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Background: Chin-on-chest deformity is a disabling manifestation of ankylosing spondylitis. Surgical treatment consists of extension osteotomy at the cervicothoracic junction. The purpose of this study was to characterize the clinical presentation of this deformity and to determine the long-term functional and radiographic outcomes of treatment.Methods: The medical records and radiographs of all twenty-six patients treated with cervicothoracic extension osteotomy by one of us between 1976 and 2001 were retrospectively reviewed. Three patients died during the two-year-minimum follow-up period. The remaining twenty-three patients were followed for an average of 4.5 years (range, two years to twenty-one years and ten months).Results: The mean sagittal correction was 38 degrees. Delayed union in two patients and additional cervical trauma in two others resulted in partial loss of the initial correction. Quadriplegia developed in one patient, who died as a result of subluxation at the osteotomy site. Five patients had irritation of the eighth cervical nerve root postoperatively.Conclusions: Extension osteotomy can reliably improve sagittal alignment and horizontal gaze as well as decrease neck pain, eating difficulties, and neurologic abnormalities. Internal fixation is recommended to prevent subluxation, delayed union, nonunion, loss of correction, or neurologic injury. There is a risk of death or catastrophic neurologic injury from the procedure. [ABSTRACT FROM AUTHOR]

Background: Ossification of the posterior longitudinal ligament is commonly associated with cervical myelopathy. Surgical treatment is a matter of controversy. We report on a series of patients who were managed with anterior cervical decompression and arthrodesis for the treatment of cervical myelopathy associated with ossification of the posterior longitudinal ligament.Methods: We retrospectively reviewed the records for all sixty-five patients who had been managed with anterior decompression and arthrodesis for the treatment of cervical ossification of the posterior longitudinal ligament and associated neurologic compression from 1982 to 2001. Sixty-one patients (thirty-nine men and twenty-two women) were followed for at least two years (or until the time of death). The average number of vertebrae resected was 2.2. The average duration of follow-up for the sixty surviving patients was four years (range, two years to fifteen years and four months). The preoperative, six-week postoperative, and final follow-up clinical status (including neurological function as assessed with the Nurick grading system) was recorded for each patient.Results: Fifty-six of the sixty-one patients had neurological improvement, with an average improvement of 1.5 Nurick grades at the time of the final follow-up. Eight patients had absent dura at the time of surgery and, of these, five had development of a cerebrospinal fluid fistula. Eight patients had development of new neurological signs and/or symptoms in the upper extremity postoperatively. Eight patients required reoperation because of a painful pseudarthrosis (one patient), strut-graft dislodgment (three), cerebrospinal fluid leakage (three), or compression of a nerve root caudad to the area of the original procedure (one). One patient died as the result of cardiac arrest on the third postoperative day. Fifty-eight patients had an osseous fusion, one had an asymptomatic nonunion, and one had a symptomatic pseudarthrosis that was treated with revision surgery.Conclusions: Anterior decompression and arthrodesis is an effective way to achieve pain relief and neurological improvement in North American patients of non-Asian descent who have cervical myelopathy associated with ossification of the posterior longitudinal ligament. The risk of durocutaneous fistula, graft dislodgment, and postoperative neurological symptoms appears to be high in patients with cervical myelopathy associated with this condition. [ABSTRACT FROM AUTHOR]

BACKGROUND: An increased rate of pseudarthrosis has been documented following posterolateral lumbar spine grafting in patients who smoke. This same relationship has been assumed for anterior cervical interbody grafting, but to our knowledge it has never been proven. This study compared the long-term radiographic and clinical results of smokers and nonsmokers who had undergone arthrodesis with autogenous bone graft following multi-level anterior cervical decompression for the treatment of cervical radiculopathy or myelopathy, or both. METHODS: One hundred and ninety patients were followed clinically and radiographically for at least two years (range, two to fifteen years). Fifty-nine of the patients had corpectomy with strut-grafting, and 131 patients had multiple discectomies and interbody grafting. Fifty-five of the 190 patients had a history of active cigarette-smoking; fifteen of the fifty-five had corpectomy with strut-grafting, and forty had multilevel discectomies and interbody grafting. Internal fixation was not used in any patient. The reconstruction techniques and postoperative bracing regimen were similar between smokers and nonsmokers. Osseous union was judged on dynamic lateral radiographs made at least two years following surgery, and clinical outcomes were judged on the basis of pain level, medication usage, and daily activity level. RESULTS: Of the forty smokers who had undergone multilevel interbody grafting, twenty had a solid fusion at all levels, whereas sixty-nine of the ninety-one nonsmokers had solid fusion at all levels (p < 0.02; chi-square test). This difference was especially pronounced among patients who had had a two-level interbody grafting procedure (p < 0.002; chi-square test). With the numbers available, there was no difference in the rate of fusion between smokers (fourteen of fifteen) and nonsmokers (forty-one of forty-four) who had undergone corpectomy and strut-grafting, as 93% of both groups had a solid union. In addition, clinical outcomes were significantly worse among smokers when compared with nonsmokers (p < 0.03; rank-sum analysis). CONCLUSIONS: Smoking had a significant negative impact on healing and clinical recovery after multilevel anterior cervical decompression and fusion with autogenous interbody graft for radiculopathy or myelopathy. Since smoking had no apparent effect upon the healing of autogenous iliac-crest or fibular strut grafts, subtotal corpectomy and autogenous strut-grafting should be considered when a multilevel anterior cervical decompression and fusion is performed in patients who are unable or unwilling to stop smoking prior to surgical treatment. [ABSTRACT FROM AUTHOR]

