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Central cord syndrome (CCS) represents a clinical phenomenon characterized by disproportionately greater motor impairment of the upper than of the lower extremities, bladder dysfunction. CSS is the most common form of incomplete traumatic spinal cord injury. The initial description of CSS was reported in 1887 secondary to cervical spinal trauma. However, recent literature describes a heterogenous injury patterns including high-energy and low-energy mechanisms and bimodal patient age distributions. Pathophysiology of clinical symptoms and neurological deficits often is affected by preexisting cervical spondylosis. Urgent clinical diagnosis is dependent on neurological examination and imaging studies. Treatment of CSS is dependent on injury mechanism and compressive lesions, neurological examination, preexisting cervical pathology, and patient-specific comorbidities. This article will review the current concepts in diagnosis, pathophysiology, and treatment of CSS with a highlighted case example.

Study design Retrospective study. Objective To assess the relation between exposure to epidural steroid injection (ESI) before surgery and occurrence of surgical site infection (SSI) for degenerative lumbar spine conditions. Summary of background data The effect of local ESI on the occurrence of SSI is controversial. Methods Patients who underwent surgery for degenerative lumbar spine conditions at two centers between 2005 and 2015 were identified. Primary outcome measure was SSI within 90 days requiring surgical intervention. Results A total of 5311 patients (age 57 ± 16 years) were analyzed of which 945 (18%) had at least one ESI within 90 days of surgery. One hundred thirty-four (2.5%) patients developed an SSI requiring reoperation. No association of exposure or dose-response relationship was identified between ESI and SSI for any of the time periods (90-, 30-, and 30-90-day). Five (1.7%) of the 290 patients who had at least one ESI within 30 days before surgery had a postoperative infection compared to 129 (2.6%) of the 5021 in the non-ESI group (unadjusted odds ratio: 0.67, 95% CI: 0.27-1.64, P = 0.376). Fifteen (2.0%) of the 761 patients who had at least one ESI within 30 to 90 days before surgery had a postoperative infection, compared to 119 (2.6%) of the 4550 in the non-ESI group (unadjusted odds ratio: 0.75, 95% CI: 0.44-1.29, P = 0.296). Conclusion In this retrospective study we investigated whether an ESI and its timing influences the postoperative risk of an SSI. We found no association-exposure or dose-response relationship-between ESI and postoperative infection, even after adjusting for potential confounders, for any of the time periods (90-, 30-, and 30-90-day ESI). In addition, we did find that longer hospital stay, greater EBL, posterior approach, and drain placement were associated with higher infection rates. Level of evidence 3.

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Study Design. Prospective observational study. Objective. To determine whether polymorphic variations of the guanosine triphosphate (GTP) cyclohydrolase 1 gene (GCH1) are associated with different outcomes in patients undergoing surgical treatment for lumbar degenerative disc disease (DDD). Summary of Background Data. GCH1, the gene encoding the rate-limiting enzyme in tetrahydrobiopterin synthesis, has been strongly implicated as a determinant of pain experience in previous animal and human studies. Methods. A total of 69 patients undergoing surgical treatment for lumbar DDD were prospectively enrolled. Genomic DNA was extracted from a venous blood sample, and DNA sequence analysis was performed of GCH1. Surgery included 65 instrumented fusions and 4 disc arthroplasty procedures. Patients were observed prospectively for 1 year following surgery. Allelic and genotype frequencies were calculated for each of 14 single nucleotide polymorphisms (SNPs). One-year postoperative Oswestry Disability Index (ODI) scores were compared to preoperative scores and the absolute change in ODI score was used to perform genetic association analyses on the basis of both individual SNP markers as well as commonly observed haplotypes for the entire gene sequence. Results. Single marker analysis revealed 1 SNP (rs998259; minor allele T) that was significantly associated with improvement in both absolute ODI score (P = 0.030) and Numerical Rating Scale back pain scores (P = 0.033) following surgery. Haplotype analysis identified a common GCH1 haplotype ("CACTTGTTTGAC") with a sample frequency of 12.3%, which was highly associated with improvement in absolute ODI score (P = 0.04). This haplotype frequency reflects the existence of both heterozygous and homozygous individuals in the study population. The presence of 1 unit of this haplotype was associated with an improvement in postoperative ODI score of 15.34 relative to the absence of this haplotype (P = 0.04). Conclusion. Preliminary results from this pilot genetic study of patients undergoing surgery for DDD suggests that the T allele at rs998259 of GCH1 may be associated with improved outcomes 1 year following surgery.

