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Object: The authors evaluated the efficacy of posterior instrumentation for the management of spontaneous spinal infections. Standard surgical management of spontaneous spinal infection is based on debridement of the infected tissue. However, this can be very challenging as most of these patients are medically debilitated and the surgical debridement requires a more aggressive approach to the spine either anteriorly or via an expanded posterior approach. The authors present their results using an alternative treatment method of posterior-only neuro-decompression and stabilization without formal debridement of anterior tissue for treating spontaneous spinal infection., Methods: Fifteen consecutive patients were treated surgically by 2 of the authors. All patients had osteomyelitis and discitis and were treated postoperatively with intravenous antibiotics for at least 6 weeks. The indications for surgery were failed medical management, progressive deformity with ongoing persistent spinal infection, or neurological deficit. Patients with simple epidural abscess without bony instability were treated with laminectomy and were not included in this series. Fourteen patients were treated with posterior-only decompression and long-segment rigid fixation, without formal debridement of the infected area. One patient was treated with staged anterior and posterior surgery due to delay in treatment related to medical comorbidities. The authors examined as their outcome the ambulatory status and recurrence of deep infection requiring additional surgery or medical treatment., Results: Of the initial 15 patients, 10 (66%) had a minimum 2-year follow-up and 14 patients had at least 1 year of followup. There were no recurrent spinal infections. There were 3 unplanned reoperations (1 for loss of fixation, 1 for early superficial wound infection, and 1 for epidural hematoma). Nine (60%) of 15 patients were nonambulatory at presentation. At final followup, 8 of 15 patients were independently ambulatory, 6 required an assistive device, and 1 remained nonambulatory., Conclusions: Long-segment fixation, without formal debridement, resulted in resolution of spinal infection in all cases and in significant neurological recovery in almost all cases. This surgical technique, when combined with aggressive antibiotic therapy and a multidisciplinary team approach, is an effective way of managing serious spinal infections in a challenging patient population.

Object: Sexual function is an often-overlooked aspect of health-related quality of life among older adults treated for spinal deformity. The authors' objective was to assess sexual function among older adults following thoracolumbar fusion with pelvic fixation for spinal deformity., Methods: This was a retrospective review of consecutive older adults (≥50 years) treated with posterior thoracolumbar instrumentation (including pelvic fixation) for spinal deformity and with a minimum 18-month follow-up. Patients completed the Changes in Sexual Function Questionnaire-14 (CSFQ-14), Oswestry Disability Index (ODI), and 12-Item Short-Form Health Survey (SF-12)., Results: Sixty-two patients (45 women and 17 men) with a mean age of 70 years (range 50-83 years) met the inclusion criteria. Eight women did not complete all questionnaires and were excluded from the subanalysis. The mean number of instrumented levels was 9.8 (range 6-18), and the mean follow-up was 36 months (range 19-69 months). Based on the CSFQ-14, 13 patients (24%) had normal sexual function, and 8 (15%), 10 (19%), and 23 (42%) had mild, moderate, and severe dysfunction, respectively. Thirty-nine percent of patients reporting severe sexual dysfunction did not have available partners-23% because of a partner's death and 16% because of a partner's illness)-or had significant medical comorbidities of their own (48%). Thirty-nine percent of assessed patients had either no or only mild sexual dysfunction. Patients with minimal or mild disability tended to have no or mild sexual dysfunction., Conclusions: The authors of this study assessed sexual function in older adults following surgical correction of spinal deformity that included posterior instrumented fusion and iliac bolts. Nearly 40% of assessed patients had either no or only mild sexual dysfunction, suggesting that despite an older age and extensive spinopelvic instrumentation, it remains very possible to maintain or achieve satisfactory sexual function.

