Primary amyloidoma in epidural and paravertebral space of the lumbar spine

Background context

Localized amyloid deposits result in a mass, that is, so-called amyloidoma; it has been reported in every anatomic site, although systemic amyloid deposition is much more common. However, primary lumbar epidural amyloidoma without bony involvement is extremely rare. To the best of our knowledge, only one case has been reported previously.

Purpose

To report and review the clinical presentations, imaging studies, and treatment of epidural and paravertebral amyloidoma.

Study design

A case report and review of the literature.

Methods

Lumbar epidural and paravertebral amyloidoma in a 75-year-old man with neurologic compromise is presented. Laminectomy with mass resection was performed.

Results

After surgery, almost complete neurologic improvement was observed. Histologically, definite diagnosis was obtained only after the specific staining of tissue. No sign of local recurrence was evident 1 year after surgery.

Conclusions

Primary amyloidoma, although rare, should be included in the differential diagnosis of epidural mass of the spine. Diagnosis before surgery is difficult as there were no characteristic findings in clinical and imaging studies. Special histologic technique and stains are useful to make a definite diagnosis.     

An unexpected complication of occipitocervical stabilization surgery: retropharyngeal hematoma

Background context

To report a unique case of an unexpected complication of occipitocervical stabilization surgery that is retropharyngeal hematoma (RH).

Purpose

Postoperative RH is a very rare complication and has never been reported after posterior occipitocervical surgery.

Study design

Case report.

Methods

A 44-year-old woman being treated for rheumatoid arthritis for 20 years was admitted to our hospital in a wheelchair with the complaints of neck pain and weakness in both upper and lower extremities. She was diagnosed with basilar invagination, and occipitocervical (C0–C5) transpedicular fixation with osteosynthesis using iliac autograft was performed. The airway was seen as obstructed after extubation. The airway was maintained with laryngeal mask, and computed tomography revealed an RH. Emergent tracheotomy was performed. The patient was decannulated because of the resorption of RH after 10 days and was discharged.

Conclusion

This patient is the first patient, to our knowledge, to be reported for unexplained RH after cervical posterior spinal surgery.     

Intramedullary arachnoid cyst in association with cervical spondylosis: case report

Background context

Intramedullary spinal arachnoid cysts are considered to be very rare, and only 11 cases have been reported previously. Development of such a cyst in association with marked cervical spondylosis has not been reported until recently.

Purpose

Brief review of reported cases and debate on likely treatment strategy when such a cyst is associated with symptomatic spondylosis.

Study design

To report the first example of a cervicothoracic intramedullary arachnoid cyst along with a symptomatic cervical spondylosis.

Methods

Evaluation of quadriparesis in a 58-year-old female resulted in detection of a cervical spondylotic stenosis that was accompanied with an intramedullary cystic lesion. Parallel management of both pathologies was through a wide laminectomy extending from the lower edge of C3 to T2 with subsequent fenestration and partial resection of the cyst wall via an appropriate dorsal entry root zone myelotomy. Cervicothoracic instrumentation from C3 down to T2 was done to prevent postlaminectomy deformity.

Result

Histopathological findings were consistent with the diagnosis of arachnoid cyst. Postoperatively, the patient exhibited marked improvement in neurologic status.

Conclusion

Through the review of the current case, first example from the literature, we concluded that surgery should target toward the proper management of both pathologies in a single-stage operation.     

Bilateral cervical spondylolysis of C7

Background context

Cervical spondylolysis, which is defined as a cleft between the superior and inferior articular facets of the articular pillar, is a rare condition. The sixth cervical vertebra (C6) is the level most commonly affected. Cases involving C2, C3, C4, or C5 have also been reported. However, to date, no case of C7 spondylolysis has been reported.

Purpose

To present a rare case of bilateral spondylolysis of the seventh cervical vertebra (C7) in a 58-year-old man.

Study design

A case report.

Methods

A 58-year-old man visited our hospital with chronic posterior neck pain radiating to the left upper extremity. Magnetic resonance imaging (MRI) study revealed left foraminal disc herniations at C5–C6 and C6–C7. Cervical spondylolysis involving C7 was discovered incidentally during computed tomography (CT)–guided transforaminal steroid injection. Plain radiographs, CT images, and MRIs were reviewed thoroughly once again.

Results

The patient’s symptoms were relieved after he received CT-guided transforaminal steroid injections. Plain radiographs revealed a radiolucent defect in the articular pillar and cleft at the spinous process of C7. Computed tomography confirmed bilateral spondylolysis and spina bifida occulta of the C7 vertebra. Magnetic resonance imaging revealed absence of edema, which was suggestive of a chronic lesion.

