See also: Sterile Seroma Resulting from Multilevel XLIF Procedure as Possible Adverse Effect of Prophylactic Vancomycin Powder: A Case ReportEvid Based Spine Care J 2014; 05(02): 127-133DOI: 10.1055/s-0034-1386754
Study Design Retrospective case review. Objective Atlantoaxial instability with and without basilar invagination poses a considerable challenge in management regarding reduction, surgical approach, decompression, instrumentation choice, and extent of fusion. A variety of strategies have been described to reduce and stabilize cranial settling with basilar invagination. Modern instrumentation options included extension to the occiput, C1-C2 transarticular fixation, and C1 lateral mass-C2 pars among others. Since not all cases of cranial settling are the same, their treatment strategies also differ. Factors such as local vascular anatomy, amount of subluxation, need for distraction, and shape of occipital condyles will dictate level and type of instrumentation. The objective of this study was to outline treatment options and provide a rationale for the surgical plan. Methods Two cases of C1-C2 instability in patients with Down syndrome are described. Case 2 underwent C1-C2 instrumented fusion, whereas case 1 involved posterior instrumented fusion to the occiput. Results Both patients tolerated the procedures well. There were no complications. Minimum follow-up was 1 year. There was no loss of reduction. Solid arthrodesis was achieved in both cases. Conclusion Successful reduction can be achieved with both C1-C2 instrumented fusion as well as O-C instrument fusion. Factors such as local vascular anatomy, amount of subluxation, need for distraction, and shape of occipital condyles will dictate level and type of instrumentation.
Study Design Case report. Objective To present a rare case of hydrocephalus following bilateral dumbbell-shaped C2 spinal neurofibromas resection and postoperative cervical pseudomeningocele in a patient with neurofibromatosis type 1 (NF1). Methods The patient's clinical course is retrospectively reviewed. A 37-year-old man affected by NF1 referred to our department for progressive weakness of both lower extremities and gait disturbance. Radiological imaging showed bilateral dumbbell-shaped C2 spinal neurofibromas. After its resection, at the 1-month follow-up evaluation, the patient reported headache and nausea. A CT brain scan showed a postoperative cervical pseudomeningocele and an increase in the ventricular sizes, resulting in hydrocephalus. Results A ventriculoperitoneal shunting was performed using a programmable valve opening pressure set to 120 mmH20. After surgery, the patient's neurological status markedly improved. Conclusion Hydrocephalus must be considered a possible complication of cervical spine tumor resection.
Study Design Systematic review. Clinical Questions Compared with no stimulation, does electrical stimulation promote bone fusion after lumbar spinal fusion procedures? Does the effect differ based on the type of electrical stimulation used? Methods Electronic databases and reference lists of key articles were searched up to October 15, 2013, to identify randomized controlled trials (RCTs) comparing the effect of electrical stimulation to no electrical stimulation on fusion rates after lumbar spinal fusion for the treatment of degenerative disease. Two independent reviewers assessed the strength of evidence using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) criteria. Results Six RCTs met the inclusion criteria. The following types of electrical stimulation were investigated: direct current (three studies), pulsed electromagnetic field (three studies), and capacitive coupling (one study). The control groups consisted of no stimulation (two studies) or placebo (four studies). Marked heterogeneity in study populations, characteristics, and design prevented a meta-analysis. Regardless of the type of electrical stimulation used, cumulative incidences of fusion varied widely across the RCTs, ranging from 35.4 to 90.6% in the intervention groups and from 33.3 to 81.9% in the control groups across 9 to 24 months of follow-up. Similarly, when stratified by the type of electrical stimulation used, fusion outcomes from individual studies varied, leading to inconsistent and conflicting results. Conclusion Given the inconsistency in study results, possibly due to heterogeneity in study populations/characteristics and quality, we are unable to conclude that electrical stimulation results in better fusion outcomes compared with no stimulation. The overall strength of evidence for the conclusions is low.