Background: Fungal infections of the spine are noncaseating, acid-fast-negative infections that occur primarily as opportunistic infections in immunocompromised patients. We analyzed eleven patients with spinal osteomyelitis caused by a fungus, and we developed suggestions for treatment.Methods: All patients with a fungal infection of the spine treated by the authors over a sixteen-year period at three teaching institutions were evaluated. There was a total of eleven patients. Medical records and roentgenograms were available for every patient. Long-term follow-up of the nine surviving patients was performed by direct examination by the authors or by the patient's primary physician.Results: For ten of the eleven patients, the average delay in the diagnosis was ninety-nine days. Nine patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. The sources of the spinal infections included direct implantation from trauma (one patient), hematogenous spread (four patients), and local extension (two patients). The infection followed elective spine surgery in three patients, and the cause was unknown in one. Paralysis secondary to the spine infection developed in eight patients. Ten patients were treated with surgical debridement. All eleven patients were treated with systemic antifungal medications for a minimum of six weeks. One patient died of generalized sepsis at thirty-three days, and another patient died of gastrointestinal hemorrhage at five months. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients.Conclusions: Treatment of fungal spondylitis is often delayed because of difficulty with the diagnosis. Delay in the diagnosis led to poorer results in terms of neurologic recovery in our study. Performing fungal cultures whenever a spinal infection is suspected might hasten the diagnosis. Patients should be given a guarded prognosis and informed of the many possible complications of the disease. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Case series. OBJECTIVE: Report long-term outcomes, complications, and surgical technique of cervical myopathy (CM) patients treated with posterior instrumented, cervico-thoracic (C-T) fusions. SUMMARY OF BACKGROUND DATA: CM is a rare, progressive, debilitating condition where weakness of neck extensor muscles results in a dropped head deformity (DHD), or severe flexible, cervico-thoracic kyphosis. Treatment algorithms are currently based on small case reports and only 1 patient's short-term surgical outcome. METHODS: Re-examination at follow-up, chart review, and radiographic analysis was carried out for all CM patients with DHD treated by the senior author. Additional outcome measures included Odom criteria, verbal rating scores for pain, and patient satisfaction ratings. Patients with less than 2-years follow-up, previous cervical spine surgery or intrinsic, structural spinal deformities were excluded. RESULTS: Nine CM patients met the study inclusion criteria with average follow-up of 6 years (range, 2-17 years) and average age 67 years. Four primary and 5 secondary myopathies after radiotherapy underwent deformity correction and posterior arthrodesis with instrumentation from the second cervical level to the upper thoracic spine. Patient presentation, deformity correction, and surgical techniques are described. All pain ratings improved, satisfaction was excellent in 7 and fair in 2 patients, and Odom scores were good to excellent in 7 and fair in 2 patients. Shoulder weakness remained equivalent or improved after surgery and all ambulated independently, though 1 continued to use a walker. Eleven postoperative complications are described. CONCLUSION: Surgical correction with posterior, instrumented C-T spinal fusion is associated with high patient satisfaction rates in CM patients with DHD. Complications are frequent but do not diminish long-term outcomes. New rod and screw instrumentation with bone morphogenic protein may improve arthrodesis and correction. [ABSTRACT FROM AUTHOR]

Study Design: A prospective and randomized study., Objectives: The objective of this study was to assess the efficacy of a novel multimodal analgesic regimen in reducing postoperative pain and intravenous morphine requirements after primary multilevel lumbar decompression surgery., Summary of Background Data: The use of opioid medications after surgery can lead to incomplete analgesia and may cause undesired side effects such as respiratory depression, somnolence, urinary retention, and nausea. Multimodal (opioid and nonopioid combination) analgesia may be an effective alternative to morphine administration leading to improved postoperative analgesia with diminished side effects., Methods: After Institutional Review Board approval, 22 patients who underwent a primary multilevel lumbar decompression procedure were randomly assigned to receive either only intravenous morphine or a multimodal (celecoxib, pregabalin, extended release oxycodone) analgesic regimen. Postoperatively, all patients were allowed to receive intravenous morphine on an as needed basis. Intravenous morphine requirements were then recorded immediately postoperative, at 6, 12, 24 hours, and the total requirement before discharge. Patient postoperative pain levels were determined using the visual analog pain scale and were documented at 0, 4, 8, 12, 16, 24, and 36 hours postoperative., Results: There were no significant differences in available patient demographics, intraoperative blood loss, or postoperative hemovac drain output between study groups. Total postoperative intravenous morphine requirements in addition to morphine requirements at all predetermined time points were less in patients randomized to receive the multimodal analgesic regimen. Visual analog pain scores were lower at all postoperative time points in patients randomized to receive the multimodal analgesic regimen. Time to solid food was significantly less in the multimodal group. There were no major identifiable postoperative complications in either treatment group., Conclusions: Opioid and nonopioid analgesic combinations appear to be safe and effective after lumbar laminectomy. Patients demonstrate lower intravenous morphine requirements, better pain scores, and earlier time to solid food intake.

The incidence of chronic and debilitating conditions in the aging population is steadily increasing, and the treatment of extreme elderly patients with spinal conditions can be challenging. Spinal stenosis and spondylolisthesis can dramatically affect patient quality of life, and patients commonly seek a surgical solution for their condition. Many extreme elderly patients are cautioned against surgery secondary due to their high complication and in-hospital mortality rates when compared with younger patients. This article describes the oldest patient (101 years old) in the English literature with severe spinal stenosis and spondylolisthesis who underwent primary lumbar decompression and fusion. His symptomatology dramatically affected his quality of life, and he was denied surgical care at another institution secondary to his advanced age and high potential risks. A successful outcome was ultimately achieved, and he was able to return to a higher level of physical functioning and social participation prior to his death of unrelated causes 3 years later. This case questions the strict indications of surgery in less-than-ideal and extreme elderly surgical candidates. The authors believe that surgery should not be denied in extreme elderly patients who have failed conservative treatment modalities and continue to have functional impairments. Successful spinal surgery may allow extreme elderly patients an improved quality to the remainder of their life., (Copyright 2012, SLACK Incorporated.)

Background Context: The use of neurophysiologic monitoring during anterior and posterior cervical decompression procedures in patients with spondylotic myelopathy remains controversial. The ideal neurophysiologic monitoring modality of choice is also highly debated., Purpose: The purpose of this study was to evaluate the utility of neurophysiologic monitoring with only somatosensory-evoked potentials (SSEPs) in a consecutive series of laminoplasty procedures with regard to the detection of new postoperative neurologic deficits., Study Design: Retrospective case series., Patient Sample: Eighty consecutive patients who underwent a posterior cervical laminoplasty were reviewed., Outcome Measures: We analyzed intraoperative SSEP amplitude and latency changes from baseline with regard to the development of new postoperative neurologic deficits., Methods: We retrospectively reviewed 80 patients who underwent a posterior cervical "open-door" laminoplasty with a standard SSEP neurophysiologic monitoring protocol. Intraoperative SSEP amplitude and latency changes from baseline ("alerts") were analyzed with regard to the development of new postoperative neurologic deficits., Results: Baseline SSEP values were obtained in all patients. There were five (6%) procedures that had SSEP alerts. All alerts occurred shortly after the lamina was hinged open. Four patients with SSEP alerts developed new postoperative neurologic deficits, including three unilateral upper extremity motor and sensory deficits and one complete spinal cord injury. In the immediate postoperative period, our experience with SSEP monitoring demonstrated 4 true-positive, 75 true-negative, and 1 false-positive monitoring results., Conclusions: In this series of laminoplasty procedures, SSEP neurophysiologic monitoring had a high sensitivity and specificity for predicting new neurologic deficits in the early postoperative period. Somatosensory-evoked potentials are an effective tool for spinal cord monitoring when performing a posterior cervical laminoplasty procedure., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Natural history studies have focused on risk for progression in lumbar curves of more than 30 degrees, while smaller curves have little data for guiding treatment. We studied curve progression in de novo degenerative scoliotic curves of no more than 30 degrees. Radiographs of 24 patients (17 women, 7 men; mean age, 68.2 years) followed for up to 14.3 years (mean, 4.85 years) were reviewed. Risk factors studied for curve progression included lumbar lordosis, lateral listhesis of more than 5 mm, sex, age, convexity direction, and position of intercrestal line. Curves averaged 14 degrees at presentation and 22 degrees at latest follow-up and progressed a mean of 2 degrees (SD, 1 degrees) per year. Mean progression was 2.5 degrees per year for patients older than 69 years and 1.5 degrees per year for younger patients. Levoscoliosis progressed 3 degrees per year and dextroscoliosis 1 degrees per year (P<.05). Forty-six percent of patients had lateral listhesis of more than 5 mm at L3 and L4. Curve progression was not linear and might occur rapidly, particularly in women older than 69 with lateral listhesis of more than 5 mm and levoscoliosis. Small curves can progress and therefore should be individualized in the context of other risk factors.

