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STUDY DESIGN Retrospective study of a consecutive series of operatively managed patients with cervical fractures with diffuse idiopathic skeletal hyperostosis (DISH) presenting to 3 institutions over an 8 year period. OBJECTIVE Assess demographics, fracture characteristics, outcome and complications in patients managed surgically. SUMMARY OF BACKGROUND DATA Cervical spine injuries related to DISH represent a difficult subgroup of trauma patients to treat. This subset is fraught with potential complications related to the injury of the ankylosed spine, high rate of co-morbidities, and older demographics. The data in the literature on treatment, outcomes and complications is largely comprised of case reports and small case series. METHODS All patients with cervical fractures in the setting of DISH between January 2001 and December 2008 were reviewed retrospectively. Charts and radiographs were reviewed assessing demographics, injury characteristics and short-term outcomes. Statistical analysis was performed analyzing the impact of distinct parameters on the incidence of medical and surgical complications. RESULTS Thirty-three patients with age 73.8 ± 11 years were identified. DISH-affected segments numbered 5.5 ± 2.1. Injury severity as assessed by the Subaxial-Injury-Classification scoring-system (SLIC) averaged 7.2 ± 1.4 points. 7 patients (20.6%) were ASIA-A on admission, 4 (11.8%) ASIA-B, 4 (11.8%) ASIA-C, 10 (29.4%) ASIA-D, and 7 (20.6%) ASIA-E. All but 2 patients (6%) had medical co-morbidities. Inpatient stay was 26.6 ± 23.4 days. 16 patients (47%) had anterior, 12 patients (35.3%) had posterior, and 5 patients (14.7%) had combined anterior-posterior instrumented fusion. 25 patients (73.5%) had medical/surgical complications. 20 patients (58.8%) suffered serious pulmonary complications not related to the neurologic injury (p < 0.05). Nine patients (26.5%) had died. Seven patients (20.6%) showed improved ASIA-scores, 18 patients (52.9%) had no improvement and 2 patients (5.9%) deteriorated. CONCLUSION The current findings pinpoint the potential for medical and surgical complications in this high risk subgroup. Surgeons should be aware of the unique aspects associated with treatment of these injuries.

STUDY DESIGN Case report and literature review. OBJECTIVE To discuss the diagnosis, limitations, and treatment of combined occipital-cervical and atlantoaxial disassociation with normal neurologic function. SUMMARY OF BACKGROUND DATA Injuries to the craniocervical junction can lead to devastating neurologic deficits. Occipital-cervical disassociation is a well-documented injury pattern that can lead to pain, spinal cord injury, and death. Early diagnosis and treatment can preserve neurologic function. Combined injuries to both the occipital-cervical and atlantoaxial segments are less common and, to date, have only been described with severe neurologic injury. METHODS Retrospective review of a case. Literature review was performed through Medline and Pubmed searches. RESULTS This is the first case to present a combined occipital-cervical and atlantoaxial disassociation with a neurologically intact patient. Initial physical examination was limited, but early imaging revealed evidence of instability. Early diagnosis and early (< 24) surgical stabilization was performed with no complications and neurologic preservation. One-year follow-up visit revealed normal neurologic examination with neck pain VAS = 2/10 and neck disability index = 6. CONCLUSION Combined injuries to the occipital-cervical and atlantoaxial can result in upper cervical instability. Despite previous reports, neurologic preservation remains a possibility in this injury pattern. Limitations in physical examination and radiographic imaging persist, but early diagnosis and surgical stabilization may improve neurologic outcomes.

