Failure of Surgical Equipoise in Posterior Cord Syndrome Myelopathy

We suggest that a clinical diagnosis of posterior cord syndrome indicates primary posterior decompression in cervical spondylotic myelopathy cases. We present two unique cases of failed anterior decompression in neutrally aligned necks with compressive myelopathy and a literature review. Two recent cases of cervical spondylotic myelopathy that failed to respond after anterior surgical decompression and fusion surgery were observed at our institution. Both patients had motor strength preservation but were unable to stand and walk independently and had other clinical findings consistent with posterior cord syndrome rather than the more common anterior or central cord syndromes, and both responded well to staged posterior decompression. Posterior cervical decompression successfully relieved posterior cord syndrome symptoms after a failed anterior decompression in both of our cases. Posterior cord syndrome is a rare syndrome best diagnosed clinically and should be considered in cases of cervical spondylotic myelopathy in which motor strength testing is preserved.

Internal lumbar disc derangement with instability catch from monosegmental discopathy. The forgotten mechanical and kinetic surgical back pain syndrome

STUDY DESIGN

This is a retrospective cohort experience reported with concurrent survey PROM outcomes.

OBJECTIVE

To describe the results of open PLIF reconstruction for a select group of mechanical back pain patients who have mono- or bi-segmental discopathy on MRI imaging, a clinical history of repeated severe and disabling acute mechanical back pain symptoms, and the irregular lumbar motion pattern in returning erect from the flexed position known as the "instability catch".

SUMMARY OF BACKGROUND DATA

The literature of fusion surgery for back pain relief in "mechanical" back pain reveals inconsistent results and in the majority presents only a vague description of these syndromes. Internal Lumbar Disc Degeneration with Instability catch "ILDDIC" may be one subset of these patients who are uniquely benefitted from spine stabilization.

METHODS

The senior author (DAB) in midsummer 2015 began to offer smaller fusion procedures to selected patients on an overnight-stay basis using a standard perioperative care protocol. For practice audit, in December 2020 a mailed survey questionnaire requesting VAS pain scores and SF-36 physical function scores was sent out to all 111 patients who had been treated this way, which group included 30 cases of ILDDIC. We report here on the success of open PLIF reconstruction in achieving back pain relief for these patients.

RESULTS

Some 24 of 30 patients returned the mailed survey questionnaire, and the remaining six could not be reached. All 24 responders reported significant relief of back pain and improved physical function, at a mean of 30 months from surgery. Review of the available clinical records (LFU < 1 year) from the six nonresponders also recorded positive early benefit.

CONCLUSION

The diagnosis of ILDDIC requires both imaging and clinical correlates and may define a subgroup of the mechanical back pain population uniquely suited to achieve pain relief through lumbar fusion.

C2 Vertebral Corpectomy for Kyphosis Malunion of Remote Dens Fracture with Atlantoaxial Ankylosis and Myelopathy: A Case Report at 15 Years of Follow-Up

CASE

We report a unique case of compressive myelopathy caused by late kyphosis angulation of a previously operated dens base fracture nonunion challenged by age-related ankyloses of the lateral articulations C1 to C2 and a solid posterior fusion mass.

CONCLUSIONS

Posterior column shortening such as commonly practiced for progressive kyphosis or myelopathy may be precluded at the atlantoaxial level for potential vascular risk to the vertebral artery. A standard anterior cervical approach and the application of basic surgical spine care principles lead to a simple solution in the unique and highly complex anatomy of our case.

Solitary C1 Posterior Fixation for Unstable Isolated Atlas Fractures: Case Report and Systematic Review of the Literature

Study Design A systematic review of the literature. Objectives To review the published results to date of motion-preserving direct reconstruction of C1 ring fractures with combined coronal plane displacement of at least 7 mm (rule of Spence) and so at risk for Dickman type I or II disruption of the transverse atlantal ligament (TAL). Methods A structured literature review prompted by successful management of a typical case. Results To date only 65 such cases are reported and follow-up is almost uniformly short. Although reported clinical success is uniform, the case mix is heterogenous and confirmation/classification of ligamentous injury at baseline is often lacking. Conclusions Direct C1 stabilization shows promise as a "more selective" option in managing displaced atlas fractures with probable TAL disruption but cannot yet be recommended as a practice standard. Prospective clinical studies are indicated and should be structured so as to differentiate between Dickman type I and type II injuries of the TAL.