Background Context: Degenerative spondylolisthesis has been well described as a disorder of the lumbar spine. Few authors have suggested that a similar disorder occurs in the cervical spine. To our knowledge, the present study represents the largest series of patients with long-term follow-up who were managed surgically for the treatment of degenerative spondylolisthesis of the cervical spine., Purpose: To describe the clinical presentation and radiographic findings associated with degenerative cervical spondylolisthesis, and to report the long-term results of surgically managed patients., Study Design: Analysis of 58 patients treated with anterior cervical decompression and fusion for degenerative spondylolisthesis of the cervical spine., Patient Sample: From 1974 to 2003, 58 patients were identified as having degenerative spondylolisthesis of the cervical spine occurring in the absence of trauma, systemic inflammatory arthropathy, or congenital abnormality. These patients were identified from a database of approximately 500 patients with degenerative cervical spine disorders treated by the senior one of us., Outcome Measures: Patient outcomes were evaluated with regard to neurologic improvement (Nurick grade myelopathy) and osseous fusion., Methods: The records of 58 patients were reviewed. The average follow-up period was 6.9 years (range, 2-24 years). Seventy-two cervical levels demonstrated spondylolisthesis. In all cases, there was radiographic evidence of facet degeneration and subluxation. All patients were treated with anterior cervical decompression and arthrodesis with iliac crest structural graft. This most commonly involved corpectomy of the caudal vertebrae. Three patients required additional posterior facet fusion., Results: Fifty-eight patients demonstrated 72 levels of involvement. The C4-C5 level was most frequently involved (43%). Two radiographically distinct types of listhesis were observed based on the amount of disc degeneration and the degree of spondylosis at adjacent levels. The average neurologic improvement was 1.5 Nurick grades. The overall fusion rate was 92%. Three patients were treated with combined anterior-posterior arthrodesis. The prevalence of myelopathy and instability pattern was greater in the listheses occurring adjacent to spondylotic levels., Conclusions: Degenerative spondylolisthesis is relatively common in the cervical spine. Common to all cases is facet arthropathy and neurologic compression. Anterior cervical decompression and arthrodesis appears to yield excellent union rates and neurological improvement in those patients having cervical degenerative spondylolisthesis and significant neurological sequelae who have failed nonoperative treatments.

Study Design: A retrospective., Objective: The proximity of the plate to the adjacent disc space appeared to be the critical determinant of adjacent level ossification development (ALOD) but we had no data on unplated arthrodesis. Without such data, we could not be positive that ALOD was a complication related to plates., Summary of Background Data: We previously described the incidence and timing of ALOD after anterior cervical arthrodesis and plating., Methods: One hundred sixty-five patients (total 330 adjacent levels) who underwent anterior cervical arthrodesis without plate fixation by a single surgeon were reviewed. The average follow-up period was 28.8 months (2-9 years); ages ranged from 32 to 79 years (median 59.86). The presence and severity of ALOD was assessed on the lateral radiographs at 3, 6, 12, and 24 months after surgery and then annually and recorded into 4 grades., Results: ALOD developed in 9 patients at 10 levels (5.5% of patients and 3% of levels). Eight patients had a single-level (proximal or distal) ALOD, whereas 1 patient had both ALOD. Proximal ALOD developed in 7 cases, distal in 1 case and both in 1 case. ALOD initially appeared between 6 and 12 months in all cases: 4 cases occurred at 6 months and 5 cases at 12 months. During follow-up period, the final grade of proximal ALOD was grade I for 4 levels and grade II for 4 levels and final grade of distal ALOD was grade I for 1 level and grade II for 1 level. One patient with C3-C4 arthrodesis had both ALOD with grade I proximally and grade II distally., Conclusion: ALOD is infrequent when certain techniques are adhered to. These include minimal stripping of the anterior longitudinal ligament and the avoidance of Caspar pins and anterior plates. It remains to be determined exactly which of these factors plays the dominant role in the production of ALOD.

Study Design: Retrospective chart review of documented adverse events in 637 consecutive patients after computed tomogram myelography and follow-up interview of the most recent 100 of these patients., Objectives: This study assessed documented prevalence of adverse events after diagnostic myelography in cervical spondylotic patients and compared with perceived adverse events and satisfaction in a subset of the same cohort of patients., Summary of Background Data: There are some data that suggest complimentary benefits of myelography to magnetic resonance imaging. However, given the invasive nature of myelography, there are little data documenting the adverse events and patient experience with myelography to guide informed consent and physician choice of this study., Methods: We analyzed the records of 637 consecutive patients (364 males and 273 females) after myelography. Five hundred forty-four patients (group 1) had a cervical approach and 93 (group 2) had a lumbar approach. The last 100 consecutive patients (85 in group 1 and 15 in group 2) were asked questions that addressed patient perceived adverse reactions, pain levels, and satisfaction., Results: There was a 4.4% (28/637) prevalence of documented abnormal reactions. Group 1 had a 4.9% (25/506) prevalence of adverse reactions compared with 3.4% (3/89) in group 2. Overall 6.6% (42/637) had to have their myelographic procedures converted. Group 1 had 7% (38/544) converted to the lumbar approach group 2 had 4.3% (4/93) converted to the cervical approach. Thirty percent of the 100 patients interviewed felt they had an unexpected reaction (28 group 1 and 2 group 2). When interviewed, 14% of patients had maximum pain scores of 10 during the procedure and 8% (all group 1) felt worse pain after the procedure was completed. Six group 1 and 2 group 2 patients would not have the procedure again even when recommended by the surgeon. There was no statistically significant difference between complication rates, conversion rates, or patient perceived unexpected reactions between the 2 groups (beta=0.90)., Conclusions: This paper demonstrated the discrepancy between documented adverse events with computed tomogram myelography and patient reported tolerance as recorded by telephone follow-up. The cervical approach had a greater degree of patient perceived discomfort and a trend toward higher documented and patient reported adverse events and rate of approach conversion to a lumbar approach (P>0.5). When choosing myelography to evaluate patients with cervical spondylosis, the surgeon should consider the low patient tolerance and frequent adverse reactions that often go undocumented.