Clinicians, policy makers, and patients need to be able to rely on high-quality scientific research to make informed decisions about health care options and policy. Frustration ensues on all levels when there is low confidence in the quality and integrity of available research on spine care. When research quality is low and reporting of it is poor, clinicians and patients may have confusion regarding best health care options. Policy makers may not reimburse for treatments or diagnostic modalities that are deemed not effective based on available evidence. At the most basic level, all parties want the same thing: to do what “works,” yet they all suffer when there is low confidence in evidence.
The avid reader of EBSJ may be surprised that we have three case reports in this issue. Of course, the editors of this fine journal are keenly aware that in the evidence pyramid, case reports rank dead last due to their limited scientific value and high variability. However, in reviewing these case reports, we found a common denominator that is hopefully of some value to our readership: that of the underlying pathomechanism being storage diseases. These conditions have truly remained somewhat of a stepchild in spine surgery; outside of the traditional realms of deformity, trauma, neoplasia, and infection, they and metabolic bone diseases have remained more on the fringes of our clinical awareness. To the present date, it remains unclear how often patients with storage diseases and spinal problems remain undiagnosed by their spine surgeons, and similarly, how infrequently the primary care providers treating the disease processes are unaware of the potential spinal implications of these disorders. In all the cases presented in this EBSJ issue, the run-up time until appropriate diagnosis was long, and also in all cases the typically late spine manifestations prevented a “cure” and rather required reconstructive intervention.
Study Design Case report. Objective Amyoplasia-type arthrogryposis is a rare congenital disease that presents as multiple contractures involving various areas of the body. To the authors' knowledge, there have been no reports of adults with amyoplasia in the current literature. We report a case of an adult patient with cervical stenosis in the setting of amyoplasia. Patients and Methods A 48-year-old patient with amyoplasia and over 30 previous orthopedic reconstructive surgeries presented with neck pain radiating down his left shoulder and into the fingers, dysesthesia in his fingertips, and left-sided periauricular headache. A diagnosis of central spinal canal stenosis and bilateral foraminal stenosis at C3-C7 with radiculopathy was made based on computed tomography scans. Because of a prior right-side sternocleidomastoid muscle transfer, a left-side C3-C4, C5-C7 anterior cervical discectomy and fusion procedure was performed. Results The patient experienced significant improvement in symptoms that was transient. Symptoms returned to preoperative values after 1 year, despite significant and persistent improvement in stenosis. Conclusions Both amyoplasia and cervical stenosis can manifest in neurologic symptoms. Distinguishing the causing pathology can be challenging. The radiographic improvement of cervical stenosis in a patient with amyoplasia is not always associated with long-standing pain relief.
STUDY RATIONALE:Cerebral palsy (CP) is a group of nonprogressive syndromes of posture and motor impairment associated with lesions of the immature brain. Spastic quadriplegia is the most severe form with a high incidence of scoliosis, back pain, respiratory compromise, pelvic obliquity, and poor sitting balance. Surgical stabilization of the spine is an effective technique for correcting deformity and restoring sitting posture. The decision to operate in this group of patients is challenging.OBJECTIVES:The aim of this study is to determine the benefits of surgical correction of scoliosis in children with spastic quadriplegia, the adverse effects of this treatment, and what preoperative factors affect patient outcome after surgical correction.MATERIALS AND METHODS:A systematic review was undertaken to identify studies describing benefits and adverse effects of surgery in spastic quadriplegia. Factors affecting patient outcome following surgical correction of scoliosis were assessed. Studies involving adults and nonspastic quadriplegia were excluded.RESULTS:A total of 10 case series and 1 prospective and 3 retrospective cohort studies met inclusion criteria. There was significant variation in the overall risk of complications (range, 10.9-70.9%), mortality (range, 2.8-19%), respiratory/pulmonary complications (range, 26.9-57.1%), and infection (range, 2.5-56.8%). Factors associated with a worse outcome were a significant degree of thoracic kyphosis, days in the intensive care unit, and poor nutritional status.CONCLUSION:Caregivers report a high degree of satisfaction with scoliosis surgery for children with spastic quadriplegia. There is limited evidence of preoperative factors that can predict patient outcome after scoliosis. There is a need for well-designed prospective studies of scoliosis surgery in spastic quadriplegia.