Proximal junctional failure (PJF) should be distinguished from proximal junctional kyphosis, which is a recurrent deformity with limited clinical impact. PJF includes mechanical failure, and is a significant complication following adult spinal deformity surgery with potential for neurologic injury and increased need for surgical revision. Risk factors for PJF include age, severity of sagittal plane deformity, and extent of operative sagittal plane realignment. Techniques for avoiding PJF will likely require refinements in both perioperative and surgical strategies., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Object: Patients requiring neurosurgical intervention are known to be at increased risk for deep vein thrombosis (DVT) and attendant morbidity and mortality. Pulmonary embolism (PE) is the most catastrophic sequela of DVT and is the direct cause of death in 16% of all in-hospital mortalities. Protocols for DVT screening and early detection, as well as treatment paradigms to prevent PE in the acute postoperative period, are needed in neurosurgery. The authors analyzed the effectiveness of weekly lower-extremity venous duplex ultrasonography (LEVDU) in patients requiring surgical intervention for cranial or spinal pathology for detection of DVT and prevention of PE., Methods: Data obtained in 1277 consecutive patients admitted to a major tertiary care center requiring neurosurgical intervention were retrospectively reviewed. All patients underwent admission (within 1 week of neurosurgical intervention) LEVDU as well as weekly LEVDU surveillance if the initial study was normal. Additional LEVDU was ordered in any patient in whom DVT was suspected on daily clinical physical examination or in patients in whom chest CT angiography confirmed a pulmonary embolus. An electronic database was created and statistical analyses performed., Results: The overall incidence of acute DVT was 2.8% (36 patients). Of these cases of DVT, a statistically significant greater number (86%) were discovered on admission (within 1-7 days after admission) screening LEVDU (p < 0.05), whereas fewer were documented 8-14 days after admission (2.8%) or after 14 days (11.2%) postadmission. Additionally, for acute DVT detection in the present population, there were no underlying statistically significant risk factors regarding baseline physical examination, age, ambulatory status, or type of surgery. The overall incidence of acute symptomatic PE was 0.3% and the mortality rate was 0%., Conclusions: Performed within 1 week of admission in patients who will undergo neurosurgical intervention, LEVDU is effective in screening for acute DVT and initiating treatment to prevent PE, thereby decreasing the overall mortality rate. Routine LEVDU beyond this time point may not be needed to detect DVT and prevent PE unless a change in the patient's physical examination status is detected.

Objective: The originally described technique of atlantoaxial stabilization using C-1 lateral mass and C-2 pars screws includes a C-2 neurectomy to provide adequate hemostasis and visualization for screw placement, enable adequate joint decortication and arthrodesis, and prevent new-onset postoperative C-2 neuralgia. However, inclusion of a C-2 neurectomy for this procedure remains controversial, likely due in part to a lack of studies that have specifically addressed whether it affects patient outcome. The authors' objective was to assess the surgical and clinical impact of routine C-2 neurectomy performed with C1-2 segmental instrumented arthrodesis in a consecutive series of elderly patients with C1-2 instability., Methods: Forty-four consecutive patients (mean age 71 years) underwent C1-2 instrumented fusion, including C-1 lateral mass screw insertion. Bilateral C-2 neurectomies were performed. Standardized clinical assessments were performed both pre- and postoperatively. Numbness or discomfort in a C-2 distribution was documented at follow-up. Fusion was assessed using the Lenke fusion grade., Results: Among all 44 patients, mean blood loss was 200 ml (range 100-350 ml) and mean operative time was 129 minutes (range 87-240 minutes). There were no intraoperative complications, and no patients reported new postoperative onset or worsening of C-2 neuralgia postoperatively. Outcomes for the 30 patients with a minimum 13-month follow-up (range 13-72 months) were assessed. At a mean follow-up of 36 months, Nurick grade and pain numeric rating scale scores improved from 3.7 to 1.0 (p < 0.001) and 9.4 to 0.6 (p < 0.001), respectively. The mean postoperative Neck Disability Index score was 7.3%. The fusion rate was 97%, and the patient satisfaction rate was 93%. All 24 patients with preoperative occipital neuralgia reported relief. Seventeen patients noticed C-2 distribution numbness only during examination in the clinic, and 2 patients reported C-2 numbness, but it did not affect their daily function., Conclusions: In this series of C1-2 instrumented arthrodesis in elderly patients, excellent fusion rates were achieved, and patient satisfaction was not negatively affected by C-2 neurectomy. In the authors' experience, C-2 neurectomy enhanced surgical exposure of the C1-2 joint, thereby facilitating hemostasis, placement of instrumentation, and decortication of the joint space for arthrodesis. Importantly, with C-2 neurectomy in the present series, no cases of new onset postoperative C-2 neuralgia occurred, in contrast to a growing number of reports in the literature documenting new-onset C-2 neuralgia without C-2 neurectomy. On the contrary, 80% of patients in the present series had preoperative occipital neuralgia and in all of these patients this neuralgia was relieved following C1-2 instrumented arthrodesis with C-2 neurectomy.