Study Design: Retrospective review of 259 lumbar discectomies., Objective: To compare rates of reoperation after subtotal discectomy versus established rates after fragment excision., Summary of Background Data: Herniated nucleus pulposes (HNP) and annular morphology influence rates of reherniation after discectomy. Certain patterns are linked to reherniation rates exceeding 20%., Methods: We retrospectively reviewed 259 single-level lumbar discectomies performed between 1980 and 2005. Mean follow-up was 60.9 months. In each case, annulotomy and subtotal discectomy was performed in addition to excision of disc fragments. HNP morphology was classified according to the 4-part system of Carragee (type 1: fragment/fissure; type 2: fragment/defect; type 3: fragment/contained; type 4: no fragment/contained). Fisher exact test was used to compare our proportion of patients with reherniation and/or reoperation to Caragee's series in which only fragment excision was performed., Results: Of 259 cases, 12 (4.5%) reoperations were performed. A significant difference in failure/reoperation rate was noted in type 2 herniations. There was a significantly lower rate of failure and reoperation for type 2 HNP after subtotal discectomy (3.4%) when compared with fragment excision alone (21.2%), P<0.003., Conclusions: Subtotal discectomy is an acceptable technique that decreases reherniation after lumbar discectomy.

Background: Neurogenic claudication secondary to lumbar stenosis is often cited by overweight and obese patients as a factor limiting their ability to lose weight. Many patients believe that they will be able to increase their activity and subsequently lose weight following relief of symptoms. The objective of this study was to evaluate weight loss in overweight and obese patients who obtained substantial pain relief after lumbar decompression surgery for spinal stenosis., Methods: Changes in the body weight and body mass index of overweight and obese patients after lumbar decompression surgery were assessed at a mean of 34.4 months postoperatively. Sixty-three patients (thirty-seven men and twenty-six women with a mean age of 53.4 years) were included in the study. Preoperative and postoperative body weight and body mass indices were calculated, and Zurich Claudication Questionnaire (ZCQ) Symptom Severity and Physical Function scores were obtained., Results: The ZCQ Symptom Severity and Physical Function scores significantly improved, by a mean of 56.4% and 53.0%, respectively. At the time of follow-up, both the mean body weight and the mean body mass index significantly increased, by 2.48 kg and 0.83 kg/m(2), respectively. Overall, 35% of the patients gained >or=5% of their preoperative body weight, 6% of the patients lost >or=5% of their preoperative body weight, and 59% remained within 5% of their preoperative body weight., Conclusions: The majority of overweight and obese patients maintain or increase their body weight and body mass index following successful lumbar decompression surgery. Substantial relief of symptoms and functional improvements do not appear to help overweight or obese patients to lose weight. This suggests that obesity is an independent disease and not simply a function of symptomatic spinal stenosis, and patients should be counseled regarding these expectations.

Background: Reherniation within the first year following subtotal lumbar discectomy is a rare but noteworthy event. We performed a retrospective, case-controlled study to evaluate the clinical outcomes after early recurrent lumbar disc reherniation., Methods: The records of 1320 patients who had undergone primary subtotal lumbar discectomy were analyzed retrospectively by an independent reviewer. Patients with documented reherniation within twelve months were evaluated with regard to the location of the reherniation, the neurologic status, the rate of reoperation, and the subjective outcome. Patients were evaluated on the basis of a physical examination and a review of medical records. Disc morphology, anular competence, and the presence of free fragments were categorized with use of a modified five-part Carragee classification system. The mean duration of follow-up for this group was 52.6 months. Clinical outcomes were assessed with use of the Oswestry score and the modified criteria of McNab. Twenty-nine historical control patients who had undergone uncomplicated subtotal lumbar discectomy were selected., Results: We identified fourteen recurrent lumbar disc herniations within one year after the index procedure. All fourteen patients had radicular pain and weakness prior to, and complete relief of radiculopathy after, the index procedure. All reherniations occurred at the same level as the index procedure, but eight occurred in a different direction than the original herniation. All patients underwent reexploration and discectomy, and two underwent single-level posterolateral arthrodesis. Two patients underwent a third procedure. The average Oswestry score at the time of the latest follow-up was 6.4 for the recurrent herniation group, compared with 6.9 for the controls. The outcomes according to the modified McNab criteria were not significantly different between the groups, with the numbers available. The mean duration of follow-up after the second discectomy was 52.6 months., Conclusions: The rate of early reherniation after subtotal lumbar discectomy is low (1%). It is important to consider the possibility of iatrogenic instability during surgery on the lumbar spine for the treatment of reherniation. Patients who undergo reoperation because of early recurrent lumbar disc herniation can have clinical outcomes comparable with those of patients undergoing an uncomplicated subtotal lumbar discectomy.

Cervical spine infections can have disastrous consequences, but techniques for minimizing infections should be evidence based. In this article, we report the incidence of spine infections in a large cohort of consecutive patients who underwent anterior cervical fusions without iodophor-impregnated incision drapes (3M Ioban; 3M Health Care, St. Paul, Minn) covering the surgical site. We reviewed the records of 581 consecutive patients (294 men, 287 women) who underwent 616 anterior cervical fusions without such drapes over the incision site and who were followed for 1 to 21 years after surgery. Mean age at the time of surgery was 52 years (range, 17-83 years). There was 0% incidence of cervical spinal infections in the group. Need for iodophor-impregnated incision drapes during anterior cervical fusion was not demonstrated. These drapes added unnecessary cost and may decrease skin mobility, making adequate exposure more difficult.

Study Design: Retrospective review., Objective: To quantify and describe perioperative complication rates in a large series of well-matched elderly patients who underwent lumbar decompression and arthrodesis., Summary of Background Data: Posterior lumbar decompression and fusion is frequently performed to treat lumbar stenosis with instability. An increasing number of elderly patients are undergoing operative treatment for degenerative lumbar disease. The reported morbidity of performing decompression and arthrodesis in this population varies widely in the literature, with recent reports showing a high rate of major complications., Methods: A total of 166 patients age 65 or older that underwent primary posterior lumbar decompression and fusion with (group 1; n = 75) or without (group 2; n = 91) instrumentation were included. Hospital records were reviewed for the occurrence of any complications (major and minor), the need for transfusion, estimated length of stay, and disposition at discharge. Logistic regression (with the presence/absence of major complications as the dependent variable) was used to identify risk factors for the occurrence of a complication., Results: Five major complications (3%) occurred (group 1, 1; group 2, 4). Minor complications developed in 30.7% of group 1 and 31.9% of group 2. There were no deaths, and only one perioperative complication was attributable to the use of instrumentation. Decompression/fusion of 4 or more segments was significantly associated with the occurrence of a major complication. Advanced age, the presence of medical comorbidities, or the use of instrumentation did not increase the rate of major or minor complications. The occurrence of either a major or minor complication prolonged hospital stay., Conclusions: Posterior lumbar decompression and fusion can be safely performed in elderly patients, with a low rate of major complications. The addition of instrumentation does not increase the complication rate. These results differ from those previously reported in the literature, which describe a significantly higher rate of complications in this age group, with a prolonged rate of hospitalization.

