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Study Design: Overall quality of life after surgical management of metastatic disease of the spine was prospectively assessed using a validated global health status quality-of-life instrument-the Edmonton Symptom Assessment Scale., Objectives: To prospectively evaluate the efficacy of surgery in patients with metastatic spinal disease with respect to quality of life., Summary of Background Data: Management of spinal metastases is palliative and is aimed at improving quality of life at an acceptable risk. Although previous studies have evaluated physical outcomes, improvements in pain, and neurologic function after surgery, a multidimensional assessment of quality of life is more relevant in the palliative patient., Methods: Twenty-five consecutive patients undergoing surgery for spinal metastases were prospectively evaluated. Pre- and postoperative assessments were performed using the Edmonton Symptom Assessment Scale. The surgical procedure consisted of decompression and instrumented stabilization., Results: After surgery, the largest improvement was noted in the domain of pain (P < 0.00001). There were also significant improvements noted in the domains of tiredness (P = 0.004), nausea (P = 0.01), anxiety (P = 0.006), drowsiness (P = 0.044), appetite (P = 0.02), and well-being (P = 0.004)., Conclusions: The current study demonstrates that in the appropriate patient, surgical management brings about a positive effect on the overall quality of life in patients with spinal metastases. The greatest benefit occurred in the reduction of a patient's level of pain.

Study Design: Two patients had postoperative posterior migration of titanium fusion cages after posterior lumbar interbody fusion. They underwent a repeat posterior procedure and posterior fusion with pedicle screws., Objective: To suggest a treatment for posterior migration of titanium-threaded cages causing spinal stenosis after posterior lumbar interbody fusion., Summary of Background Data: The use of titanium fusion cages in posterior lumbar interbody fusion is gaining popularity as a technique for arthrodesis. The literature contains only a few reports concerning complications associated with their use., Methods: Two patients had retropulsion of titanium threaded cages, ten days and 2 months after posterior lumbar interbody fusion. The retropulsed cages compressing the dura, caused sudden onset of back pain and radiating pain to the lower extremities. Both patients underwent repeat posterior procedure that included repositioning of the cages and posterior fusion with pedicle screws., Results: Symptoms of back and leg pain subsided after repositioning of the cages and application of the pedicle screws., Conclusions: A repeat posterior approach and repositioning of the retropulsed titanium fusion cages in addition to posterior fusion with pedicle screws successfully managed this complication.

Study Design: This is a report of a rare presentation of a split cord malformation with diastometamyelia., Objectives: This report draws attention to the fact that the only manifestation of diastmetamyelia in the adult patient may be neurogenic claudication., Summary of Background Data: Patients with split cord malformations and diastometamyelia rarely have symptomatic onset in adulthood. When present, a traumatic event leading to an acute neurologic change is the usual presentation., Methods: An adult patient presented with symptoms of neurogenic claudication in the left leg. Magnetic resonance imaging examination showed a split cord malformation and diastometamylia at L3-L4 with spinal stenosis of the left hemicord. Decompressive laminectomy and subtotal resection of the bony spur were performed., Results: Two years after decompression, the patient has complete resolution of his leg symptoms and is back to work., Conclusions: Neurogenic claudication without any objective neurologic deficit or neurocutaneous stigmas of an underlying spinal cord abnormality may be the only presentation in the adult with diastometamyelia. Decompression to relieve both clinical and radiologic evidence of spinal stenosis obtained excellent outcome.

Study Design: Insertion torque and pull-out strengths of conical and cylindrical pedicle screws were compared in human cadaveric vertebral bodies., Objectives: To compare the performance of the conical design with the cylindrical design, and to determine whether insertional torque correlates with pull-out strength., Summary of Background Data: A tapered pedicle screw design may lessen the likelihood of implant failure. Its effect on thread purchase is not known. Previous studies of cylindrical designs on the relation between insertion torque and pull-out strength have been conducted in bovine and synthetic bone., Methods: Seventy-eight pedicles were assigned randomly to one of the following pedicle screw: Texas Scottish Rite Hospital (Sofamor-Danek, Memphis, TN), Steffee VSP (Acromed, Cleveland, OH), Diapason (Dimso, Paris, France), AO Schanz (Synthes, Paoli, PA), or Synthes USS (Synthes, Paoli, PA). Pedicle screws were inserted with a torque screwdriver. Each screw was extracted axially from the pedicle at a rate of 1.0 mm/sec until failure using an MTS machine (Bionix 858, Minneapolis, MN). Force data were recorded., Results: The conical design had the highest insertion torque. There were no significant differences in pull-out between any of the screw types. Correlation between insertional torque and pull-out strength was statistically significant only with the Texas Scottish Rite Hospital and Steffee VSP in L4 and AO Schanz in L5., Conclusions: A conical screw profile increases insertion torque, although insertional torque is not a reliable predictor of pull-out strength in cadaveric bone. Screw profile (with similar dimensions) has little effect on straight axial pull-out strengths in cadaveric bone.

Study Design: A patient with open posterior dislocation of the lumbosacral junction is reported., Objectives: Treatment with primary anterior open reduction with internal fixation followed by delayed posterior stabilization and fusion., Summary of Background Data: This injury has been reported previously on two occasions; however, anterior stabilization was not used. In this case, anterior fixation was necessary because of the posterior soft tissue contamination., Methods: After an anterior open reduction of L5-S1, stabilization was performed using instrumentation. Posterior wound care was then performed, with delayed posterior fusion and instrumentation of L5-S1 at 2 weeks., Results: At 18 months there was solid fusion of the lumbosacral junction with no evidence of infection., Conclusions: Satisfactory results were obtained when principles of open fracture management were followed. Primary anterior stabilization allowed appropriate wound care. Definitive posterior stabilization and fusion can be done when soft tissue stability is obtained.