Study Design Retrospective analysis. Clinical Question Is there a difference between the screw-rod construct (SRC) procedure without wiring and the SRC procedure with wiring with respect to fusion, implant failure, reoperation, donor-site morbidity, and complication rates? Patients and Methods We performed a retrospective analysis of 26 patients who underwent C1-2 fixation between 2004 and 2012 (SRC with wiring and structural bone graft, 13 patients; SRC with autograft but without wiring, 13 patients). Fusion was assessed using dynamic X-rays in all patients and computed tomographic scans in selected cases. Pseudoarthrosis was confirmed during reoperation. Results The mean follow-up time was 2 years and 5 months for the SRC without wiring group and 2 years and 1 month for the SRC with wiring group. Patients with less than 1-year follow-up time were excluded. The fusion rate, implant failure rate, and reoperation rates for the SRC without wiring group were 92, 8, and 8%, respectively. The fusion, implant failure, and reoperation rates for the SRC with wiring group were 100, 0, and 0%, respectively. There were no donor-site morbidities or complications in either group (both 0%). There were no differences in parameters we examined between the two groups (p > 0.05 for each rate, Fisher exact test). Conclusions The results suggest that supplementing the SRC procedure with wiring may increase fusion rate, but this difference is not statistically significant. Although the sample size was small, there was not a significant discrepancy in outcomes between the two groups at an average follow-up of 2 years. [Table: see text].
Design Retrospective case series. Objective The objective of this study was to assess the reoperation rate after microdiscectomy for the treatment of lumbar disc herniation (LDH) in patients with ≥ 5-year follow-up and identify demographic, perioperative, and outcome-related differences between patients with and without a reoperation. Methods The medical records, operative reports, and office notes of patients who had undergone microdiscectomy at a single institution between March 1994 and December 2007 were reviewed and long-term follow-up was assessed via a telephone questionnaire. Results Forty patients (M:24, F:16) with an average age at surgery of 39.9 ± 12.5 years (range: 18-80) underwent microdiscectomy at the levels L5-S1 (n = 28, 70%), L4-L5 (n = 9, 22.5%), L3-L4 (n = 2, 5.0%), and L1-L2 (n = 1, 2.5%). After an average of 40.4 ± 40.1 months (range: 1-128), 25% of patients (10/40) required further spine surgery related to the initial microdiscectomy. At an average postoperative follow-up of 11.1 ± 4.0 years (range: 5-19), additional symptoms apart from back and leg pain were reported more frequently by patients who underwent a reoperation (p = 0.005). Patient satisfaction was significantly higher in patients who did not undergo a reoperation (p = 0.041). For the Oswestry disability index, pain intensity (p = 0.036), and pain-related sleep disturbances (p = 0.006) were reported to be more severe in the reoperation group. Conclusions Microdiscectomy for the treatment of LDH results in a favorable long-term outcome in the majority of cases. The reoperation rate was higher in our series than reported in previous investigations with shorter follow-up. Although there were no statistically significant pre-/perioperative differences between patients with and without reoperation, our findings suggest a difference in self-reported long-term outcome measures.