STUDY DESIGN/SETTING Retrospective review of a consecutive, nonrandomized series operated on by 2 surgeons. OBJECTIVE To evaluate the clinical and radiographic effectiveness of a silicated hydroxyapatite ceramic as a bone graft substitute in a series of patients undergoing posterolateral instrumented lumbar fusion. SUMMARY OF BACKGROUND DATA Newer-generation synthetic ceramics have been refined to maximize their host-graft interaction and stimulation of new tissue formation, including silicate-substitution. METHODS An independent radiologist interpreted the computed tomography images at 6, 12, and 24 months after surgery. Forty-two patients with 1- or 2-level lumbar degenerative disorders underwent posterior laminectomy (when indicated) and posterolateral fusion with instrumentation. Surgical levels included 15 patients who underwent 2-level and 27 single-level fusion procedures (57 levels operated on in total). RESULTS The average back pain scores improved from 5.6 ± 2.5 preoperative to 2.1 ± 2.5 at follow-up (P < 0.05). Similar results were seen with leg pain improvement from 5.8 ± 2.5 to 1.4 ± 1.9 (P < 0.05). At 6 months, 35% of levels revealed fusion, which increased to 76.2% and 76.5% at 12 and 24 months, respectively. No evidence of ectopic bone formation or osteolysis was noted. CONCLUSION In this study, a silicated calcium phosphate-based ceramic has been shown to be effective as a graft substitute and eliminate the need for autogenous iliac crest bone graft. The results confirm radiographic healing in posterolateral instrumented lumbar fusion at 24-months follow-up. The clinical outcomes also substantiate significant pain improvement consistent with published data in the literature compared with other bone graft alternatives.

STUDY DESIGN Retrospective study. OBJECTIVES To determine the frequency of pedicle screw violation of superior nonfused facet joints adjacent to the most cephalad pedicle screws after a midline approach for lumbar fusion. SUMMARY OF BACKGROUND DATA Facet-joint violations have been evaluated in patients undergoing lumbar pedicle screw instrumentation and fusion with a Wiltse muscle-splitting approach, but not via the more common midline approach. METHODS Between 1995 and 2003, 204 patients underwent this procedure. Computed tomography scans (within 1 year postsurgery) were evaluated independently for superior facet-joint violation. chi tests were used to examine bivariate associations of superior level facet-joint violation, patient age, construct level, diagnosis, and revision status for significance (P < or = 0.05). RESULTS Superior-level facet-joint violation occurred in 24% of patients and 15% of screws, twice as often on the left side (P = 0.0396) than on the right, more frequently in single than in multiple-level procedures (P < 0.0001), and most frequently with the most cephalad screws at L5 (48%). We found no significant associations between violation rates and other designated parameters. CONCLUSION The left side, single-level fusion, and most cephalad pedicle screws at L5 are targets for interventions to reduce pedicle violations in this procedure.

The current debate over the efficacy of lumbar fusion for low back pain has not been settled. Fritzell et al published a landmark paper entitled "Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish lumbar spine study group." Their goal was to provide objective evidence supporting lumbar fusion. While it was well designed and important to our knowledge base, it has limitations. We set out to review their work in an unbiased yet critical manner. Our goals are to summarize the strengths and weaknesses of the paper, place it in the context of current knowledge, and highlight its significance for present-day practice and research. From technical and study design perspectives, Fritzell et al were able to validate the use of lumbar fusion for the treatment of low back pain. However, their use of "usual nonoperative" care and nonspecific definition of low back pain precluded a truly genuine comparison of operative and nonoperative groups. We commend the Swedish lumbar spine study group and their remarkable efforts; they elevated the sophistication of spine research and spawned many more excellent works to help settle the ongoing controversy on the ideal treatment of low back pain.