Study Design: An independent retrospective chart review combined with a review of current literature., Objectives: To describe a series of destructive, calcific masses of the cervical spine causing pain, neurologic dysfunction, and instability in patients with scleroderma and detail the surgical interventions required. To review benign, calcific cervical spine lesions associated with scleroderma and collagen vascular disorders., Summary of Background Data: Little is know about the diagnosis and management of the destructive, calcific lesions of scleroderma in the cervical spine., Methods: The medical and radiographic records of 3 patients with scleroderma lesions in the cervical spine were reviewed. A computer-based literature search of Ovid and PubMed databases was used to compile a comprehensive review of the topic., Results: The perioperative and surgical management of 3 cases of scleroderma of the cervical spine are discussed in the context of a complete literature review on the topic. These complex lesions were found to require significant resources with regard to diagnosis and management., Conclusions: Destructive, calcific masses in the cervical spine associated with scleroderma and an indication for surgical treatment are rare. Treatment is complex and not without significant risk to the patient.

Background Context: It is known that positioning patients on the Jackson and Andrews operative tables causes changes in lumbar lordosis and pelvic rotation. However, it is unknown if the relationship between the iliac crest and underlying lumbar levels, in particular the L4-L5 interspace, changes from standing to prone on these tables., Purpose: To assess the changes in the relationship between the iliac crests and lumbar spinal levels from standing to prone on two different operative positions using the Jackson and Andrews frames., Study Design/setting: Comparative analysis of iliac crest position relative to spinal levels in the preoperative standing position and while positioned on the Jackson and Andrews frames., Patient Sample: 48 randomly selected patients who underwent spinal surgery on either the Jackson or Andrews frame., Outcome Measures: Imaging., Method: Comparative measurements were made of the preoperative and intraoperative plain lateral lumbar radiographs. The location of the superior border of the iliac crest relative to the L4 lumbar spine level was compared between radiographs., Results: Preoperatively, the iliac crest aligned with L4/L4-L5 spinal level in 79.2% of the 48 patients compared with 85.5% of intraoperative cases (p=.59). Intraoperative iliac crest level aligned with the L4/L4-L5 level in 80.8% and 90.9% of the patients on the Andrews and Jackson tables respectively (p=.43). Thirty-four patients (70.8%) demonstrated no change in iliac crest alignment between intraoperative and preoperative radiographs. There was a trend for the iliac crest to shift cephalad with operative positioning., Conclusion: Approximately 30% of patients demonstrated changes in the relationship between the iliac crest and lumbar levels between standing and positioning prone. The intraoperative position of the iliac crest aligned more accurately with the L4/L4-L5 spine level on the Jackson and Andrews frame compared with preoperative standing radiographs respectively. Further biomechanical studies should investigate the implication for lumbopelvic fixation.

Objective: Prior cadaveric research showed that the lateral mass and facets are landmarks to determine the initial starting point for lateral mass screws and that the optimum screw trajectory was 30 degrees lateral and 15 degrees cephalad. The missing link was an intraoperative landmark to guide the trajectory for drilling according to these angles. The authors hypothesized that spinous processes can be used to guide the trajectory for lateral mass screw placement., Methods: The authors analyzed 144 lateral masses of 72 cervical vertebrae in 18 cadavers (7 males and 11 females). The lateral and cephalocaudad angles were measured for each lateral mass from C3 to C6 while using the spinous processes of the adjacent three caudad vertebrae at each level to guide the starting trajectories for a total of 864 angles. The lateral and cephalad trajectory angles at each spinous process relative to the starting hole were compared with 30 degrees and 15 degrees . For each angle measured at a particular level, the same starting hole was used in the lateral mass, and the superolateral cortex of each spinous process was the most medial point., Results: When drilling for the C3 and C4 lateral mass screws, the C4 and C5 spinous processes provided an accurate starting point, respectively, for the lateral angle but moderately overestimated the cephalocaudad angle. For C5 and C6 lateral mass screws, the C6 and C7 spinous processes provided an accurate starting point, respectively, for both the lateral and the cephalocaudad angles., Conclusion: The spinous processes can be an accurate local anatomic guide for lateral mass screw trajectory and will allow greater safety while drilling before performing laminectomies. These guides may change in patients with cervical spinal deformities.

Degenerative disorders in the spine are normal, age-related phenomena and largely asymptomatic in most cases. Conservative management of lumbar and cervical spondylosis is the mainstay of treatment, and most patients with symptomatic degenerative changes respond appropriately with nonsurgical management. Surgical intervention can be considered an appropriate and viable option when conservative measures have failed. Treatment options should always be directed toward the specific nature and location of the patient's individual pathology. Although current standards in the surgical management of lumbar and cervical degenerative disorders include discectomy, neural decompression, and instrumented spinal arthrodesis, new approaches that address this often-challenging clinical entity are on the horizon.

Study Design: Retrospective review of spinal exostoses treated at our institution and literature review., Objectives: Review of 12 cases of spinal exostoses treated at our institution compared with 165 cases of spinal exostoses reported in the literature., Summary of Background Data: Spinal exostoses are uncommon. Most reports consist of 1 to 3 cases. The relationship between solitary exostoses and those associated with multiple hereditary exostoses (MHE), as well as the incidence of intraspinal and extraspinal location, symptoms presentation, and results of treatment are unclear., Methods: The medical records, operative reports, and diagnostic imaging of 12 patients with spinal exostoses treated at our institution between 1972 and 2002 were reviewed. The literature was reviewed using MEDLINE search of English literature and bibliographies of published manuscripts., Results: Solitary spinal exostoses were more common than those associated with MHE. Lesions were most common in the upper cervical spine and originated from the posterior elements. Patients with exostoses associated with MHE were significantly younger and had a higher incidence of symptoms consistent with neural structure compression than patients with solitary exostoses. Complete excision resulted in resolution of preoperative symptoms. Intralesional excision resulted in recurrence in all cases., Conclusions: Spinal exostoses are more common than reported previously. Patients with MHE that present with back pain or neurological symptoms should produce a high index of suspicion. Evaluation should include both computed tomography and magnetic resonance imaging to define the origin of the exostosis and the presence of neural structure compression. Surgical excision should be preformed en bloc.

Study Design: Retrospective analysis of pelvic incidence and other radiographic parameters as a predictor of progression of isthmic spondylolisthesis., Objectives: To evaluate the predictive value of various radiographic parameters, including pelvic incidence, in determining the risk for progression of lumbosacral isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA Although pelvic incidence has recently been shown to be positively correlated to the severity of spondylolisthesis, it has not been confirmed as a predictor of spondylolisthetic progression., Materials and Methods: Thirty-six patients who have undergone primary posterior lumbosacral fusion for isthmic spondylolisthesis at our institution from 1977 to 2001 were retrospectively analyzed. There were 24 females and 12 males with a mean age of 21.3 +/- 2.0 years (range, 12 to 53 y). Twenty-two patients had high-grade (Meyerding class III, IV, V) and 14 patients had low-grade (Meyerding class I, II) spondylolisthesis, respectively. Factors evaluated included age, gender, neurologic deficits, reason for surgery, and documented evidence of progression. Slip percentage, high-grade or low-grade slip, slip angle, sacral inclination, sacral rounding, trapezoidal L5 vertebra, and pelvic incidence were measured from immediate preoperative standing lateral radiographs. These factors were statistically analyzed for risk of progression. Continuous variables were analyzed using one-way analysis of variance. Nominal variables were analyzed using chi2 test., Results: Pelvic incidence (P = 0.66) was not predictive of spondylolisthetic progression. Of the other radiographic measurements, slip percentage (P < 0.001), slip angle (P = 0.016), and high-grade spondylolisthesis (P < 0.0001) were highly predictive of progression. Interestingly, sacral inclination (P = 0.33) was not predictive of progression., Conclusions: Pelvic incidence cannot adequately predict the probability of spondylolisthetic progression. Analysis of the other clinical and radiographic parameters revealed that slip percentage and high-grade spondylolisthesis remain the most positive predictors of progression.