STUDY DESIGN:Systematic review.STUDY RATIONALE:The surgical treatment of adult degenerative lumbar conditions remains controversial. Conventional techniques include posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF). A new direct approach known as lumbar lateral interbody fusion (LLIF), or extreme lateral interbody fusion (XLIF(®)) or direct lateral interbody fusion (DLIF), has been introduced. Objectives The objective of this article is to determine the comparative effectiveness and safety of LLIF, at one or more levels with or without instrumentation, versus PLIF or TLIF surgery in adults with lumbar degenerative conditions, and to determine which preoperative factors affect patient outcomes following LLIF surgery.MATERIALS AND METHODS:A systematic review of the literature was performed using PubMed and bibliographies of key articles. Articles were reviewed by two independent reviewers based on predetermined inclusion and exclusion criteria. Each article was evaluated using a predefined quality rating scheme.RESULTS:The search yielded 258 citations and the following met our inclusion criteria: three retrospective cohort studies (all using historical cohorts) (class of evidence [CoE] III) examining the comparative effectiveness and safety of LLIF/XLIF(®)/DLIF versus PLIF or TLIF surgery, and one prospective cohort study (CoE II) and two retrospective cohort studies (CoE III) assessing factors affecting patient outcome following LLIF. Patients in the LLIF group experienced less estimated blood loss and a lower mortality risk compared with the PLIF group. The number of levels treated and the preoperative diagnosis were significant predictors of perioperative or early complications in two studies.CONCLUSION:There is insufficient evidence of the comparative effectiveness of LLIF versus PLIF/TLIF surgery. There is low-quality evidence suggesting that LLIF surgery results in fewer complications or reoperations than PLIF/TLIF surgery. And there is insufficient evidence that any preoperative factors exist that predict patient outcome after LLIF surgery.
Abstract Study Design Systematic review. Study Rationale As the length of stay after cervical spine surgery has decreased substantially, the feasibility and safety of outpatient cervical spine surgery come into question. Although minimal length of stay is a targeted metric for quality and costs for medical centers, the safety of outpatient cervical spine surgery has not been clearly defined. Objective The objective of this article is to evaluate the safety of inpatient versus outpatient surgery in the cervical spine for adult patients with symptomatic or asymptomatic degenerative disc disease. Methods A systematic review of the literature was undertaken for articles published through February 19, 2014. Electronic databases and the bibliographies of key articles were searched to identify comparative studies evaluating the safety of inpatient versus outpatient surgery in the cervical spine. Spinal cord stimulation, spinal injections, and diagnostic procedures were excluded. Two independent reviewers assessed the strength of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, and disagreements were resolved by consensus. Results Five studies that met the inclusion criteria were identified. One study reported low risk of hematoma (0% of outpatients and 1.6% of inpatients). Two studies reported on mortality and both reported no deaths in either group following surgery. Dysphagia risks ranged from 0 to 10% of outpatients and 1.6 to 5% of inpatients, and infection risks ranged from 0 to 1% of outpatients and 2 to 2.8% of inpatients. One study reported that no (0) outpatients were readmitted to the hospital due to a complication, compared with four inpatients (7%). The overall strength of evidence was insufficient for all safety outcomes examined. Conclusion Though the studies in our systematic review did not suggest an increased risk of complication with outpatient cervical spine surgery, the strength of evidence to make a recommendation was insufficient. Further study is needed to more clearly define the role of outpatient cervical spine surgery.
STUDY DESIGN:Systematic review.STUDY RATIONALE:The purpose of this review is to further define the published literature with respect to vertebral artery (VA) anomaly and injury in patients with degenerative cervical spinal conditions.OBJECTIVES:In adult patients with cervical spine or degenerative cervical spine disorders receiving cervical spine surgery, what is the incidence of VA injury, and among resulting VA injuries, which treatments result in a successful outcome and what percent are successfully repaired?MATERIALS AND METHODS:A systematic review of pertinent articles published up to April 2013. Studies involving traumatic onset, fracture, infection, deformity or congenital abnormality, instability, inflammatory spinal diseases, or neoplasms were excluded. Two independent reviewers assessed the level of evidence quality using the Grades of Recommendation Assessment, Development and Evaluation criteria; disagreements were resolved by consensus.RESULTS:From a total of 72 possible citations, the following met our inclusion criteria and formed the basis for this report. Incidence of VA injuries ranged from 0.20 to 1.96%. None of the studies reported using preoperative imaging to identify anomalous or tortuous VA. Primary repair and ligation were the most effective in treating VA injuries.CONCLUSION:The incidence of VA injuries in degenerative cervical spinal surgery might be as high as 1.96% and is likely underreported. Direct surgical repair is the most effective treatment option. The most important preventative technique for VA injuries is preoperative magnetic resonance imaging or computed tomography angiographic imaging to detect VA anomalies. The overall strength of evidence for the conclusions is low.