Conclusion

Involvement of C7 is not exceptional in a case of cervical spondylolysis.     

Thirty-day readmissions after elective spine surgery for degenerative conditions among US Medicare beneficiaries

Background context

Readmissions within 30 days of hospital discharge are undesirable and costly. Little is known about reasons for and predictors of readmissions after elective spine surgery to help plan preventative strategies.

Purpose

To examine readmissions within 30 days of hospital discharge, reasons for readmission, and predictors of readmission among patients undergoing elective cervical and lumbar spine surgery for degenerative conditions.

Study design

Retrospective cohort study.

Patient sample

Patient sample includes 343,068 Medicare beneficiaries who underwent cervical and lumbar spine surgery for degenerative conditions from 2003 to 2007.

Outcome measures

Readmissions within 30 days of discharge, excluding readmissions for rehabilitation.

Methods

Patients were identified in Medicare claims data using validated algorithms. Reasons for readmission were classified into clinically meaningful categories using a standardized coding system (Clinical Classification Software).

Results

Thirty-day readmissions were 7.9% after cervical surgery and 7.3% after lumbar surgery. There was no dominant reason for readmissions. The most common reasons for readmissions were complications of surgery (26%–33%) and musculoskeletal conditions in the same area of the operation (15%). Significant predictors of readmission for both operations included older age, greater comorbidity, dual eligibility for Medicare/Medicaid, and greater number of fused levels. For cervical spine readmissions, additional risk factors were male sex, a diagnosis of myelopathy, and a posterior or combined anterior/posterior surgical approach; for lumbar spine readmissions, additional risk factors were black race, Middle Atlantic geographic region, fusion surgery, and an anterior surgical approach. Our model explained more than 60% of the variability in readmissions.

Conclusions

Among Medicare beneficiaries, 30-day readmissions after elective spine surgery for degenerative conditions represent a target for improvement. Both patient factors and operative techniques are associated with readmissions. Interventions to minimize readmissions should be specific to surgical site and focus on high-risk subgroups where clinical trials of interventions may be of greatest benefit.     

Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature

Background context

Subdural spinal hematoma (SDH) is a very rare entity; however, it can lead to serious complications resulting from injuries to the spinal cord and roots. Although acupuncture has been a popular method for the management of pain control, we encountered the first case of SDH after acupuncture.

Purpose

The purpose of this case report was to present the first case of subdural hematoma after acupuncture and the reasons for the risks of blind cervical acupuncture.

Study design

A case report and review of the previous literature are presented.

Methods

A 69-year-old man complained of progressive weakness in the right upper and lower extremities 2 hours after acupuncture on the cervical spine and back. The diagnosis was delayed because of unilateral weakness, and the symptom was initially misinterpreted as a transient ischemic attack because of no sensory change and pain and normal findings of two brain magnetic resonance imaging (MRI).

Results

Cervical MRI 36 hours after onset revealed acute hematoma from the C3–C5 level; hematoma showed an isointensity on T1-weighted image (WI) with the preservation of epidural fat and a hypointensity on T2WI. A decompressive surgery was scheduled to perform within 2 days after the cervical MRI scan because of a previous anticoagulation therapy, but the patient refused it. Finally, 9 days after the onset, surgical decompression and removal of hematoma were performed. Three months postoperatively, the patient had fully recovered demonstrating fine hand movement and good ability to walk up and down the stairs.

Conclusions

Our study indicates that it is essential to perform cervical MRI when a patient does not show an improvement in the neurologic deficit and has a negative brain MRI after acupuncture. In addition, blind acupuncture if not correctly practiced may be harmful to the cervical structures.     

Detection of postoperative neurologic deficits using somatosensory-evoked potentials alone during posterior cervical laminoplasty

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.     

High-Dose Melphalan and Autologous Hematopoietic Stem Cell Transplantation in Primary Amyloidosis: Single-Center Results

Background

Systemic immunoglobulin light-chain amyloidosis (AL) is a plasma cell dyscrasia resulting in multisystem organ failure and death. Autologous hematopoietic stem-cell transplantation (ASCT) has been widely used to treat patients with AL. However, treatment-related mortality remains high and reported series are subject to selection bias.

Methods

To define the role of patient selection in stem cell transplantation, we evaluated 24 consecutive AL patients transplanted at our center.