Sacral Stress Fracture Mimicking Lumbar Radiculopathy in a Mounted Police Officer: Case Report and Literature Review

Study Design Case report and review of the literature. Objective To present a unique case of L5 radiculopathy caused by a sacral stress fracture without neurologic compression. Methods We present our case and its clinical evolution and review the available literature on similar pathologies. Results Relief of the unusual mechanical loading causing sacral stress fracture led to rapid resolution of radiculopathy. Conclusion L5 radiculopathy can be caused by a sacral stress fracture and can be relieved by simple mechanical treatment of the fracture.

Uncovertebral anatomic midline targeting for cervical disc arthroplasty

Study Design Prospective observational cohort. Objective To document the accuracy of uncovertebral anatomic targeting in positioning cervical disc arthroplasty. Summary of Background Data Disc arthroplasty implants depend on midline placement for optimum mechanical function. Fluoroscopy is used to delineate the midline. Anatomic targeting from the uncovertebral joints in the neck may be adequate. We have investigated the efficacy of uncovertebral anatomic targeting for cervical disc arthroplasty. Methods Anatomic uncovertebral midline targeting for disc arthroplasty insertion was performed in 18 male (mean age 51 years, range 27 to 67) and 22 female (mean age 50, range 35 to 70) patients receiving a total of 59 implants over a 5-year period. Device insertion was under only lateral imaging control. Postinsertion operative fluoroscopy with optimized centering was used to record implant position in the anteroposterior plane, and centerline analysis was performed using cursor measurement technology from the GE PACS™ imaging system (GE Medical Systems, Mt. Prospect, IL). Results Analysis found a mean deviation from the ideal midline placement of only 0.7 mm (range, 0 to 2.9 mm). Only three devices were more than 2 mm off the anatomic midline. Conclusion This anatomic technique is effective, safely minimizing imaging resource needs and X-ray exposure to the patient and operating team.

Tranexamic acid for hemostasis in the surgical treatment of metastatic tumors of the spine

STUDY DESIGN

This is a retrospective study of sequential cohorts.

OBJECTIVE

To assess the efficacy of tranexamic acid in decreasing operative blood loss and the need for intraoperative transfusion in metastatic spine surgery.

SUMMARY OF BACKGROUND DATA

Significant published data have established the efficacy of antifibrinolytic drugs in limiting surgical bleeding during heart surgery and total joint replacement. One study in scoliosis suggested benefit in spine surgery as well.

METHODS

During a 6-month trial period, 14 patients with spine cancer undergoing palliative intralesional tumor excision and concomitant instrumentation to stabilize the spine in the hands of a single surgeon were administered tranexamic acid intraoperatively in the attempt to minimize operative blood loss. They were then compared to the immediately preceding 14 patients.

RESULTS

Estimated operative blood loss was 1385 mL in the study group treated with tranexamic acid and 1815 mL in controls not receiving the drug, and was not found to be significantly decreased in this study.

CONCLUSIONS

Control of operative bleeding in metastatic spine surgery can be problematical. Optimum protocol might include routine preoperative angiographic tumor embolization to decrease lesion vascularity in all cases, but angiography is not without risk. Noninvasive prophylaxis of tumor bleeding would have obvious desirable advantages but was, unfortunately, not achieved in this study.

Failure of reconstitution of open-section, posterior iliac-wing bone graft donor sites after lumbar spinal fusion. Observations with implications for the etiology of donor site pain

The objective of this cohort study--conducted at a regional trauma unit in southern Ontario, Canada--was to review the imaging history of open-section, iliac-wing bone graft donor sites in lumbar fusion patients. Intervention entailed review of available X-ray and CT scan images for all patients undergoing lumbar fusion with iliac autograft in the senior author's practice over a 4-year period. Outcome was radiographic confirmation of the absence of bony reconstitution at the iliac harvest site. Of 239 primary fusions performed, 209 complete imaging records were available for review. The images of a further 20 patients who had surgery with the senior author prior to the study period and who presented at the office in the first half of 2000 were also assessed. All cases showed persistence of the iliac donor harvest site defect. Only minimal marginal sclerosis to suggest attempted remodeling was observed. We conclude that iliac-wing bone graft donor sites do not remodel. Given that iliac harvesting is known to increase strain in the pelvis, and that lumbosacral stabilization increases stress in the pelvis, permanent deficiency of iliac bone stock at donor harvest site may be a factor in both primary donor site pain and the observed high frequency of this problem in lumbosacral fusion patients.