Study Design Systematic review. Clinical Question What is the prevalence of incidental magnetic resonance imaging (MRI) findings of the spine in asymptomatic pediatric patients? Methods Electronic databases and reference lists of key articles were searched up to December 15, 2013, to identify studies reporting the incidence or prevalence of incidental findings on MRI in asymptomatic pediatric patients. Athletes or children with a known history of trauma, infection, or congenital abnormalities were excluded. Results Seven publications, one prospective cohort, and six cross-sectional studies met the inclusion criteria. The most commonly reported findings on MRI were disc-related and included degenerative disc disease (seven studies, prevalence 19.6%), disc herniation/protrusion (four studies, 2.9%), disc height/narrowed disc space (two studies, 33.7%), and endplate changes (two studies, 5.3%). Other disc-related findings, reported by one study each, included bulging disc, abnormal nucleus shape, annular tear, high intensity zone, and nerve root compression, with prevalences ranging from 4.5 to 51.6%. Spondylolisthesis and spondylolysis were reported by one study each with a prevalence of 2.3 and 0%, respectively. Other findings reported included tumors and infections (one study, 0% for both) and Scheuermann-type changes (one study, 7.7%). Conclusions The prevalence of positive MRI findings in the asymptomatic pediatric population is higher than previously assumed, particularly in regard to disc morphology, highlighting the importance of correlating the history and physical examination to the MRI findings to avoid misdiagnosis or over-treatment in the pediatric population.
Spine care has come under increased scrutiny due to its substantial contribution to our unfavorable healthcare cost development. This has brought a growing awareness to the question of the relationship of the costs relative to benefits derived from spine interventions. Undoubtedly, this is probably the most pressing “hot button” topic in spine surgery around the world. While there is a general consensus that the current healthcare cost trajectories are unsustainable for just about any of the global economies, the specific methods for the calculation of value of spine care is less than straightforward as valid measurements for outcomes are just beginning to become more well defined, and calculations of cost in health remain surprisingly difficult to establish—especially when the impact of observation time frames is becoming increasingly apparent.1 In this issue of Evidence-Based Spine-Care Journal (EBSJ), our readership will find several articles that address the issue of value in spine care directly or indirectly. For instance, the impact of potentially unnecessary studies and surgical techniques (magnetic resonance imaging in adolescents and electrical stimulation to enhance spinal fusions) and a critical reflection on the safety of performing spine surgery in an outpatient setting are examples of opportunities to achieve meaningful cost savings by being more selective in our application of resources. Specifically, outpatient spine surgery performed in specialized ambulatory surgery centers has become an increasingly appealing choice in many countries for certain spine procedures in an effort to minimize the major cost factor in spine-care delivery hospitals.2 As we are looking for ways to measure outcomes, the frequently vague window of follow-up is becoming an increasingly relevant concern. In the study by Aichmair et al,3 attempts were made to reconnect with discectomy patients up to 10 years later. Despite some methodological limitations of achieving sizeable follow-up numbers in one of the most diverse metropolitan areas in the world—New York—with its notorious horizontal migration patterns, one of the cardinal insights of this study underscores the importance of defining follow-up parameters relative to outcomes assessments. Finally, a critical “Science in Spine” article points out the limitations and potential of “big data” mined from increasingly readily available administrative databases. These types of databases have recently gained popularity for value-related studies on spine surgery. It is important to realize what information can be gleaned from these types of investigations and where their shortcomings lie. Staying with the theme of “value in spine care,” the EBSJ readership might find interest in a prospectively randomized study that looked at 400 patients treated with epidural injections with and without steroids for lumbar spinal stenosis. In what is destined to become a hotly debated future landmark study, the widespread use of epidural steroid injections may very well be called in question as the study group who received steroids and the control group who received lidocaine alone showed no differences by 6 weeks, with higher complications reported for the technically more challenging transforaminal injections compared with interlaminar injections.4 Compared with surgery, nonoperative modalities represent a far larger component of costs in spine care. The impact of this study on reimbursement and ultimately utilization of epidural steroid injections will be interesting to see in years to come. Finally, EBSJ would like to point its readership to the Fall 2014 Spine focus issue, created by members of AOSpine North America. The focus is on “Value-Based Health Care,” and it will hopefully contribute to an enhanced understanding of this truly “hot-button” topic to spine surgeons around the world.