STUDY DESIGN Retrospective cohort study using a large clinical database. OBJECTIVE Assess hospital-based rates of thoracolumbar spine arthrodesis within the United States for patients with a thoracolumbar spine fracture. SUMMARY OF BACKGROUND DATA Substantial variation has been documented in per capita rates of elective lumbar spinal arthrodesis. Similar data regarding rates of arthrodesis for traumatic thoracolumbar injuries have not been reported. METHODS Data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2002 was used. ICD-9-CM codes were used to identify patients with thoracolumbar vertebral fractures with and without associated neurologic injury. Hospitals were grouped by teaching status and volume of thoracolumbar fracture patients and compared for rates of arthrodesis. Arthrodesis rates for the 25 highest fracture volume hospitals in the database were compared individually. RESULTS A total of 24,098 patients with thoracolumbar fracture were identified: 91.7% had a thoracolumbar fracture without neurologic injury, while 8.3% had a thoracolumbar fracture with neurologic injury. Overall, 9.1% of thoracolumbar fracture patients without neurologic injury underwent arthrodesis, while 61.4% of thoracolumbar fracture patients with neurologic injury underwent arthrodesis. For all patients, rates of arthrodesis at high-volume hospitals were significantly greater than arthrodesis rates at lower-volume hospitals. Similarly, urban teaching hospitals had higher rates of arthrodesis than those at urban nonteaching hospitals. Among the 25 highest-volume hospitals in our sample, spinal arthrodesis rates for patients without associated neurologic injury ranged from 4% to 23%, a 5.8-fold variation. Among fracture patients with neurologic injury, arthrodesis rates ranged from 50% to 91%, a 1.8-fold variation. CONCLUSION Hospital teaching status and spine fracture volume affected rates of spine arthrodesis in thoracolumbar fracture patients with and without neurologic injury. Variability in fusion rate for thoracolumbar spine trauma appears to be lower than that reported for elective spine procedures, especially in the presence of a neurologic injury.

Study design Case report. Objective To report the occurrence of a rare complication following revision of a spinal cord stimulator. Summary of background data Puncture of the dura with placement of an electrode within the spinal cord has not been reported as a complication of spinal cord stimulation. Methods A patient presented with upper and lower extremity weakness following inadvertent placement of an electrode into the spinal cord. The clinical case is presented as well as review of the literature. Results The patient had the electrode successfully removed; however, her neurologic status deteriorated. Conclusion Revision of spinal cord stimulators is usually a safe procedure. However, placement of an electrode within the spinal cord during the revision process is a potential complication resulting in severe neurologic injury.

Study Design. Case presentation. Objectives. To review the diagnosis and treatment of rare anterior lumbosacral fracture dislocations. Summary of Background Data. The severity of closed anterior and open and closed posterior lumbosacral dislocations has been documented; however, there have been no reports of open anterior lumbosacral dislocations in the literature. Two patients are reported who experienced acute open anterior lumbosacral fracture dislocations. Methods. Review of the patient history and physical examination, radiologic review, operative techniques, and a review of the literature. Results. Fractures healed in both patients, with no major infections. Both patients had persistent neurologic deficits at last follow-up. Conclusions. Open lumbosacral fracture dislocations are complex injuries that require diligence on the part of the surgeons involved to recognize the severity of the injury, to prevent or resolve any infectious process, to prevent further neurologic injury, and then to obtain and maintain alignment of the spine on the pelvis.

Study design A prospective review was done of a new intraoperative technique developed to detect and prevent neurologic compromise during pedicle screw insertion. Objectives To describe in sufficient detail the technique of persistently electrified pedicle stimulation instruments, so that this technique will be available generally to all clinical neurophysiologists and spine surgeons; and to demonstrate the use, typical results, interpretation, and protocol of the technique. Summary and background data Fusion techniques that use pedicle instrumentation have the potential to cause nerve root injury. Several authors have proposed imaging and neurophysiologic methods to improve outcome. The present method represents a significant theoretical departure and advance from previously reported methods. Methods All relevant instruments used during pedicle instrumentation were converted easily, inexpensively, and quickly into monopolar stimulators with appropriate stimulus voltages to identify broaches of pedicle bone via evoked-electromyograms from relevant muscle groups. Results The persistently electrified pedicle stimulation instrument technique provided accurate intraoperative neurophysiologic information concerning pedicle, integrity in the patients studied. The protocol is standardized and adaptable easily, inexpensively, and quickly to most clinical applications. Conclusions The persistently electrified pedicle stimulation instrument technique described here is useful for monitoring instrumented lumbar fusion procedures. The use of this protocol may help confirm intraosseous placement of pedicle screws and prevent neurologic injury.

Traumatic facet dislocation of the lumbosacral joint is uncommon. This report of a bilateral L5-S1 facet dislocation is compared with prior reported unilateral and bilateral cases with respect to mechanism of injury, neurologic injury, surgical reduction and fixation, and clinical outcome. Attention to the disk injury is recognized as essential to prevent cauda equina or root compression after reduction and fixation of the dislocation.