Nonbridging external fixation for fractures of the distal radius

OBJECTIVE

To assess the feasibility of using standard components from the small AO external fixator set to support fractures of the distal radius with a construct incorporating distal fixation in the periarticular radius fragment that would allow for primary mobilization of the wrist joint during fracture healing.

METHODS

In a prospective pilot study of a nonbridging external fixator in early 2001, 6 consecutive cases of fracture in the distal radius presenting at a tertiary care centre, the Hamilton General Division of Hamilton Health Sciences, were compared with 6 historical controls treated with a standard bridging construct immobilizing the wrist. Both groups were or had been treated with closed reduction and external fixation of the distal radius under fluoroscopic control. Fracture alignment was measured on radiographs after healing and removal of the fixation devices; additional (secondary) outcome measures were pin-tract sepsis and implant loosening (treatment failure).

RESULTS

Compared radiographically with controls, alignments after fracture healing were improved (and virtually anatomic) with use of the nonbridging external fixator. The incidence of pin-tract sepsis was similar in the 2 groups, neither of which included any treatment failures.

CONCLUSIONS

Nonbridging external fixation of comminuted distal radius fractures can be accomplished safely and effectively. The results of this pilot study suggest that improved radiographic alignment may be achieved with this technique.

Assessment of stability of the cervical spine in blunt trauma patients: review of the literature, with presentation and preliminary results of a modified traction test protocol

OBJECTIVE

To review the reported efficacy of various imaging techniques in assessing stability of the neck in blunt trauma patients, and to present the protocol and preliminary results of a modified traction test protocol.

DESIGN

This is a prospective cohort study.

SETTING

A regional trauma unit in Southern Ontario.

PATIENTS

People with blunt-trauma injuries who came to the author's consultant practice with "C-spine not cleared" status, from January 2001 through December 2003.

INTERVENTIONS

A fluoroscopically controlled test of axial traction followed by flexion/extension stressing.

OUTCOME MEASURES

Radiographic confirmation of the absence of pathological motion under load.

RESULTS

In 51 cases studied to date, no instabilities have been found. Four cases of minor ligamentous hypermobility have been detected, with stability confirmed and no surgery required. There have been no failures to depict the neck completely, no missed instabilities and no complications of the procedure.

CONCLUSIONS

Cervical stability can be reliably confirmed with this test without any requirement for advanced imaging technology.

Efficacy of orthotic immobilization of the unstable subaxial cervical spine of the elderly patient: investigation in a cadaver model

OBJECTIVE

To assess the efficacy of soft, semirigid and hard cervical collars to immobilize the neck in a destabilized cadaver model.

DESIGN

This is a laboratory experiment.

SETTING

The anatomy research lab of McMaster University.

PATIENTS

None. Fresh cadavers from elderly patients suffering terminal medical illness and free of cervical structural disease were studied.

INTERVENTIONS

Destabilizing discoligamentous lesions of the neck were created in the cadavers. Radiographs were taken in maximum displacement in the prone, decubitus and side-bending positions, first unsupported and then with soft, semirigid and hard collars applied. Displacements in angulation and translation were measured from the radiographs.

OUTCOME MEASURES

Radiographic displacement under gravity load.

RESULTS

In all cases there was no effective limitation of pathological displacement, and in many cases displacement was increased after collar application.

CONCLUSIONS

Cervical collars do not effectively support the unstable neck, and may be ineffective in preventing pathological displacements.

Tensile failure of C2 pedicles and of subsequent direct repair in a porcine model

STUDY DESIGN

This repeated-measures biomechanical study evaluated the tensile force required to cause bipedicular (hangman's) fractures in isolated porcine C2 specimens, and the subsequent force to failure after direct fracture repair with bipedicular lag screws.

OBJECTIVES

To assess the pullout strength of direct lag screw fixation of hangman's fracture, relative to the strength of the intact specimens.

SUMMARY OF BACKGROUND DATA

Clinical studies have reported successful treatment of hangman's fractures by direct screw repair followed by a collar after surgery. However, to the authors' best knowledge, there has not yet been a biomechanical analysis of the force required for screw pullout after direct repair.