Study Design Case report. Objective The objective of this study was to present the unusual case of a 59-year-old woman with a reoccurring sterile postoperative seroma. Methods A patient was observed postoperatively for any complications or adverse side effects resulting from an initial multilevel anterior/posterior lumbar fusion surgery where 2 g (1 g combined with the bone graft used for posterolateral fusion and 1 g placed in the soft tissues) of prophylactic vancomycin powder was placed within the soft tissues posteriorly before wound closure. The patient's progress was monitored through 6 months following the initial procedure. Six weeks postoperatively, the patient sustained a fall and had increased pain. Magnetic resonance imaging, computed tomography, and X-rays demonstrated a displaced sacral fracture, a large epidural fluid collection, and severe compression of the thecal sac at the lumbar operative sites (L3-5). Results On the basis of the aforementioned imaging studies and the patient's progressive neurologic deficit, it was apparent at the 6-week follow-up that emergent surgical intervention was necessary. Drainage and examination of an epidural fluid collection along with treatment of a displaced sacral fracture (S1-S2) were performed. The patient had an uneventful postoperative course with resolution of her back pain and neurologic deficit; however, recurrence of the epidural fluid collection requiring serial aspirations confounded the patients' clinical presentation. Conclusions With the recurrent nature of the seroma being unusual, the cause of the fluid collection and formation is undetermined. With lack of bone morphogenetic protein usage, and few confounding variables accountable, an acute allergic response to topical vancomycin powder is a possible etiology. Analysis with larger patient populations comparing postoperative adverse effects of prophylactic vancomycin powder is recommended.
There is increasing interest in the use of administrative data in health services and clinical research. Administrative data are routinely collected during clinic, hospital, laboratory, or pharmacy visits for administrative purposes.[1] Administrative databases provide easy and cheap access to large numbers of patients over expansive geographic regions. Although these databases were initially designed to reimburse health care services and to track differences in services and the use for state and national agencies, they are increasingly being used for epidemiological, effectiveness, and safety outcomes research. However, there are several limitations that must be considered, and critical appraisal of studies that utilize administrative databases is important.