Study Design: A retrospective review of consecutive patients with graft migration or displacement after anterior cervical corpectomy surgery was performed., Objectives: To examine the associated risk factors and results of treatment among patients who sustained graft displacement or migration after anterior cervical corpectomy surgery., Summary of Background Data: Graft migration or displacement after anterior cervical corpectomy is a potential complication that may require revision surgery, but because of the low incidence, the factors associated with graft movement and the results of treatment are not well defined., Methods: All patients who had undergone a cervical corpectomy were examined for graft migration or displacement. None of the patients had a previous cervical laminectomy or prior posterior cervical surgery. All the patients were treated with autogenous strut grafting after decompression., Results: Over a 25-year period, 249 consecutive patients underwent one- to five-level anterior cervical corpectomies and strut grafting. All the patients were fused using autogenous bone grafts (iliac crest or fibula). During the postoperative period, 16 of the patients (10 women and 6 men; average age, 61.4 years) experienced migration of their grafts. The average follow-up period was 4.7 years (range, 2-12 years). The graft migration rates increased with more levels of fusion (odds ratio of 1.65 for having a displaced graft with each additional level): 4 of 95 single-level grafts, 4 of 76 two-level grafts, 7 of 71 three-level grafts, and 1 of 6 for four-level grafts. Of the 16 patients with graft migration, 14 had procedures involving a corpectomy of C6 with a fusion inferiorly extending to the C7 vertebral body (P = 0.001, statistically significant difference). Of these 16 patients, 5 underwent revision surgeries acutely for displacement and associated fracture of the inferior graft and vertebral body junction. None of the patients sustained a neurologic or respiratory complication as a result of graft migration ordisplacement. All of the patients went on to successfulfusion., Conclusions: This study demonstrated that a greater number of vertebral bodies removed and a longer graft are directly related to an increased frequency of graft displacement. Graft displacement may require revision surgery, but no patient in this study experienced a permanent adverse result from this complication. Corpectomies involving a fusion ending at the C7 vertebral body were associated with a higher rate of graft migration.

Study Design: Reconstruction techniques after multilevel anterior cervical decompression were retrospectively compared., Objective: To compare radiographic and clinical outcomes of multiple interbody grafting with strut grafting., Summary of Background Data: Previous studies have reported lower fusion rates for anterior cervical decompressions reconstructed with multiple interbody grafts as opposed to a single strut graft, although these techniques have never been directly compared in a consecutive series of patients who underwent surgery by a single surgeon., Methods: Over a 20-year period, 190 patients underwent anterior cervical decompression and autogenous grafting without internal fixation and were followed for an average of 68 months. There were 98 two-level and 33 three-level discectomies with interbody grafting. These were compared with 16 one-level, 21 two-level, 20 three-level, and 2 four-level corpectomies with strut grafting. Radiographic and clinical outcomes were compared between the groups by chi2 and rank-sum analysis, respectively., Results: Of the 59 patients who underwent strut grafting, 55 achieved a solid arthrodesis (93%), as compared with 87 of the 131 patients who underwent multiple interbody grafting (66%) (P = 0.0002). There were six cases of graft displacement or extrusion among the 59 patients who had strut grafts, as compared with no graft-related complications among the 131 patients who had interbody grafts (P < 0.0001). More "good" and "excellent" clinical outcomes were found among patients who underwent strut-grafting (88% vs 84%), although the difference was not statistically significant (P = 0.73). However, patients with a pseudarthrosis had significantly poorer clinical outcomes (P < 0.0001)., Conclusions: A much higher fusion rate was achieved after corpectomy and strut grafting than after multilevel discectomy and interbody grafting. Although there were strut graft-related complications, four of these six complications occurred among patients who had a postlaminectomy kyphosis. Because pseudarthrosis resulted in poorer clinical outcomes, strut grafting should be considered after multilevel anterior cervical decompression to increase the likelihood of successful fusion.

Study Design: A retrospective investigation of the results of operative treatment of patients with symptomatic thoracic spinal stenosis., Objectives: To establish the effectiveness and define the limitations of surgical treatment for stenosis of the thoracic spinal canal., Summary of Background Data: In contrast to cervical and lumbar stenosis, symptomatic narrowing of the thoracic spinal canal is rarely encountered. Although the treatment of thoracic stenosis has been described in multiple case reports and in several small series with minimal follow-up evaluation, there are few studies of patients treated surgically for this condition with follow-up evaluation beyond 2 years., Methods: Twelve patients who underwent operative decompression for symptomatic stenosis of the lower thoracic spine were followed up for an average period of 62.4 months. Surgery was performed on the thoracic spine alone in four cases and on the combined thoracolumbar spine in eight. Factors that were investigated included pain severity, lower extremity motor function, ambulatory status, and postoperative complications., Results: The level of pain after surgery was decreased in eight patients and unchanged in four patients. Of the 10 patients with a motor deficit before surgery, eight had improvement of muscle function. Of the 11 patients with a gait disturbance before surgery, ambulatory status was improved in seven, unchanged in two, and worse in two. One patient lost neural function secondary to surgical intervention. There were five cases in which the early result subsequently deteriorated because of recurrent stenosis, spinal deformity/instability, or both., Conclusions: Thoracic stenosis can occur in isolation or, more commonly, in association with lumbar stenosis. Ideally, operative treatment should address all stenotic segments and directly decompress the primary anatomic abnormalities causing neural element compression. Although satisfactory short-term results can be expected, deterioration of the early outcome because of the potential for recurrent stenosis and deformity/instability at the thoracolumbar junction can sometimes be seen with longer follow-up evaluation periods.