Background: Considerable attention has focused on concerns of increased complications with recombinant human bone morphogenetic protein-2 (rhBMP-2) use for anterior cervical fusion, but few reports have assessed its use for posterior cervical fusions., Objective: To assess the safety, efficacy, and dosing of rhBMP-2 as an adjunct for instrumented posterior cervical arthrodesis., Methods: All patients treated by the senior author with posterior cervical or cervicothoracic instrumented fusion using rhBMP-2 from 2003 to 2008 with a minimum of 2 years of follow-up were included. Diagnosis, levels fused, rhBMP-2 dose, complications, and fusion were assessed., Results: Fifty-three patients with a mean age of 55.7 years (range, 2-89 years) and an average follow-up of 40 months (range, 25-80 months) met inclusion criteria. Surgical indications included basilar invagination (n = 6), fracture (n = 6), atlantoaxial instability (n = 16), kyphosis/kyphoscoliosis (n = 22), osteomyelitis (n = 1), spondylolisthesis (n = 1), and cyst (n = 1). Fifteen patients had confirmed rheumatoid disease. The average rhBMP-2 dose was 1.8 mg per level, with a total of 282 levels treated (average, 5.3 levels; SD, 2.8 levels). Among 53 patients, only 2 complications (3.8%) were identified: a superficial wound infection and an adjacent-level degeneration. No cases of dysphagia or neck swelling requiring treatment were identified. At the last follow-up, all patients had achieved fusion., Conclusion: Despite many of the patients in the present series having complex pathology and/or rheumatoid arthritis, a 100% fusion rate was achieved. Collectively, these data suggest that use of rhBMP-2 as an adjunct for posterior cervical fusion is safe and effective at an average dose of 1.8 mg per level.

Background: Nonvascularized autologous grafts used for sellar reconstruction in transseptal transsphenoidal surgery are commonly applied in the setting of intraoperative cerebrospinal fluid (CSF) leak and have been shown to be effective in preventing postoperative complications., Objective: To assess the clinical implications of intraoperative CSF leak, to evaluate the efficacy of repair techniques using autologous nonvascularized materials, and to analyze the nature and timing of failures. These data may serve as a basis for assessing the utility of innovations in techniques and implant technologies., Methods: A review was conducted of 257 consecutive patients who underwent transsphenoidal surgery that was complicated by intraoperative CSF leak from 1995 to 2001. Sellar reconstruction was performed with autologous materials except in reoperations in which septal materials were not available; lumbar drain catheters were used selectively., Results: Six of the 257 patients (2.3%) developed postoperative CSF rhinorrhea occurring an average of 6.6 days after surgery. All 6 underwent reoperation, with 5 of 6 managed with operative lumbar drainage. Bacterial meningitis developed in 3 of 257 (1.2%). Worsening in visual function occurred in 8 of 257 (3.1%), with 1 of 257 (0.3%) suffering from permanent worsening of visual function. Additional surgery was performed in 2 of these patients, resulting in successful reversal of visual loss. Ten of 257 patients (3.9%) developed a subcutaneous hematoma at the fat graft harvest site, with 1 patient requiring surgical re-exploration., Conclusions: Watertight closure of the sella with autologous materials is effective in preventing postoperative rhinorrhea. Complications specific to the technique include graft site hematoma (4%) and rare instances of visual loss caused by optic nerve compression.

Object: This is a retrospective review of 10,242 adults with degenerative spondylolisthesis (DS) and isthmic spondylolisthesis (IS) from the morbidity and mortality (M&M) index of the Scoliosis Research Society (SRS). This database was reviewed to assess complication incidence, and to identify factors that were associated with increased complication rates., Methods: The SRS M&M database was queried to identify cases of DS and IS treated between 2004 and 2007. Complications were identified and analyzed based on age, surgical approach, spondylolisthesis type/grade, and history of previous surgery. Age was stratified into 2 categories: > 65 years and ≤ 65 years. Surgical approach was stratified into the following categories: decompression without fusion, anterior, anterior/posterior, posterior without instrumentation, posterior with instrumentation, and interbody fusion. Spondylolisthesis grades were divided into low-grade (Meyerding I and II) versus high-grade (Meyerding III, IV, and V) groups. Both univariate and multivariate analyses were performed., Results: In the 10,242 cases of DS and IS reported, there were 945 complications (9.2%) in 813 patients (7.9%). The most common complications were dural tears, wound infections, implant complications, and neurological complications (range 0.7%-2.1%). The mortality rate was 0.1%. Diagnosis of DS had a significantly higher complication rate (8.5%) when compared with IS (6.6%; p = 0.002). High-grade spondylolisthesis correlated strongly with a higher complication rate (22.9% vs 8.3%, p < 0.0001). Age > 65 years was associated with a significantly higher complication rate (p = 0.02). History of previous surgery and surgical approach were not significantly associated with higher complication rates. On multivariate analysis, only the grade of spondylolisthesis (low vs high) was in the final best-fit model of factors associated with the occurrence of complications (p < 0.0001)., Conclusions: The rate of total complications for treatment of DS and IS in this series was 9.2%. The total percentage of patients with complications was 7.9%. On univariate analysis, the complication rate was significantly higher in patients with high-grade spondylolisthesis, a diagnosis of DS, and in older patients. Surgical approach and history of previous surgery were not significantly correlated with increased complication rates. On multivariate analysis, only the grade of spondylolisthesis was significantly associated with the occurrence of complications.