Results

Complete hematologic response was achieved in all 20 patients surviving >100 days posttransplantation. The 1-year overall survival (OS) rate after ASCT was 78.5%. The 5- and 10-year progression-free and OS rates were 57% and 47%, respectively. Treatment-related deaths owing to cardiovascular problems occurred in 16% of cases.

Conclusion

ASCT for AL amyloidosis can be safely performed in experienced transplantation centers, and increased risk is associated mainly with cardiovascular system involvement.     

Is magnetic resonance imaging in addition to a computed tomographic scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients?

Background

Guidelines are in place directing the clearance of the cervical spine in patients who are awake, alert, and oriented, but a gold standard has not been recognized for patients who are obtunded. Our study is designed to determine if magnetic resonance imaging (MRI) detects clinically significant injuries not seen on computed tomographic (CT) scans.

Methods

The trauma registry was used to identify and retrospectively review medical records of blunt trauma patients from January 1, 2005, to March 30, 2012. Only obtunded patients with a CT scan and MRI of the cervical spine were included.

Results

The study cohort consisted of 277 patients. In 13 (5%) patients, MRI detected clinically significant cervical spine injuries that were missed by CT scans, and in 7 (3%) these injuries required intervention. The number needed to screen with MRI to prevent 1 missed injury was 21.

Conclusions

The findings suggest that the routine use of MRI in clearing the cervical spine in the obtunded blunt trauma patient.     

Postoperative spinal cord herniation with pseudomeningocele in the cervical spine: a case report

Background context

Postoperative spinal cord herniation with pseudomeningocele is a rare disease, with only five cases reported before the present study.

Purpose

To describe the clinical features and radiologic findings of postoperative spinal cord herniation with pseudomeningocele.

Study design

Case report.

Methods

A case of a 51-year-old man who suffered from postoperative spinal cord herniation with pseudomeningocele was reported, and previous reports on this subject are reviewed.

Results

He had undergone excision of a spinal cord tumor in the cervical spine 10 years previously. He had progressive paraparesis and urinary disturbance 10 years later. The Computed Tomography Multi Planner Reconstruction myelogram showed dilation of the ventral subarachnoid space with left deviation of the spinal cord into the pseudomeningocele at C7. On observation at surgery, the spinal cord appeared displaced dorsally and herniated through the defect of the dorsal dura mater. The spinal cord was tightly adhesive around the dural defect. We released the adhesion of the spinal cord and the dural defect under the spinal cord, and the dural defect was repaired using an artificial dura mater.

Conclusions

The release of adhesion around dural defect and repair of dural defect under spinal cord monitoring resulted in a satisfactory neurologic recovery. Surgical repair of the dural defect with a dural substitute was necessary.     

Clinical adjacent-segment pathology after anterior cervical discectomy and fusion: results after a minimum of 10-year follow-up

Background context

Anterior cervical discectomy and fusion using cervical plates has been seen as effective at relieving cervical radiculopathy and myelopathy symptoms. Although it is commonly used, subsequent disc degeneration at levels adjacent to the fusion remains an important problem. However, data on the frequency, impact, and predisposing factors for this pathology are still rare.

Purpose

To evaluate the incidence, predisposing factors, and impact of radiographic and clinical adjacent-segment pathologies after anterior cervical discectomy and fusion using cervical plates and to analyze the efficacy of this surgical method over the long term, after a minimum follow-up period of 10 years.

Study design

Retrospective clinical study.

Patient sample

Our study was a retrospective analysis of 177 patients who underwent anterior cervical discectomy and fusion using cervical plates, with follow-up periods of at least 10 years (mean 16.2 years).

Outcome measures

Radiographic adjacent-segment pathology using plain radiographs and clinical adjacent-segment pathology after anterior cervical discectomy and fusion using cervical plates.

Methods

We defined a new grading system of plain radiographic evidence of degenerative changes in adjacent discs after anterior cervical discectomy and fusion using cervical plates; Grade 0 is considered normal, and Grade V consists the presence of posterior osteophytes and a decrease in disc height to less than 50% of normal. The incidence, predisposing factors, and impact of radiographic and clinical adjacent-segment pathologies were analyzed according to etiologies, number of fused segments, and plate-to-disc distance.

Results

Radiographic and clinical adjacent-segment pathologies were found in 92.1% and 19.2%, respectively, of patients. By etiology, clinical adjacent-segment pathology was observed in 13.5% of patients who had sustained trauma, 12.7% of those with disc herniation, and 33.3% of those with spondylosis. By number of fused segments, clinical adjacent-segment pathology was found in 13.2% of patients who underwent single-level fusion and in 32.1% of those who underwent multilevel fusion surgeries. Patients with a plate-to-disc distance of less than 5 mm, who had spondylosis, or who underwent multilevel fusion had a higher incidence of clinical adjacent-segment pathology after anterior cervical discectomy and fusion using cervical plates than other groups did (p<.05). Of all patients, only 6.8% needed follow-up surgery.