Background: Basilar invagination can be difficult to diagnose with plain radiography in patients with rheumatoid arthritis. Although numerous radiographic criteria have been described, few studies have addressed the reliability of these parameters in the rheumatoid population. The purpose of the present study was to validate and compare the most widely accepted plain radiographic criteria for basilar invagination in this patient population., Methods: Cervical radiographs of 131 rheumatoid patients were examined. Of these patients, sixty-seven (twenty-nine with basilar invagination and thirty-eight without it) were also evaluated with tomograms, magnetic resonance imaging, and/or sagittally reconstructed computed tomography scans to detect the presence of basilar invagination. Three observers who were blinded with regard to the diagnosis independently scored each radiograph as positive, negative, or indeterminate according to the established criteria for invagination proposed by Clark et al., McRae and Barnum, Chamberlain, McGregor, Redlund-Johnell and Pettersson, Ranawat et al., Fischgold and Metzger, and Wackenheim. Interobserver and intraobserver variability, sensitivity, specificity, total percentage of correct results, and negative and positive predictive values were determined for each criterion as well as for various combinations of the criteria., Results: No single test had a sensitivity and a negative predictive value of greater than 90% as well as a reasonable specificity and a reasonable positive predictive value. The combination of the Clark station, the Redlund-Johnell criterion, and the Ranawat criterion, scored as positive for basilar invagination if any of the three were positive, proved to be better than any single criterion; the sensitivity of the combined criteria was 94%, and the negative predictive value was 91%., Conclusions: A screening test for basilar invagination should have a high sensitivity and a high negative predictive value, so that the disease will not be missed, and yet be specific, so that the disease will not be overdiagnosed. Our data suggest that none of the widely utilized plain radiographic criteria meet these goals. We recommend that measurements be made according to the methods described by Clark et al., Redlund-Johnell et al., and Ranawat et al. and, if any of these suggests basilar invagination, tomography or magnetic resonance imaging should be performed. Since approximately 6% of the cases of basilar invagination in rheumatoid patients would still be missed with this approach, tomography or magnetic resonance imaging should be performed on a rheumatoid patient whenever plain radiographs leave any doubt about the diagnosis of basilar invagination.

Study Design: Both the cadaveric and clinical examples of anomalous vertebral artery courses are described. The incidence of this anomaly in the general population and recognition, complications, and treatment options for these patients when undergoing anterior cervical decompression are discussed., Objectives: Cadaveric study: In this study vertebral artery's course through the cervical spine in the adult population was analyzed. The relation between an abnormal vertebral artery course and surgical landmarks are described. Clinical study: Complications and alternative treatment methods for decompression in patients with the anomaly are described., Summary of Background Data: The incidence of anomalous vertebral artery course is low, but failure to recognize a medially located vertebral artery may result in a life-threatening iatrogenic injury during decompression. Neither the relation between the vertebral arteries and the surgical landmarks nor the guidelines for decompression in the face of a tortuous vertebral artery have been well described., Methods: Transverse foramens of the cervical spine were measured in 222 cadaveric spines. The measurements were taken describing the relation between transverse foramens and other surgical landmarks. Three patients with anomalies were identified in clinical practice. The complications and treatment options are identified in these patients., Results: In the cadaveric specimens, a 2.7% incidence of tortuous vertebral artery course was identified. In these abnormal specimens, the transverse foramen was located an average of 0.14 mm medial to the joint of Luschka. In one patient, the abnormal course of the vertebral artery was recognized after laceration of the artery during a routine corpectomy. Anomalies in the other two patients were recognized before surgery, and the patients underwent modified anterior decompression by combining a discectomy at the anomalous level with a corpectomy at other levels. Vertebral artery ectasia is identifiable on axial magnetic resonance or computed tomographic images., Conclusions: Aberrant vertebral artery is rare. Preoperative recognition and appropriate modification of anterior decompression can yield excellent clinical results without risking significant complications.

The literature provides little data to guide surgical management of spinal stenosis adjacent to previous lumbar fusion. Thirty-three consecutive patients who had surgical decompression for spinal stenosis at the lumbar segments adjacent to a previous lumbar fusion were studied. The mean interval between fusion and the adjacent segment surgery was 94 months. Of the 33 patients, 26 were followed for 3-14 years (mean: 5 years) after adjacent segment surgery and were clinically evaluated and independently completed an outcome questionnaire. Of the 26 patients, 15 rated their outcome as completely satisfactory, 6 were neutral toward the surgery, and 5 considered their surgery a failure. The surgery was generally effective at improving or relieving lower extremity neurogenic claudication. The strongest independent predictive factor of patient dissatisfaction was ongoing postoperative low back pain (r = 0.7, p = 0.001). A higher back pain score at follow-up was associated with continued narcotic use (p = 0.001) and decreased ability to perform activities of daily living (p = 0.05). Six patients required further lumbar surgery during the follow-up period. This study provides the longest published follow-up data of surgical results for symptomatic spinal stenosis adjacent to a previously asymptomatic lumbar fusion.

A retrospective independent radiographic and chart review was undertaken for 17 patients who underwent a unique anterior salvage procedure for iatrogenic and progressive postoperative spondylolisthesis. This one-stage anterior transabdominal discectomy, reduction, stabilization, and arthrodesis was first performed in 1979. Of the 17 patients, all complained of leg pain, 14 of back pain, 11 had neurogenic claudication, and 2 were bedridden preoperatively because of their pain. Of the 17 patients, 7 had no neurologic deficits, 2 had cauda equina syndrome, and the remaining 8 had motor root deficits. The average number of posterior operations before our salvage procedure was 1.8, with a range of 1 to 3. Eight patients had an average of 1.6 attempts at posterior arthrodesis, with a range of 1 to 3 procedures. Two patients had a grade I spondylolisthesis, 11 a grade II, and 4 a grade III. Follow-up was available for 16 patients from 2 years and 3 months to 11 years and 5 months after the index operation (mean, 6 years and 5 months). One patient with severe cardiovascular disease died perioperatively. This anterior procedure was able to restore spinal stability and decompress the neural elements in 13 of 16 patients. Eleven obtained a solid arthrodesis. Three patients required further spinal surgery: two posterior fusions for symptomatic nonunions and one posterior foraminotomy for persistent foraminal stenosis. No patient deteriorated neurologically, the two with cauda equina syndrome recovered, and all but one patient with motor root deficits recovered fully. At latest follow-up, there were six excellent, seven good, and three fair results. There were no poor results. Although technically difficult and troubled by complications, the relative historical merits and principles of this unique anterior salvage procedure probably warrant further consideration, especially in light of evolving anterior surgical technologies.

Study Design: A case report of a patient with a known diagnosis of congenital insensitivity to pain who developed a herniated cervical disc., Objectives: To study the clinical manifestations of cervical radiculopathy in a patient with congenital insensitivity to pain and the long-term outcome after surgical treatment., Summary of Background Data: There have been no reports in the English literature documenting such a patient., Methods: Retrospective case report and long-term clinical and radiographic follow-up., Results: This patient with a known diagnosis of congenital insensitivity to pain had neurologic motor weakness with "neck and shoulder pain." Clear radicular pattern could not be elicited. The patient underwent a successful anterior discectomy and fusion with long-term clinical and radiographic results., Conclusion: Patients with congenital insensitivity to pain who develop a cervical disc herniation may present with atypical symptoms not manifesting in the classic radicular pattern. Higher index of suspicion by the clinician must be practiced to make the appropriate diagnosis. Successful surgical outcome may be achieved in these patients.

