STUDY DESIGN:Case report with review of the literature.OBJECTIVES:Presented is the first case of vertebral artery dissection secondary to intraoperative traction in cervical spine surgery. The pathogenesis and management of vertebral dissection in the immediate postoperative period are reviewed in detail.SUMMARY OF BACKGROUND DATA:Vertebral artery dissection is commonly associated with direct trauma, atraumatic or spontaneous. There are numerous reports of direct injury to the vertebral artery with cervical spine surgery, and it is a well-recognized risk. Cervical traction is also used routinely for improved placement of intervertebral devices/grafts. This is the first report of vertebral artery dissection occurring intraoperatively secondary to traction. The postoperative management is reviewed in detail.METHODS:Case study with extensive review of the literature.RESULTS:The patient underwent C6 corpectomy without intraoperative complications. Intraoperative wake-up test was normal. The patient remained intubated overnight for airway precautions. On postoperative day 1, the patient was lethargic and not following commands. Emergent CT of the brain and cervical spine revealed multiple posterior circulation infarcts with normal cervical spine and no hematoma. A stat angiogram revealed vertebral dissection. Medical management was initially attempted; however, infarcts continued, eventually requiring posterior fossa craniectomy/decompression and sacrificing the vertebral at the O-A junction.CONCLUSIONS:This is the first report of vertebral artery dissection occurring secondary to traction in cervical spine surgery. Surgeons must be aware that traction, even when performed appropriately, is not without risks. Anomalous vertebral arteries, osteophytes, and numerous other anatomic variants can lead to vertebral injury with traction.

This study represents the first 39 patients with at least 6-month follow-up enrolled in a prospective randomized Food and Drug Administration study evaluating the safety and efficacy of the ProDisc II versus the control, a 360° lumbar spinal fusion. Data were collected preoperatively and at 6 weeks, 3 months, and 6 months postoperatively. Visual Analog Scale (VAS), Oswestry Low Back Pain Disability Questionnaire (ODQ), and patient satisfaction rates were evaluated at these intervals, as well as range of motion, return to work, and recreational and ambulatory status. There were 28 ProDisc patients and 11 who underwent fusion. Six patients had two-level surgery. Estimated blood loss (ProDisc = 69 mL versus fusion = 175 mL) and operative time (ProDisc = 75 minutes versus fusion = 219 minutes) were significantly different (P < 0.01). Hospital stays were shorter (ProDisc = 2.1 days versus fusion = 3.5 days [P < 0.01]) for ProDisc patients. There was a significantly greater reduction in the ODQ scores at 3 months in the ProDisc group compared with the fusion group (P < 0.05). No difference was noted in VAS. A trend was identified at 6 months in patient satisfaction rates favoring ProDisc versus fusion (P = 0.08), and motion was significantly improved in ProDisc patients compared with the fusion group (P = 0.02). Ambulatory status as well as recreational activity improved faster in the ProDisc group. The data suggest that total disc arthroplasty may be an attractive option as opposed to lumbar fusion for the surgical treatment of disabling mechanical low back pain secondary to lumbar disc disease.

There is an increasing population of immunocompromised patients with HIV, IV drug abuse, organ transplantation, and long-term steroid treatment developing spinal infections. Delayed diagnosis because of blunted host immune response and lack of outward signs and symptoms places the treating physician at a disadvantage in the treatment of this type of disease, which presents at a later stage of development. Immunocompromised patients are infected by a different group of pathogens than their healthier cohorts (e.g., Pseudomonas, gram-negative bacteria and fungal infections) because their host defenses are diminished. Osteomyelitis with or with out pyomyositis and epidural abscess may occur. The overriding symptom is back pain. Radiculopathy, myelopathy, and sensory loss may accompany local pain and tenderness. Plain film radiography, CT scan, MR image, and bone scan is invaluable in the diagnosis of these infections. The cornerstone of treatment is identification of the responsible pathogen, appropriate medical therapy, immobilization of the affected segment of the spine, and physical therapy to combat physical deconditioning. Psoas abscesses may require surgical debridement if they cannot be adequately drained by CT-guided percutaneous catheterization. Epidural abscesses with neurologic compromise require surgical drainage. Impingement of the spinal cord or cauda equina by collapsed osteomyelitic vertebral bodies requires surgical debridement by anterior vertebrectomy, with an autologous tricortical iliac crest strut and immobilization of the spine using external bracing or posterior instrumentation as dictated by the disease.

Treatment of the diseased spine in the elderly is a difficult challenge for the practitioner. Spinal surgery for this population requires specialized surgical skills. Patient evaluation, nonoperative treatment, surgical indications, surgical techniques, and postoperative management involve unique considerations. The patient's functional expectations, general medical condition, and proposed benefits from surgery must be addressed before any surgical intervention. Spinal surgery for the aged requires the orthopaedic surgeon to consider this patient as more than just an older individual and demands that the entire perioperative milieu be examined and its issues resolved. The projected data on aging of the United States population make this issue increasingly important.