Background: There have been few reports on the use of recombinant human bone morphogenetic protein (rhBMP)-2 in posterior spine. However, no study has investigated the dosing, safety, and efficacy of its use in the posterior atlantoaxial, and/or craniovertebral junction. Recent case report of the cytokine-mediated inflammatory reaction, following off label use of rhBMP-2 as an adjunct for cervical fusion, particularly in complex cases, has increased concern about complications associated with the product., Objective: To assess the safety, efficacy, and dosing of rhBMP-2 as an adjunct for instrumented posterior atlantoaxial and/or craniovertebral junction arthrodesis., Materials and Methods: We included all patients treated by the senior author that included posterior atlantoaxial and/or craniovertebral junction instrumented fusion using rhBMP-2 from 2003 to 2008 with a minimum two year follow-up. Diagnosis, levels fused, rhBMP-2 dose, complications, and fusion were assessed., Results: Twenty three patients with a mean age of 60.9 years (range 4 - 89 years) and an average follow-up of 45 months (range 27 to 84 months) met inclusion criteria. The indications for surgery included, atlantoaxial instability (n = 16), basilar invagination (n = 6), and kyphoscoliosis (n = 1). The specific pathologic diagnosis included type 2 dens fracture (n = 7), complex C1 and C2 ring fracture (n = 2), chordoma (n = 2), degenerative/osteoporosis (n = 3), rheumatoid disease (n = 8), and pseudogout (n = 1). The average rhBMP-2 dose was 2.38 mg/level, with a total of 76 levels treated (average 3.3 levels, SD= 1.4 levels). There were no complications. During the most recent follow-up, all patients had achieved fusion., Conclusions: In a series of patients with complex pathology and/or rheumatoid arthritis, 100% fusion rate was achieved with adjunct use of rhBMP-2, with a safe and effective average rhBMP-2 dose of 2.38 mg per level.

Pseudoaneurysms are rare lesions with a multitude of causes, including infectious, traumatic, and iatrogenic origins. In addition, there are a number of potential treatment options, all of which require consideration to determine the most appropriate management. Historically, surgical intervention has been the method of choice, but because the histopathological features of these lesions make them largely unsuitable for clipping, trapping or excision is often required. More recently endovascular methods have been used, including coil embolization, stent reconstruction, or parent artery occlusion. Although these methods are often successful, situations arise in which they are not technically feasible. The authors describe such a case in a pediatric patient with an iatrogenic pseudoaneurysm. Onyx was used to embolize the lesion and the results were excellent.

We present a literature review of the diagnosis and treatment of acquired lumbar spinal stenosis (LS), with a brief description of new surgical techniques. LS is the most common cause of spinal surgery in individuals older than 65 years of age. Neurogenic claudication and radiculopathy result from compression of the cauda equina and lumbosacral nerve roots by degenerated spinal elements. Surgical decompression is a well established treatment for patients with refractory, or moderate to severe clinical symptoms. However, the variety of surgical options is vast. New techniques have been developed with the goal of increasing long term functional outcomes. In this article we review lumbar decompression and fusion as treatment options for LS but also present other recent developments. Prospective long term studies are necessary to know which procedures would result in optimal patient outcome.