Anterior cervical discectomy and fusion (ACDF) is a successful procedure for the degenerative cervical spine. One goal of the fusion is to restore the loss of disc height that results from the degenerative process. Whereas cervical alignment improves with increased disc height, the ideal graft size used for disc space restoration is unknown. Few studies have examined the relationships between these changes in cervical alignment and clinical outcomes.All patients underwent a single-level ACDF at the authors' institution. Radiographs at early and final follow-up were examined, and three measurements were made: disc height, disc space angulation, and spinous process distance. These radiographic measurements were correlated with Visual Analog Scales (VASs) for neck and arm pain and Oswestry Disability Index (ODI).There were significant changes in disc height (5.3 vs 7.0 mm) as well as disc space angulation (3.3 degrees vs 0.1 degrees ). Reduction in neck pain VAS score (6.7 vs 3.2) and arm pain VAS score (5.1 vs 2.3) was significant. ODI scores were not statistically different, but improvement of 20.1% was observed. Correlations between radiographic parameters and clinical outcomes were moderate to low, and none was significant.While restoration of cervical alignment and disc height is important, clinical results are critical in analysis of outcomes following ACDF. We have shown that although clinical outcomes remain good, there does not appear to be any strong correlation with radiographic results. Emphasis on restoration of cervical alignment appears justified, but its influence on clinical outcomes may be overstated.

Anterior cervical discectomy and fusion with autograft is a safe and effective procedure for the treatment of cervical radiculopathy and myelopathy and has been extensively studied in the literature. Controversies arise as to the optimal graft material for insertion into the disc space as well as the use of, and indications for, anterior plating. Recently, cervical interbody cages have added to this controversy. Many cervical cage designs exist; however, the most common is the threaded titanium interbody device. Proponents of the cervical cage believe that the cage can achieve the same fusion rate as anterior cervical discectomy and fusion with minimal complications. Furthermore, cervical cage use can circumvent the morbidity associated with autograft harvest and the risk of infection associated with allograft. The literature from the last 2 years has focused mainly on in vivo fusion rates and in vitro biomechanical flexibility and stability analysis.

The authors performed a prospective study of 63 patients with cervical radiculopathy treated with Robinson anterior cervical discectomy and fusion and compared the traditional or standard and reverse graft techniques. Modifications of the standard Robinson grafting techniques have been proposed. The reverse graft technique has theoretical advantages, including limiting the deleterious effects of graft extrusion and maintaining rigid middle column support. A radiographic evaluation and an assessment of clinical outcome based on the criteria of Odom were performed prospectively for as long as 1 year after surgery. Thirty-one patients were treated with the standard grafting technique and 32 with the reverse graft orientation. The radiographic evaluation showed no significant differences between the two techniques with regard to sagittal alignment and disk heights. The overall fusion grade was higher in the reverse graft technique (p < 0.05). There were 93% and 96% good to excellent results in the standard graft and reverse graft groups, respectively. The authors report no significant differences associated with the standard or reverse anterior cervical grafting techniques in terms of radiographic alignment or disk height loss over time or at early clinical outcome. However, improved fusion grade was noted with the reverse graft technique, which may be related to end plate and intervertebral space preparation. The reverse grafting technique is an acceptable alternative to the standard graft orientation.

Neck pain can originate from any number of factors. Perhaps the most difficult symptom complex to resolve is axial neck pain arising from upper cervical nerve root compression. The purpose of this study is to report the results of surgical intervention in a series of patients with neck pain from C4 radiculopathy. Twelve consecutive patients who were diagnosed with C4 radiculopathy were retrospectively reviewed (follow-up, 22+/-16.3 months). Patients underwent either anterior cervical discectomy and fusion or posterior laminoforaminotomy at the C3-C4 segment. The results show that a good to excellent clinical result can be achieved in most patients (92% in our series). The importance of identifying patients with C4 radiculopathy lies in the fact that surgery can alter the natural history of neck pain secondary to upper cervical root radiculopathy, unlike axial neck pain from degenerative disk disease.

The authors report a patient with delayed inferior thyroid artery pseudoaneurysm after uneventful anterior cervical discectomy and fusion. The Smith-Robinson approach to the anterior cervical spine is a commonly used and relatively safe surgical approach for cervical disc disease. This case is unusual in two respects: 1) the vascular complication occurred 9 days postoperatively; and 2) the inferior thyroid artery was embolized without the need for immediate exploration and surgical ligation. The patient was successfully managed with therapeutic embolization. [Key words: anterior discectomy, embolization, Smith-Robinson approach, vascular complications] Spine 1994;19:1291–1293