METHODS

Of 60 mounted porcine C2 specimens subjected to tensile anteroposterior force, hangman's fracture occurred in 15 cases, 12 of which were fixed with bipedicular 4.0-mm lag screws. These fixed specimens were retested to failure in the same manner.

RESULTS

Most specimens had laminar fractures after the application of tensile force, with 15 of 60 (25%) showing bipedicular fractures. The force to bipedicular failure was 3259.1 +/- 148.5 N (mean +/- standard error of the mean). After screw fixation, the force to failure of the same specimens was 882.0 +/- 108.5 N (mean +/- standard error of the mean), or 27.3% of the intact bone.

CONCLUSIONS

The pullout strength was substantial (882 N), although the relative strength of fixation was only 27.3% of the fracture strength shown by the intact specimens. The findings are discussed in relation to previous studies. To the authors' best knowledge, this is the first study to examine screw pullout forces after direct repair of hangman's fracture.

Protocol and results of a day-surgical program for the removal of lumbar pedicle screw implants

The removal of potentially painful lumbar pedicle screw implants is a recognized procedure not yet extensively reported in the literature. The extensive dissection required to accomplish it is such that this operation is generally done on an inpatient basis. A defined protocol of pre-, intra-, and postoperative care was instituted in the senior author's practice in 1995, with the goal of accomplishing these operations on a day-surgical basis. We report the results of 70 such procedures performed in the calendar years 1995-1999 with attention to the efficacy of the protocol in facilitating ambulatory care. The protocol is safe and effective.

Relationship between pain and vertebral motion in chronic low-back pain subjects

OBJECTIVES

To investigate the relationship between intervertebral motion, intravertebral deformation and pain in chronic low-back pain patients.

DESIGN

This study measured vertebral motion of the lumbar spine and associated pain in a select group of chronic low-back pain patients as they performed a standard battery of motions in all planes.

BACKGROUND

Numerous studies have demonstrated that individuals with low-back pain have impaired spinal motion, yet few studies have examined the specific relationship between pain and motion parameters. Although it is accepted that the pain in mechanical low-back patients is due to specific spinal motions, no studies have related specific motions to pain measures.

METHODS

Percutaneous intra-pedicle screws were placed into the right and left L4 (or L5) and S1 segments of nine chronic low-back pain patients. The external fixator frame was removed following the clinical external fixation test. The 3D locations of the pedicle screws and the level of pain were recorded as the subjects performed a battery of motions. The relationship between the pain and motion parameters was assessed using linear discriminant analysis and neural network models.

RESULTS

The neural network model showed a strong relationship between observed and predicted pain (R(2)=0.997). The discriminant analysis showed a weak relationship (R(2)=0.5).

CONCLUSIONS

Vertebral motion parameters are strongly predictive of pain in this select group of chronic low-back pain patients. The nature of the relationship is nonlinear and involves interactions; neural networks are able to effectively describe these relationships.

RELEVANCE

Specific patterns of intervertebral motion and intravertebral deformation result in pain in chronic low-back pain patients. This substantiates the mechanical back pain aetiology.

Postoperative Clostridium perfringens lumbar discitis with septicemia: report of a case with survival

This case report describes the successful treatment of a case of Clostridium perfringens postoperative discitis and suggests a management protocol for this condition. The medical literature to date reports only one similar case, treated without success. The patient has been well but the affected space later collapsed with mechanical pain and has required fusion. C. perfringens discitis can be treated successfully.

Surgical management of lumbar degenerative spinal stenosis with spondylolisthesis via posterior reduction with minimal laminectomy

Degenerative lumbar spondylolisthesis with spinal stenosis is commonly treated with laminectomy. Recent reports have consistently supported the incremental clinical benefit of associated in situ arthrodesis with or without instrumentation. Resection of the lamina may result in intraoperative dural tear or epidural scar formation. Fifty-six consecutive patients with back pain, neuroclaudication, or both, in addition to degenerative spondylolisthesis with spinal stenosis, underwent a surgical procedure that incorporated fusion after reduction of the spondylolisthesis deformity with preservation of the lamina and the balance of the posterior elements. Clinical records were reviewed and patients interviewed at a mean of 33 months after surgery. Oswestry Disability Index scores were obtained independently at baseline and at a late review. Late imaging was available a mean of 28 months after operation. Clinical and imaging analyses and Oswestry scoring confirmed results comparable to the published outcomes of in situ fusion after formal laminectomy. Resection of the lamina may not be necessary in the treatment of degenerative lumbar spinal stenosis with spondylolisthesis.