Study Type Retrospective cohort study. Introduction Acute proximal junctional failure (APJF) was recently defined by the International Spine Study Group as: postoperative fracture of the upper instrumented vertebrae (UIV) or UIV + 1; UIV implant failure; proximal junctional kyphosis (PJK) increase > 15 degrees; or need for proximal extension of the fusion within 6 months of surgery.1 The incidence and revision rates of APJF have been reported to be higher when the UIV is located in the lower thoracolumbar (TL) spine mostly because of high incidence of UIV or UIV + 1 fractures.2 Sagittal deformity overcorrection has been considered as a potential risk factor.34 Objective The purpose of this study is to assess independent predictive factors and timing for revisions of APJF in adult deformity patients with UIV in the TL (T9-L2) spine. Methods Retrospective review of 135 consecutive patients with minimum 2-year follow-up, treated at a single institution for adult spinal deformity, all with UIV in the TL spine (T9-L2). Fusions were divided into three cohorts based on the UIV location (T9-T10 vs. T11-T12 vs. L1-L2). Demographic data were reviewed and radiographic parameters were measured preoperatively, immediately postoperatively, at 6 months and at the final follow-up. Incidence and failure modes of APJF, as well as timing for APJF revision are reported. Risk factors for APJF were assessed with univariate and multivariate regression analysis models. Results A total of 135 consecutive patients were reviewed, with mean follow-up 42 months (24-126). Mean age was 66 years (24-86). There were no differences in the preoperative radiographic parameters between patients in any of the three cohorts with APJF. The incidence of APJF was 38.5%, with a trend toward higher APJF in the T9-T10 group (p = 0.07) (Table 1). When UIV was at T10, the incidence of APJF was 57.1%, significantly higher than the adjacent vertebrae, T9 and T11 (p = 0.03 and p = 0.01, respectively). The overall revision rate for APJF was 17%, most often for UIV fracture, while PJK > 15 degrees alone had the highest 2 and 5 years survival (100%) (Fig. 1). Univariate analysis revealed preoperative sagittal vertical axis > 5 cm, postoperative PJA > 5 degrees and thoracic kyphosis > 30 degrees, and instrumentation to the pelvis as risk factors for APJF (Table 2). Multivariate regression analysis confirmed postoperative PJA > 5 degrees, and greater correction of lumbar lordosis (LL) as independent risk factors for APJF (Table 3). Conclusion The incidence of APJF in adult deformity patients is high if the UIV is in the lower thoracic or lumbar spine, with a trend toward higher rates when the UIV is at T10. Fracture at the UIV lead to the highest revision rate, while PJK > 15 degrees without fracture or hardware failure had the longest revision-free survival. Postoperative PJA > 5 degrees and greater correction of LL are independent risk factors for APJF.
Study Design Case report. Objective The objective of this study was to report a case of an unstable C1 burst fracture in the setting of a vertebral artery anomaly at the craniovertebral junction. Methods A 55-year-old man was admitted to the hospital with severe neck pain after falling approximately 15 feet and landing on his head. Computed tomography scan of the cervical spine revealed an unstable fracture of the C1 ring with magnetic resonance imaging evidence of a transverse ligament rupture as well as a congenital synchondrosis of the posterior arch of C1. He was neurologically intact. CT angiography (CTA) of the neck revealed an anomalous course of the right vertebral artery at the C1-C2 level. Results Surgical intervention consisted of occiput-C3 fusion, thus avoiding the placement of C1 lateral mass screws and risking vertebral artery injury. Conclusion We present a case of an unstable C1 burst fracture with an anomalous course of the right vertebral artery demonstrated by CTA. The presence of vertebral artery anomalies at the craniovertebral junction may prevent safe placement of C1 lateral mass screws and therefore influence the treatment options for upper cervical spine pathologies. To minimize the risk of vertebral artery injury, we elected to perform an occiput to C3 fusion. Thorough assessment of the vascular anatomy is recommended before operative intervention in the upper cervical spine to minimize the risk of complications.
Study Design Case report and review of the literature. Objective We present the case of a two-level lumbar spondylectomy at L4 and L5 for en bloc resection of a giant cell tumor (GCT) and lumbopelvic reconstruction. Methods A 58-year-old woman presented with a 7-month history of progressive intractable back and leg pain secondary to a biopsy-proven Enneking stage III GCT of the L4 and L5 vertebrae. The patient underwent a successful L4-L5 spondylectomy and lumbopelvic reconstruction using a combined posterior and anterior approach over two operative stages. Results Postoperative complications included a deep wound infection and a cerebrospinal fluid leak; however, following surgical debridement and long-term antibiotic treatment, the patient was neurologically intact with minimal pain and there was no evidence of tumor recurrence or instrumentation failure at more than 2 years of follow-up. Conclusion Spondylectomy that achieves en bloc resection is a viable and effective treatment option that can be curative for Enneking stage III GCTs involving the lower lumbar spine. The lumbosacral junction represents a challenging anatomic location for spinal reconstruction after spondylectomy with unique technical considerations.
