative, traumatic, neoplastic, or infectious disorders of cervical spine. Following treatment in this series, radiculopathy always improved and myelopathy was reversed in most patients.

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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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High cervical disc herniation presenting with C-2 radiculopathy

Case report and review of the literature

Vivek R. Deshmukh, Harold L. Rekate and Volker K. H. Sonntag

✓ The authors report the case of a 78-year-old man with a C2–3 disc herniation that had migrated rostrally, causing C-2 radiculopathy. The C-2 radiculopathy manifested immediately after the patient underwent placement of a ventriculoperitoneal shunt for normal-pressure hydrocephalus. Myelography and computerized tomography scanning of the cervical spine revealed an extradural lesion anterolateral to the thecal sac eccentric to the right. The patient underwent a C1–3 laminectomy, C-2 nerve root decompression, and excision of the lesion. Postoperatively the patient's radiculopathy resolved completely. To the authors' knowledge, this is the first case of a C2–3 disc herniation manifesting as C-2 radiculopathy and treated via a posterior extradural approach.

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Christopher G. Paramore, Curtis A. Dickman and Volker K. H. Sonntag

✓ Although they are excellent clinical tools, Caspar anterior cervical plates have not been studied closely with regard to their mechanisms of failure. As more extensive operations are contemplated on older, sicker patients, it is imperative to know when a plating system might be prone to failure and what the mechanism of that failure might be. Therefore, the authors reviewed 49 patients undergoing Caspar plate placement in whom sufficient radiographs were obtained to determine if the fate of the hardware was related to the patient's age, type of operation, and the length of construct. Eleven of 49 patients suffered hardware failure, defined as any amount of screw backout or breakage, plate pullout, or pseudarthrosis. Four patients underwent hardware removal; one underwent posterior fusion for pseudarthrosis. Only two required treatment in a halo brace. There was an eventual fusion rate of 100%, including one fibrous union, and one of the patients who underwent repeat surgery was lost to follow-up review. No graft extrusions or new neurological deficits were incurred as a result of hardware failure. Plate length predicted plate failure in a statistically significant manner. Increasing age and reoperation correlated with plate failure but were not statistically significant in this small number of patients. Telescoping of the bone graft and vertebral bodies, with concomitant migration of the plate and slippage of the screws, was common. However, telescoping was more profound in the group in which the plates failed. The authors conclude that Caspar plate failures are more likely to occur in the elderly and in patients who need longer constructs. Bone fusion can be expected even when the hardware loosens.

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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.

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Suprascapular nerve entrapment

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.

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