Failure of external spinal skeletal fixation to improve predictability of lumbar arthrodesis

BACKGROUND

Whether lumbar arthrodesis can relieve isolated low-back pain in the absence of focal neurological findings or instability is unclear. The results of published studies are also inconsistent with regard to whether temporary back-pain relief with external spinal skeletal fixation can predict lasting back-pain relief after arthrodesis. This report presents the results, with regard to clinical benefit and complications, of more than 100 external spinal skeletal fixation procedures undertaken as a prelude to lumbar arthrodesis.

METHODS

The records of all patients who underwent external spinal skeletal fixation between 1989 and 1999 were reviewed with attention to perioperative complications, pain relief from the test procedure, the clinical benefit from a subsequent arthrodesis, and the functional status after the arthrodesis. Analyzed data included the frequency of neurological complications and infections and the benefit (Prolo score) after staged spinal arthrodesis in patients who underwent arthrodesis after temporarily experiencing pain relief with the test procedure.

RESULTS

A total of 103 external spinal skeletal fixation procedures were undertaken. Neurological complications occurred in two procedures (2%); one resulted in permanent sciatica. Infections occurred in five patients (5%). Sixty patients experienced pain relief during the external fixation test, but only twenty-seven of forty-nine patients who went on to have an arthrodesis and had sufficient follow-up reported that they were doing well at a minimum of one year later. In no case did the external spinal skeletal fixation procedure cause a permanent increase in low-back pain.

CONCLUSIONS

On the basis of this analysis, external spinal skeletal fixation should not be used as a predictor of pain relief after lumbar arthrodesis.

Analysis of factors affecting successful discharge in patients undergoing lumbar discectomy for sciatica performed on a day-surgical basis: a prospective study of sequential cohorts

This is a prospective study of sequential cohorts of patients undergoing elective lumbar discectomy scheduled on a day-surgical basis between April 1995 and October 1998, representing all such cases from the author's practice during the review period. Preliminary review of the first 38 cases was undertaken 18 months after this surgical program was initiated and revealed an 18% rate of failure in achieving same-day discharge. Subsequent review of the balance of 92 additional cases revealed this failure rate was decreased to only 2% through a combination of appropriate perioperative patient education and the institution of a low-dose perioperative narcotic routine.

Measuring collagen fiber orientation: a two-dimensional quantitative macroscopic technique

This paper describes the design, evaluation, and application of a new system for quantifying two-dimensional collagen fiber orientation in soft tissue. Series of transmitted polarized light images were collected using a custom-designed macroscope. Combined analysis of pixel brightness, and hue from images collected with a compensator plate, permitted the assignment of each pixel into the appropriate orientation band. Experiments were performed to quantify the linearity and noise of the system. Validation was performed on a specimen composed of strain-birefringent plastic strips at various orientations. Preliminary collagen fiber orientation data is presented from a tendon specimen. This study demonstrates the utility of this approach for studying collagen fiber orientation across large areas.

Procurement of bone graft from the iliac crest. An operative approach with decreased morbidity

We compared the donor site morbidity in fifty-seven consecutive patients in whom a bone graft had been procured from the iliac crest through an incision parallel to the superior cluneal nerves and perpendicular to the posterior iliac crest (the study group) with that in fifty-three consecutive patients in whom the graft had been procured through an oblique incision parallel to the posterior iliac crest (the control group). Numbness, tenderness, and pain at the donor site one and six months postoperatively were assessed by means of an interview with the patient and a review of the records. The prevalence of symptoms in the control group was greater than that in the study group. At one month, thirty-nine patients (74 per cent) in the control group had numbness, compared with twenty-five (44 per cent) in the study group (p = 0.001). At six months, thirty-one patients (58 per cent) in the control group had numbness, compared with fourteen (25 per cent) in the study group (p = 0.0002). Thirty-six patients (68 per cent) in the control group and twenty-four (42 per cent) in the study group had tenderness over the incision at one month (p = 0.005), and twenty-seven (51 per cent) and eleven (19 per cent), respectively, had tenderness at six months (p = 0.0003). Forty patients (75 per cent) in the control group and forty-six patients (81 per cent) in the study group had deep pain in the region of the iliac crest at one month, compared with thirty-two (60 per cent) and thirty-one (54 per cent), respectively, at six months. The mean analog score for pain at the donor site was 7 of 10 points in the control group and 6 points in the study group (p = 0.001) at one month and 3 and 2 points, respectively, at six months (p = 0.001).