Study design Systematic review. Objective To review the published literature on the use of pedicle screws in pediatric spinal deformity to quantify the risks and complications associated with pedicle screw instrumentation, particularly in the thoracic spine. Summary of background data The use of pedicle screws in adolescent scoliosis surgery is common. Although many reports have been published regarding the use of pedicle screws in pediatric patients, there has been no systematic review on the risks of complications. Methods PubMed, Ovid Medline, and Cochrane databases were searched for studies reporting the use of thoracic pedicle screws in pediatric deformity. We excluded articles dealing with neuromuscular scoliosis or bone dysplasia to focus mostly on adolescent thoracic idiopathic scoliosis and the likes. We then searched for cases reports dealing with thoracic pedicle screws complications. Results This systematic review retrieved 21 studies with a total of 4570 pedicle screws in 1666 patients. The mean age of the patients was 17.6 years; 812 patients were women and 252 were men, and 5 studies did not identify sex. Overall, 518 (4.2%) screws were reported as malpositioned. However, in studies in which postoperative computed tomography scans were done systematically, the rate of screw malpositioning was as high as 15.7%. The reported percentage of patients with screw malpositioned is around 11%. Eleven patients underwent revision surgery for instrumentation malposition. Other complications reported include loss of curve correction, intraoperative pedicle fracture or loosening, dural laceration, deep infection, pseudarthrosis, and transient neurologic injury. There were no major vascular complications reported in these 21 studies. We could identify 9 case report articles dealing with complications of pedicle screws. Such complications were mostly either vascular (10 cases) or neurologic (4 cases), without any irreversible complications. Conclusion Malposition is the most commonly reported complication of thoracic pedicle screw placement, at a rate of 15.7% per screw inserted with postoperative computed tomography scans. The use of pedicle screws in the thoracic spine for the treatment of pediatric deformity has been reported to be safe despite the high rate of patients with malpositioned screws (11%). Major complications, such as neurologic or vascular injury, were almost never reported in this literature review of case series. Cases reports on the other hand have started to identify such complications.

Study Design. A cadaveric specimen study. Objectives. To determine the applicability of a modified C2 translaminar screw placement in the general adult population and to provide pertinent clinical data for screw insertion. Summary of Background Data. C2 intralaminar screw fixation has recently been popularized, but this technique carries a potential drawback that the screw may breakout ventrally into the spinal canal. For this reason, a modified C2 translaminar screw fixation technique was developed to intraoperatively verify screw position and thereby decrease the risk or canal compromise. To our knowledge, there has been not an anatomic study evaluating this modification of the translaminar screw technique. Methods. The tips of the modified screws were aimed such that they exited the dorsal cortex of the center of the contralateral lateral mass, achieving bicortical fixation. A total of 120 adult C2 vertebrae were evaluated bilaterally for the following: thickness of the cranial, midportion, and caudal edge of C2 lamina; the heights of the spinous process, lamina, and lateral mass; inclination angle of the laminae, screw projection length, and trajectory angle of cranial and caudal C2 translaminar screw. Results. A total of 83.3% specimens had bilateral laminar thicknesses ≥4.0 mm and a spinous process height ≥9.0 mm; 5% had a laminar thickness less than 4.0-mm bilaterally; 9.2% had a laminar thickness less than 4.0 mm on one side; 2.5% had a spinous process height lower than 9.0 mm. Conclusion. A large percentages of C2 laminae are of sufficient size to safely accommodate a bicortical 3.5-mm diameter screw. The thickness of the lamina and the height of the spinous process are the 2 limiting factors for safe translaminar screws placement. Using a bicortical technique confirms the position of the screw and thereby helps to decrease the risk of neurologic injury from screw penetration of the inner cortex of the lamina.

Four patients with traumatic occipitoatlantal dislocation are presented. The dislocations were the result of rapid deceleration motor vehicle accidents. The mechanism of injury was by hyperextension-rotation combined with a distraction force. Three patients sustained multiple injuries. Neurologic findings were variable. One patient with complete cord transection and closed head trauma died 4 days after the injury. In the three surviving patients, the occipitoatlantal dislocation was not diagnosed by the initial examiner. Prompt recognition and stabilization are essential to avoid further neurologic injury. Care must be taken not to increase the dislocation. A halo applied before operation facilitates reduction and allows posterior occipitoatlantal fusion to be performed under optimum conditions.