Ninety-six successful cervical spine fusions performed for trauma, with a minimum of 5 years' follow-up, were retrospectively reviewed. Radiographic degenerative changes adjacent to fusion masses were assessed and correlated with clinical symptoms. The type of fusion, fusion extension, and final kyphosis of the involved segments were also analyzed. Twenty-eight patients had fusion masses aligned in 20 degrees or more of kyphosis. There was a significant increase in complaints of cervical pain in patients with neck fusions equal to or exceeding 20 degrees of kyphosis (P < 0.01). Evidence of mild degenerative changes adjacent to fusion masses was common, but did not correlate with symptoms.

We attempted to determine if nonsurgical treatment could be successful in treating instability of upper thoracic spine fractures, which may receive some stabilization and splinting from the ribs. From 1966 to 1989, the records of all patients treated at Rancho Los Amigos Medical Center for fractures from T-1 to T-8 were reviewed. Penetrating injuries and malignant lesions were excluded. A total of 118 patients were admitted during this period; 49 patients had nonsurgical treatment. Complications included 1 patient with neurologic worsening, brace-related skin necrosis in 8 cases, and deep venous thrombosis in 12 patients. No failure of arthrodesis was noted. Rib fractures did not adversely affect late stability. We conclude that orthotic treatment of thoracic spine instability from T-1 to T-8 can be successful, especially in cases where early surgery is not possible.

From 1980 until 1989, 69 patients with lumbar fractures resulting in incomplete paraparesis were admitted to the authors' medical center for treatment. Thirty had anterior vertebrectomy, including 18 who had posterior instrumentation and four who had anterior instrumentation. Twenty-two patients were treated with a posterolateral decompression and fusion, including four who also required an anterior decompression. Nineteen of the remaining 21 patients required posterior spine instrumentation and fusion only. The American Spinal Injury Association (ASIA) motor index score was determined for each patient pre- and postoperatively and used to compare these three treatment groups. Average follow-up period for the patients was 19 months. The improvement in ASIA motor score for all patients treated with decompression averaged 10 and similar improvement was obtained in those who were treated with posterior decompression(10.2 points). The average improvement in those who had vertebrectomy was 9.9 points. For those who had fusion without decompression, average improvement was 4.2 points. Comparing those patients who were surgically decompressed, either anteriorly or posteriorly, with those patients who only underwent fusion, the difference in neurologic improvement was statistically significant. Neurologic outcome after lumbar fractures is improved by surgical decompression. The neurologic outcome results were similar after anterior and posterior decompression.

One hundred forty-seven patients with unstable low thoracic and lumbar fractures were examined. All patients had significant neurologic injuries. Ninety-one patients exhibited incomplete lesions whereas fifty-six had complete lesions. Age, sex, cause of injury, fracture location, fracture mechanism, and complications were recorded and analyzed. The average follow-up was 25 months (range 2-148). Incomplete neurologic lesions demonstrated a significant increase in ASIA motor points if both decompression and stabilization were performed at the same operative sitting. When decompression was performed before stabilization a decrease in improvement was noted. Patients with complete lesions demonstrated a significant reduction in rehabilitation time if stabilization was augmented with sublaminar wires rather than Drummond wires or Harrington rods alone.

We performed a retrospective review of the medical records of 316 patients with spinal cord injury (SCI) secondary to gunshot wounds (GSW) admitted to Rancho Los Amigos Medical Center for rehabilitation between 1980 and 1988. There were 289 male and 27 female patients whose mean age was 25.9 years (range, 11-56 years). Of these, 238 were paraplegic (103 incomplete, 135 complete), and 78 were quadriplegic (45 incomplete, 33 complete). Forty were shot by handguns of known caliber and four by shotguns; in 272 cases, the type of weapon was unknown. A total of 230 cases sustained a single bullet wound, and 86 had multiple bullet wounds. The length of acute hospitalization, but not rehabilitation hospital stay, increased with the number of associated injuries. Rehabilitation and, hence, total length of stay was significantly less (mean, 100 and 130 days, respectively) for SCI/GSW victims than for SCI victims of motor vehicle accidents, falls, or diving accidents. The methods of calculating costs for admission were based upon Rancho Los Amigos Medical Center financial statistics. This hospital has charged for a daily occupancy fee. The fee is based upon an average of all charges for all patients. No additional fees are charged for special tests or procedures. In 1980, the average daily admission hospitalization charge was $785. In 1990, the last quoted hospital charge was $1,125. This is for the basic spinal cord injury rehabilitative stay. In general, at Rancho Los Amigos, patients are admitted for rehabilitation when all acute medical and surgical problems have been cleared and the patient is ready to participate in rehabilitation evaluation and therapy programs.(ABSTRACT TRUNCATED AT 250 WORDS)

Pyogenic osteomyelitis rarely affects the first and second cervical vertebrae, and when it does it can progress to abscess formation, compressing the spinal cord. If the process is unrecognized, it can be fatal. The cases of five patients are reported. Two patients were treated by anterior débridement and posterior cervical-occipital arthrodesis; one, by transoral drainage; one, by posterior cervical-occipital arthrodesis; and the fifth, by posterior atlanto-axial arthrodesis. The causative organism was Staphylococcus aureus in four patients and Pasteurella multocida in one. In all patients, intravenous antibiotics were used, followed by prolonged administration of oral antibiotics. All five patients recovered.