New insight into the mechanics of the lumbar interspinous ligament

STUDY DESIGN

Repeated in vitro mechanical tests were performed on porcine and human interspinous ligament specimens with progressive disruption of the collagen fiber network to evaluate the existence of mechanical interactions between collagen fibers.

OBJECTIVE

To evaluate the existence of a load pathway in the interspinous ligament whereby loads are transmitted between collagen fibers.

SUMMARY OF BACKGROUND DATA

Mechanical tests demonstrate that the interspinous ligament resists spinal flexion, but the collagen fibers are not oriented to oppose separation of the spinous processes. This seeming contradiction could be explained by the existence of mechanical interactions between collagen fibers of the interspinous ligament.

METHODS

In vitro mechanical tests were performed on porcine and human bone-interspinous ligament-bone specimens. The collagen network of the ligament substance was disrupted by passing a scalpel blade though the ligament substance. Repeated tests were performed with progressive disruption of the collagen fiber network.

RESULTS

The stiffness of the interspinous ligament specimens was reduced as the collagen fiber network was disrupted, but approximately half of the initial stiffness was maintained when the collagen fiber network was severely disrupted. In this case, no intact collagen fibers remained.

CONCLUSIONS

Mechanical interactions exist between collagen fibers in the interspinous ligament. The mechanism of the interactions is unknown.

External spinal skeletal fixation in the management of back pain

External spinal skeletal fixation, pioneered by the Association for the Study of Internal Fixation as an alternative in thoracolumbar fracture management, has been effective in temporarily relieving mechanical low back pain. This investigational technique was been proposed as an alternative in the selection of patients with back pain as candidates for pain relief through fusion. This is the report of a prospective and randomized clinical trial that has defined prognostic benefit (good outcome in 61% of control patients versus 90% of the study group) in selecting patients with mechanical back pain (verified through facet blocks or discograms) as candidates for pain relief through fusion surgery.

Identifiable risk factors for secondary neurologic deterioration in the cervical spine-injured patient

STUDY DESIGN

This was a retrospective prevalence study.

OBJECTIVE

A review of structural cervical spine injuries (fracture or dislocation) treated at a regional spine injury referral center from 1987 to 1992 was undertaken to identify and analyze patients who had secondary neurologic deterioration after they had arrived and had primary assessment in stable neurologic condition (intact or compromised, but not evolving).

SUMMARY OF BACKGROUND DATA

Multiple case reports and cohort studies have suggested possible risk factors for late neurologic deterioration without probabilities analysis.

METHODS

Information was obtained retrospectively from clinical records and radiographs. Three-hundred-twelve cases were reviewed. Thirty-one were excluded and 281 were analyzed.

RESULTS

An index group of 15 patients (5%) had motor neurologic deterioration after primary assessment at the referral center. Control group "A" was composed of 70 patients (25%) who had a motor neurologic deficit on admission and did not deteriorate. Control group "B" was the balance of 196 patients (70%) with structural cervical injuries, but no neurologic compromise. Factors distinguishing the index group from control subjects included flexural mechanism of injury and chronic multilevel spinal arthritis with ankylosis. All secondary deteriorations occurred with the injury level caudad to the fourth cervical vertebra. Routine three-view cervical radiographs were relatively insensitive in detecting injury in the index group compared with the pooled control subjects. Patients' ability to comply with recommended treatment was not a factor in secondary deteriorations and there generally was no identifiable precipitant event before secondary deterioration.

CONCLUSION

Cervical traumatized patients with flexural injury or chronic multilevel spinal arthritis with ankylosis are at increased risk of having secondary motor neurologic deterioration.

Observations on the pathomorphology of the thoracolumbar fascia in chronic mechanical back pain. A microscopic study

STUDY DESIGN

Human tissue specimens were examined for the presence of neural end-organs under light and electron microscopy.

OBJECTIVES

To define the innervation of the thoracolumbar fascia in problem back pain patients who have articular abnormality defined through pain-provocation discography or facet blocks.

SUMMARY OF BACKGROUND DATA

Previous investigators have defined the presence of innervation in control (no back pain) tissue specimens.