The authors report on the experience obtained in using L-rods and sublaminar wires in obtaining lower lumbar fusions of three or more levels in degenerative diseases of the lumbar spine. A successful fusion was obtained in 86% of the patients. The technique, while offering a satisfactory method of fusion, does violate the spinal canal with sublaminar wires with potential for neurologic injury. Specifically, the passage of sacral wires should be avoided.

STUDY DESIGN A retrospective review of spinal cord monitoring (SCM) results of patients with neural axis abnormalities (NAA) as compared with a control group of adolescent idiopathic scoliosis (AIS) patients. OBJECTIVE To analyze SCM on a group of patients who had a NAA undergoing spinal deformity surgery. SUMMARY OF BACKGROUND DATA To our knowledge, only 1 report in the literature has analyzed the accuracy and reliability of SCM in patients with NAA. METHODS Over a 10-year period, 41 patients with NAA had SCM while undergoing surgery for spinal deformity. These patients were retrospectively compared with a group of 136 AIS patients. RESULTS The average ages were similar (14.4 vs. 14.6 years), but there were more males (48.8% vs. 19.1%) and greater preoperative curve magnitude in the NAA group (65.9 degrees vs. 59.8 degrees ) (P < 0.05). Good baseline values were achieved less often in the NAA group for somatosensory-evoked potentials (SSEP) (85.4% vs. 98.5%) and motor-evoked potentials (MEP) (82.6% vs. 100%) (P < 0.05). Significant deviations from baseline values were seen more often in the NAA group for SSEP (8.6% vs. 1.5%) and MEP (5.3% vs. 2.5%). There were no false negatives in either group. CONCLUSIONS SCM in patients who have NAA can be more difficult to obtain than in AIS but results in few false positives and does not miss neurologic injury.

Review article.To outline current concepts regarding the assessment and treatment of odontoid fractures.Odontoid fractures account for 9% to 15% of adult, cervical spine fractures. These injuries usually result from hyperflexion or hyperextension of the cervical spine during low-energy impacts in the elderly or high-energy impacts in the young and middle aged. Neurologic injury associated with these fractures is rare.A review of pertinent literature was conducted. The information gleaned from this review was summarized.Odontoid fractures should be evaluated with appropriate imaging to assess the fracture itself as well as exclude other contiguous or noncontiguous fractures. The Anderson and D'Alonzo classification system is most commonly used. True type I and III odontoid fractures are generally thought to be relatively stable and are often treated nonoperatively with immobilization. Type II fractures at the base of the odontoid are less stable, and there are differing opinions regarding the precise definition and optimal treatment of these injuries. Nonoperative treatment options for odontoid fractures include external immobilization with a collar or halo. Operative treatment options for odontoid fractures include one of several posterior C1-C2 fusion constructs or anterior odontoid fixation if the fracture pattern is amenable.Despite the frequency of odontoid fractures, there is still much debate regarding the optimal treatment of these fractures, especially the type II fractures. This fact may be because of the absence of an ideal solution for this clinical problem. Certainly, prospective controlled clinical studies are needed.

Study design Segmental fixation is the preferred technique for the surgical treatment of adolescent idiopathic scoliosis. Sublaminar wiring is a widely used, strong type of segmental fixation. The most common drawback of the sublaminar wiring is the risk of neurologic injury. The authors have applied subtransverse wiring for 3 years, and the technique seems promising. Objectives To show that subtransverse wiring is a technique strong enough to correct scoliosis curves and does not carry neurologic injury risks. Summary of background data Sublaminar wiring is a commonly used fixation method for posterior fusion in the treatment of scoliosis. Because of its associated risk of neurologic injury, it is mostly recommended for long neuromuscular curves. Methods The authors used the subtransverse wiring technique in 12 cases of adolescent idiopathic scoliosis and followed them for an average of 22 months. Results The average correction rate was 65%, and correction loss at the end of the follow-up period was 5 degrees. No neurologic complications were encountered. Conclusions Subtransverse wiring is strong enough to correct scoliotic curves. It requires less operative time and skill and is neurologically safe.