Background: The purpose of this study was to evaluate the complications of anterior cervical corpectomy and arthrodesis in patients who had had a previous cervical laminectomy. The results of previous studies have suggested that these patients can be managed with anterior decompression and an arthrodesis with either plate fixation or immobilization in a halo vest. However, no studies that we are aware of have specifically focused on the complications of these types of procedures., Methods: The records and radiographs of eighteen patients who had been managed with a one to four-level corpectomy with strut-grafting were retrospectively reviewed. The reviews were independently performed by the three of us who were not involved in the original operation. The interval between the laminectomy and the corpectomy ranged from one month to twenty-two years (mean, eight years)., Results: Eleven of the eighteen patients sustained a total of sixteen complications during the follow-up period, which averaged 2.7 years (range, seven months to six years and four months), and nine of the eleven had graft-related complications. Five grafts extruded or collapsed, or both. There were four reoperations. Immobilization in a halo vest did not prevent extrusions, as three of the four extrusions occurred while the patient wore a halo vest. Four patients had a pseudarthrosis. In three patients, the kyphosis increased by 10 degrees or more from the immediate preoperative period to the most recent follow-up evaluation. Two patients had respiratory distress that necessitated reintubation, one patient had a small dural tear, and one had transient dysphagia., Conclusions: Our data suggest that anterior cervical corpectomy without instrumentation in a patient who has had a previous laminectomy is associated with a great risk of graft-related complications despite the use of a halo vest. This previously unreported finding is relevant in that it contradicts the recommendation previously made by Zdeblick and the senior one of us, who advocated postoperative immobilization in a halo vest for these patients. Anterior cervical corpectomy should be performed with caution and knowledge of the potential complications in a patient who has had a previous laminectomy.

Background: We studied the incidence, prevalence, and radiographic progression of symptomatic adjacent-segment disease, which we defined as the development of new radiculopathy or myelopathy referable to a motion segment adjacent to the site of a previous anterior arthrodesis of the cervical spine., Methods: A consecutive series of 374 patients who had a total of 409 anterior cervical arthrodeses for the treatment of cervical spondylosis with radiculopathy or myelopathy, or both, were followed for a maximum of twenty-one years after the operation. The annual incidence of symptomatic adjacent-segment disease was defined as the percentage of patients who had been disease-free at the start of a given year of follow-up in whom new disease developed during that year. The prevalence was defined as the percentage of all patients in whom symptomatic adjacent-segment disease developed within a given period of follow-up. The natural history of the disease was predicted with use of a Kaplan-Meier survivorship analysis. The hypothesis that new disease at an adjacent level is more likely to develop following a multilevel arthrodesis than it is following a single-level arthrodesis was tested with logistic regression., Results: Symptomatic adjacent-segment disease occurred at a relatively constant incidence of 2.9 percent per year (range, 0.0 to 4.8 percent per year) during the ten years after the operation. Survivorship analysis predicted that 25.6 percent of the patients (95 percent confidence interval, 20 to 32 percent) who had an anterior cervical arthrodesis would have new disease at an adjacent level within ten years after the operation. There were highly significant differences among the motion segments with regard to the likelihood of symptomatic adjacent-segment disease (p<0.0001); the greatest risk was at the interspaces between the fifth and sixth and between the sixth and seventh cervical vertebrae. Contrary to our hypothesis, we found that the risk of new disease at an adjacent level was significantly lower following a multilevel arthrodesis than it was following a single-level arthrodesis (p<0.001). More than two-thirds of all patients in whom the new disease developed had failure of nonoperative management and needed additional operative procedures., Conclusions: Symptomatic adjacent-segment disease may affect more than one-fourth of all patients within ten years after an anterior cervical arthrodesis. A single-level arthrodesis involving the fifth or sixth cervical vertebra and preexisting radiographic evidence of degeneration at adjacent levels appear to be the greatest risk factors for new disease. Therefore, we believe that all degenerated segments causing radiculopathy or myelopathy should be included in an anterior cervical arthrodesis. Although our findings suggest that symptomatic adjacent-segment disease is the result of progressive spondylosis, patients should be informed of the substantial possibility that new disease will develop at an adjacent level over the long term.

We reviewed the results of acute management of patients who had sustained a dural tear during an operation on the lumbar spine, and we attempted to determine the long-term sequelae of this complication. In the five years from July 1989 to July 1994, 641 consecutive patients had a decompression of the lumbar spine, performed by the senior one of us; of these patients, eighty-eight (14 percent) sustained a dural tear, which was repaired during the operation. The duration of follow-up ranged from two to eight years (average, 4.3 years). Postoperative management consisted of closed suction wound drainage for an average of 2.1 days and bed rest for an average of 2.9 days. Of the eighty-eight procedures that resulted in a dural tear, forty-five were revisions; these revisions were performed after an average of 2.2 previous operations on the lumbar spine, all of which resulted in a scar adherent to the dura. Only eight patients had headaches related to the spinal procedure and photophobia in the postoperative period; these symptoms resolved in all but two patients, both of whom had had a revision operation. Each of the two patients had symptoms of a persistent leak of spinal fluid and needed a reoperation for repair. Overall, seventy-six patients had a good or excellent result and twelve had a poor or satisfactory result with some residual back pain. One patient had arachnoiditis, and another had symptoms of viral meningitis one month postoperatively. A dural tear that occurs during an operation on the lumbar spine can be treated successfully with primary repair followed by bed rest. Such a tear does not appear to have any long-term deleterious effects or to increase the risk of postoperative infection, neural damage, or arachnoiditis. Closed suction wound drainage does not seem to aggravate the leak and can be used safely in the presence of a dural repair.

We reviewed the cases of 108 patients with cervical spondylotic myelopathy who had been managed with anterior decompression and arthrodesis at our institution. Operative treatment consisted of anterior discectomy, partial corpectomy, or subtotal corpectomy at one level or more, followed by placement of autogenous bone graft from the iliac crest or the fibula. At the latest follow-up examination, thirty-eight of the eighty-two patients who had had a preoperative gait abnormality had a normal gait, thirty-three had an improvement in gait, six had no change, four had improvement and later deterioration, and one had a worse gait abnormality. Of the eighty-seven patients who had had a preoperative motor deficit, fifty-four had complete recovery; twenty-six, partial recovery; six, no change; and one had a worse deficit. The average grade according to the system of Nurick improved from 2.4 preoperatively to 1.2 (range, 0.0 to 5.0) postoperatively. A pseudarthrosis developed in sixteen patients, thirteen of whom had had a multilevel discectomy. Only one of thirty-eight arthrodeses that had been performed with use of a fibular strut graft was followed by a non-union. An unsatisfactory outcome with respect to pain was significantly associated with pseudarthrosis (p < 0.001). The development of complications other than non-union was associated with a history of one previous operative procedure or more (p = 0.005). Recurrent myelopathy was rare, but when it occurred it was associated with a pseudarthrosis or stenosis at a new level. The strongest predictive factor for recovery from myelopathy was the severity of the myelopathy before the operative intervention--that is, better preoperative neurological function was associated with a better neurological outcome. Anterior decompression and arthrodesis with autogenous bone-grafting can be performed safely, and is associated with a high rate of neurological recovery, functional improvement, and pain relief, in patients who have cervical spondylotic myelopathy.