METHODS

Tissue specimens were harvested during surgery from 24 back pain patients who had not undergone previous lumbar surgery. Specimens were fixed immediately in the operating room and later processed and studied under light and electron microscopy.

RESULTS

Structural and ultrastructural studies failed to identify specific neural end-organs in any of the specimens. Serendipidously, microscopic changes suggestive of ischemia or inflammation in this tissue were found.

CONCLUSIONS

These findings suggest that the thoracolumbar fascia may be deficiently innervated in problem back pain patients.

Management of type II odontoid process fractures in geriatric patients; a prospective study of sequential cohorts with attention to survivorship

After institutional review defined an unacceptable mortality rate in nonoperative treatment of elderly patients with odontoid process fracture without neurological deficit, we undertook a prospective study to determine the influence of early surgical stabilization on perioperative mortality in geriatric odontoid process fracture patients without neurologic injury. Analysis suggests that acute perifracture mortality in this high-risk group can be significantly decreased and potentially eliminated by this approach.

Anterior and posterior spinal fusion: comparison of one-stage and two-stage procedures

OBJECTIVE

To compare postoperative morbidity and length of hospital stay after combined anterior and posterior spinal fusion for patients treated by a one-stage procedure and those treated in two stages, 1 to 2 weeks apart.

DESIGN

Retrospective review of all cases handled by the first author between July 1989 and November 1991. The patients had been referred for treatment of severe spinal deformity, scoliosis or kyphosis by combined anterior and posterior spinal fusion.

SETTING

The operations were performed at McMaster University Medical Centre, Hamilton, Ont., by the first author, who was assisted by another specialist in spinal surgery and a fellow or resident.

PATIENTS

Eleven operations of each type were performed. The mean age of the 22 patients was 16.6 and 14.6 years for those who underwent the one-stage and the two-stage procedures respectively. The diagnoses included neuromuscular disease, neurofibromatosis, spina bifida, congenital kyphoscoliosis and severe idiopathic spinal curvature. The one-stage procedure was used after the surgical team became able to provide the care associated with this type of major surgery; selection of patients also involved preoperative risk assessment and the feasibility of combining two surgical procedures that would take a maximum of 9 hours. The preoperative plan was to spend a maximum of 9 hours in performing the one-stage procedure.

INTERVENTIONS

Similar surgical procedures were performed in both groups. The average number of intervertebral levels fused during the anterior component of the operation was 4.6 in the one-stage procedure and 6.0 in the two-stage procedure. Thoracolaparotomy was performed in four patients who underwent the two-stage procedure. During the posterior component of the operation, instrumentation was inserted through an average of 11.6 and 12.6 intervertebral levels in the groups undergoing the one-stage and the two-stage procedures respectively. Total operating time averaged 7 hours and 15 minutes for the one-stage procedure and 11 hours for the two-stage procedure. Mean blood loss was 1830 mL for the one-stage procedure and 2270 mL for the two-stage procedure.

MAIN OUTCOME MEASURES

The number of days spent in the intensive care unit (ICU) and the total number of days spent in hospital, as well as morbidity after the operation, were determined.

RESULTS

Postoperative morbidity included five minor complications in patients who underwent a one-stage procedure; all of these complications resolved well. Among those who underwent the two-stage procedure there were 11 complications; in two patients further surgery was required. The patients' stay in the ICU averaged 2.6 and 7.7 days respectively for one-stage and two-stage procedures, and the total stay in hospital averaged 14 and 33 days respectively.

CONCLUSIONS

When possible, the one-stage procedure for anterior and posterior spinal fusion is preferred over the two-stage procedure because of a significant reduction in the length of stay in the ICU and in hospital, as well as reduced morbidity. However, this analysis should be interpreted cautiously because of the small number of cases and the variables encountered in treating this type of spinal deformity.

Intramedullary nailing of femoral shaft fractures: reoperation and return to work

OBJECTIVE

To define the functional outcome and residual disability in adults treated for isolated femoral shaft fractures.

DESIGN

A retrospective case study of HMRI records. The mean follow-up was 34.5 months from the time of injury.

SETTING

A tertiary-care teaching hospital.

PATIENTS

One hundred and thirty adults with femoral shaft fractures. Of these, 47 were isolated and qualified for study.

INTERVENTIONS

Primary reamed intramedullary nailing performed between April 1987 and September 1990.