Background: Bone morphogenic protein products enable lumber spine fusion. Few outcome studies have been performed to evaluate function and pain relief after posterior lumber decompression for degenerative disease, and few studies have provided detailed results of posterior lumbar fusion in elderly patients. This retrospective analysis presents a comprehensive examination of spinal fusion, functional outcomes, and pain relief in a growing elderly population in which a BMP was used., Methods: Fifty-five patients, 25 men and 30 women (moderately disabled to bedridden), with both mean and median ages of 68 years, underwent surgery for symptoms of lumbar degenerative disease between August 2003 and June 2004. Surgery involved multilevel lumbar total laminectomies with medial facetectomies and posterior lateral fusion, which was performed using INFUSE Bone Graft (Medtronic Sofamor Dane K. Inc, Minneapolis, MN) with recombinant human BMP-2 as the active ingredient. Forty-seven patients (22 men and 25 women) were available for follow-up and participated in this study. Of these 47 patients, the average number of levels decompressed and fused was 2. Thirteen patients had 1 level, 18 patients with 2 levels, 15 patients with 3 levels, and 1 patient with 4 levels. An analysis of fusion was performed using computed tomography beginning at an average of 6 months (range, 3-36 months) postsurgery. At an average of 34 months (range, 29-36 months) of follow-up, 2 questionnaires--the Modified Oswestry Low Back Pain Disability Questionnaire and the SF-12 Health Survey--were completed by the patient., Results: Long-term follow-up indicates that more than 85% of patients exhibited high functioning ability and had improved index scores and pain relief. Patients with improved pain and function scores also had better than average health status. In addition, grading the patients' fusion rates with the Lenke fusion scale [J Spinal Disord 5(4) (1992) 433-442] showed an 80% fusion (Lenke Grades A and B) rate., Conclusions: The use of rhBMP-2 to augment fusion leads to satisfactory outcomes, specifically improved pain relief, function, and bone formation, in elderly patients without the use of instrumentation.

Object: Adjuvant treatment with radiation (radiation therapy or radiosurgery) is a mainstay of treatment for patients harboring glioblastomas multiforme (GBM). Hypoxic regions within the tumor make cells less sensitive to radiation therapy. Trans sodium crocetinate (TSC) has been shown to increase oxygen diffusion in the brain and elevate the partial brain oxygen level. The goal of this study was to evaluate the radiosensitizing effects of TSC on GBM tumors., Methods: A rat C6 glioma model was used, in which C6 glioma cells were stereotactically injected into the rat brain to create a tumor. Following creation of a right frontal tumor, animals were randomized into 1 of 4 groups: 1) TSC alone (animal treated with moderate-dose TSC only); 2) radiation (animals receiving 8 Gy of cranial radiation); 3) radiation and low-dose TSC (animals receiving 8 Gy of radiation and 50 microg/kg of TSC); or 4) radiation and moderate-dose TSC (animals receiving 8 Gy of radiation and 100 microg/kg of TSC). Animals were observed clinically for 60 days or until death. Magnetic resonance (MR) imaging was performed at 2-week intervals on each animal and quantitatively evaluated for tumor response. Immunohistochemical analysis was performed on all brain tumors. Survival differences were also evaluated using the Kaplan-Meier method., Results: On MR imaging, a statistically significant reduction in tumor size was seen in the group receiving moderate-dose TSC and radiation treatment compared with the group receiving radiation treatment alone. The rate of tumor growth was significantly less for the combination of TSC and radiation treatment compared with either modality alone. Median survival times for the TSC-only and the radiation therapy-only groups were 15 and 30 days, respectively. The 60-day median survival times for the groups receiving a combination of either low- or moderate-dose TSC with radiation therapy were statistically improved compared with those for the other treatment groups., Conclusions: Use of TSC improves the extent of GBM tumor regression following radiation therapy and enhances survival. Radiosensitization of hypoxic tumors through increased oxygen diffusion may have clinical utility in patients with GBM tumors but must be explored in a clinical trial.

Healthcare organizations face continuous and accelerating external change and thus must be prepared to manage their own change initiatives proactively. Given that many believe that the U.S. healthcare system is broken and most healthcare organizations are dealing with pervasive problems, some organizations may choose to seek transformational change to achieve the six aims identified by the Institute of Medicine: healthcare that is safe, effective, patient-centered, timely, efficient, and equitable. Transformational change will almost certainly involve organizational culture. Culture change may be most effective when linked to other organizational change initiatives such as organizational strategy, structure, policies, procedures, and recruiting. Significant organizational change often requires accompanying facility change. There is an interdependent relationship between facility design and organizational culture. They affect each other and both impact organizational performance. Sociotechnical theory promotes joint optimization of the social (culture) and technical (facilities) aspects of an organization to achieve sustained positive change. To achieve organizational transformation and to sustain positive change, organizations must be prepared to adopt collaborative efforts in culture change and facility design. The authors propose a model for accomplishing joint optimization of culture change and evidence-based facility design.