Study Design. This is a report of a woman with an atlanto-occipital coalition who experienced a traumatic vertical atlantoaxial facet dislocation and severe associated neurologic injury. Objective. To describe the radiographic and pathoanatomic characteristics of the injury process. Summary of Background Data. Severe injuries of the occipito-atlantoaxial complex are uncommon and only rarely are associated with patient survival. This is the first report of this particular injury. Methods. Plain radiography and tomography demonstrated the facet dislocation and instability of the injury. Surgical exploration for repair of the torn dura mater and bony arthrodesis demonstrated the gross pathoanatomy. Results. The patient's vertical atlantoaxial instability was stabilized, her dura mater reconstructed, and her necrologic status has improved to allow mobilization with a cane. Conclusion. Vertical atlantoaxial instability has not been described previously. From the somewhat subtle radiographic findings, one might underestimate the severity of the neurologic damage. Aggressive work-up and management of this injury is suggested to avoid potential further necrologic sequelae.

Study design Thirty-five patients with spinal fractures in a series of 1019 patients deteriorated neurologically while in the hospital. Thirty-two were available for review. Objectives To determine whether there was a preponderance of a fracture type associated with early neurologic deterioration. Methods Patients were evaluated by means of plain radiographs and computed tomography scans according to the classification of Denis for the fracture types. This was compared with a newer classification. Neurologic assessment was according to the Frankel grading system and the motor score index. Results Ten patients deteriorated by one Frankel grade and two deteriorated by three Frankel grades; the remaining deteriorated, but within the same grade. The motor score index dropped from 33.5 to 26.8. In the Denis classification, the most common injury was a burst fracture, including a significant number of rotational bursts. In the newer classification, those fractures that contained a component of rotation were the most commonly seen. Conclusion When a torsional mechanism has been identified, additional care should be taken in managing patients with spinal fractures because of the risk of further neurologic injury.

METHODS: A wire-holding frame developed for sublaminar segmental instrumentation (SSI) has been used at the authors' institution for 14 years. RESULTS: In addition to careful technique of sublaminar wire passage, the frame reduces the risk of potential neurologic injury after wire passage by keeping the wires taut against the undersurface of the lamina. CONCLUSION: Operative efficiency is increased by organizing the sequence of the wires. The risk of glove perforation is also reduced by keeping the sharp ends of the wires away from the operative field.

This study investigated the relationship between cervical spine sagittal canal diameter and neurologic injury in cases of spinal fracture-dislocation. A group of 98 patients with such injuries was reviewed; 45 had no neurologic deficits, 39 had incomplete quadriplegia, and 14 had complete quadriplegia. Spinal canal sagittal diameter was measured in all, and large diameter and small canals were defined. Small diameter canals were correlated significantly with neurologic injury, while large diameter canals allowed protection from neurologic injury in cervical fracture dislocation.

Two patients with congenital scoliosis underwent surgical correction with segmental spinal instrumentation and fusion. This technique, coupled with spinal monitoring, provides greater correction of a curve than does cast treatment and eliminates the risk of neurologic injury associated with distraction.

UNLABELLED In an attempt to enhance the immediate stability of posterior interspinous fusion constructs, the authors conducted the following project. Twenty-four adult mongrel dogs underwent a posterior C4-C5 fusion using iliac crest autogenous graft and internal fixation using either ulna struts (12) or metallic struts (12) fixed into position by sublaminar wires. Half of the animals were killed at either 1 week or 3 months postoperatively, and their C4-C5 motion segments were excised and studied radiologically, mechanically, and histologically. Both fusions created immediate and 3-month stability equivalent or superior to normal C4-C5 canine spinal segments. However, three dogs were rendered completely and two dogs incompletely quadriplegic by the surgery. CLINICAL RELEVANCE Because of the relatively high rate of neurologic injury associated with these procedures in normal dogs, the authors hesitate to endorse their use in all but complete quadriplegic patients.

Cervical manipulation may result in serious neurologic injury arising specifically from trauma to the vertebrobasilar system. The vertebral arteries are susceptible to trauma at three locations: in the transverse foraminae, at the atlantoaxial joint, and at the occipitoatlantal joint. Because of frequent inequality in the size of the two vertebral arteries, damage to the larger artery may lead to ischemia of the brain stem. Vertebral artery obstruction may be produced by extension with rotation, even within normal ranges of motion. Neurologic injury following manipulation requires accurate diagnosis and prompt manipulation requires accurate diagnosis and prompt anticoagulant therapy.