MAIN OUTCOME MEASURES

Reoperation and return to work.

RESULTS

Of the 47 patients, primary healing occurred in 41 (87%) patients; 6 (13%) patients had delayed union or nonunion. Twenty (43%) patients had delayed implant-related pain after fracture healing; 85% of these had relief of pain after implant removal. Of 41 patients available for analysis of function based on return to work, 33 (80%) had returned to work full time in their original occupation at the time of follow-up, and 4 (10%) were working in other full-time employment; 3 (7%) were working part time. Only one (2%) patient was disabled and unable to work.

CONCLUSIONS

Primary reamed intramedullary nailing is an effective method of achieving consistent primary union in adults with femoral shaft fractures. However, the majority of patients will require secondary surgery. Most patients will be able to return to work after these injuries.

Complications of forearm-plate removal

Reconstruction of long-bone fractures with compression plates may give rise to stress shielding under the metal plate, which may be associated with late clinical problems due to insufficiency fractures around the implants. Therefore, it is common practice to remove forearm plates after fracture healing is completed. Increasing concern has been expressed recently about the complications and morbidity associated with forearm-implant removal. A retrospective review of the management of 111 forearm diaphyseal fractures at a major Canadian centre confirmed a substantial complication rate in elective forearm-plate removal. Because the true incidence of late insufficiency fracture is not well defined, elective forearm-plate removal may be contraindicated in the asymptomatic patient.

Lumbosacral fusion in a patient with recurring Guillain-Barré syndrome and acute brachial neuritis

A lumbar decompression and fusion with instrumentation was successfully completed on a patient with a history of acute brachial neuritis (ABN) and recurring Guillain Barré syndrome (GBS). Three weeks post-surgery there was a mild exacerbation of the GBS, which resolved with plasmapheresis. This case report shows that surgery may be conducted safely on a patient whose history includes GBS and ABN, without devastating neurological consequences.

Screw fixation of odontoid fractures and nonunions

Surgical treatment of odontoid fractures has usually been carried out by C1-2 arthrodesis rather than by fracture fixation. An alternative treatment of compression screw fixation was used to treat selected acute odontoid fractures and nonunions. Ten patients were operated on. A variety of lag-screw types were used to compress and secure the fracture. Screw placement was considered excellent in five cases; in four, the screw tip protruded through the posterosuperior cortex of the dens by 1-3 mm. One patient died as a result of multiple injuries 2 days after surgery. In all other cases, including four cases of odontoid pseudarthroses, the fractures achieved solid union. It was concluded that screw fixation can be used for the successful treatment of selected odontoid fractures and nonunions.

Surgical palliation of spinal oncologic disease: a review and analysis of current approaches

The clinical problem of primary and secondary vertebral tumours is encountered with increasing frequency throughout North America as oncologic management protocols evolve and the population continues to age. These lesions can present problems of pain, instability and paralysis. Optimal surgical palliation is often of benefit when more conservative methods have been unsuccessful. Vertebral tumours can be approached either anteriorly or posteriorly. These alternatives have led to the evolution in the clinical community of two "camps" championing their respective approaches. The authors have reviewed the accumulated literature up to December 1988 and have found that anterior approaches offer improved clinical outcome without substantially increased morbidity.

Post-traumatic compartment syndrome of the foot

Post-traumatic compartment syndrome in the foot is an unusual but well-recognized entity. If there is an awareness of the condition at the time of presentation it can be diagnosed and treated effectively. A case of compartment syndrome in the foot of a 17-year-old boy after massive lower-extremity trauma is described. The simple and readily available diagnostic techniques are emphasized and an alternative approach to plantar decompression, which avoids exposure of and potential damage to the posterior tibial neurovascular bundle, is presented.

The spinal pedicle screw: techniques and systems

New spine instrumentation systems are being developed that incorporate pedicle screws for purchase. This review article outlines techniques for the safe insertion of these devices. A description of the various screw-rod and screw-plate systems currently available is presented.

Mycotic abdominal aortic aneurysm: a case report

A case of mycotic aneurysm of the abdominal aorta, arising as a complication of subacute bacterial endocarditis in a 75-year-old white woman, is presented. The dramatically expansile nature of this aneurysm is well documented. The history, clinical presentation, etiology, microbiology and surgical management of this rapidly progressive and often fatal condition are discussed through a review of the literature.