Conclusions

We found that over the long term, at a minimum follow-up point of 10 years, a plate-to-disc distance of less than 5 mm, having spondylosis, and undergoing multilevel fusion were predisposing factors for the occurrence of clinical adjacent-segment pathology. Nevertheless, the incidence of clinical findings of adjacent-segment pathology was much lower than the incidence of radiographic findings. Also, the rate of follow-up surgery was low. Therefore, anterior cervical discectomy and fusion using cervical plates can be considered a safe and effective procedure.     

Understanding post-hospital morbidity associated with immobilisation of cervical spine fractures in older people using geriatric medicine assessment techniques: A pilot study

Introduction

There is a paucity of research into the outcomes and complications of cervical spine immobilisation (hard collar or halothoracic brace) in older people.

Aims

To identify morbidity and mortality outcomes using geriatric medicine assessment techniques following cervical immobilisation in older people with isolated cervical spine fractures.

Patients and methods

We identified participants using an injury database. We completed a questionnaire measuring pre-admission medical co-morbidities and functional independence. We recorded the surgical plan and all complications. A further questionnaire was completed three months later recording complications and functional independence.

Results

Sixteen patients were recruited over a three month period. Eight were immobilised with halothoracic brace, 8 with external hard collar. Three deaths occurred during the study. Lower respiratory tract infection was the most common complication (7/16) followed by delirium (6/16). Most patients were unable to return home following the acute admission, requiring sub-acute care on discharge. The majority of patients were from home prior to a fall, 6/16 were residing there at 3 months. Most participants had an increase in their care needs at 3 months. There was no difference in the type or incidence of complications between the different modes of immobilisation.

Conclusions

Geriatric medicine assessment techniques identified the morbidity and functional impairment associated with cervical spine immobilisation. This often results in a prolonged length of stay in supported care. This small pilot study recommends a larger study over a longer period using geriatric medicine assessment techniques to better define the issues.     

Post laminoplasty cervical kyphosis—Case report

INTRODUCTION

Cervical kyphosis is a progressive cervical sagittal plane deformity that may cause a reduction in the ability to look horizontally, breathing and swallowing difficulties, sense of thoracic oppression and social isolation. Moreover, cervical kyphosis can cause myelopathy due to a direct compression by osteo-articular structures on the spinal cord or to a transitory ischaemic injury. The treatment of choice is surgery. The goals of surgery are: nervous structures decompression, cervical and global sagittal balance correction and vertebral stabilization and fusion.

PRESENTATION OF CASE

In October 2008 a 35 years old woman underwent surgical removal of a cervical-bulbar ependymoma with C1–C5 laminectomy and a C2–C5 laminoplasty. Five months after surgery, the patient developed a kyphotic posture, with intense neck and scapular girdle pain. The patients had a flexible cervical kyphosis. Therefore, we decided to perform an anterior surgical approach. We performed a corpectomy C4–C5 in order to achieve the anterior decompression; we placed a titanium expansion mesh.

DISCUSSION

Cervical kyphosis can be flexible or fixed. Some authors have reported the use of anterior surgery only for flexible cervical kyphosis as discectomy and corpectomy. This approach is useful for anterior column load sharing however it is not required for deformity correction.

CONCLUSION

The anterior approach is a good surgical option in flexible cervical kyphosis. It is of primary importance the sagittal alignment of the cervical spine in order to decompress the nervous structures and to guarantee a long-term stability.     

Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan?

Background

There are variations in cervical spine (CS) clearance protocols in neurologically intact blunt trauma patients with negative radiological imaging but persistent neck pain. Current guidelines from the current Eastern Association for the Surgery of Trauma include options of maintaining the cervical collar or obtaining either magnetic resonance imaging (MRI) or flexion-extension films (FEF). We evaluated the utility of FEF in the current era of routine computerized tomography (CT) for imaging the CS in trauma.

Materials and methods

All neurologically intact, awake, nonintoxicated patients who underwent FEF for persistent neck pain after negative CT scan of the CS at our level I trauma center over a 13-mo period were identified. Their charts were reviewed and demographic data obtained.

Results

There were 354 patients (58.5% male) with negative cervical CS CT scans who had FEF for residual neck pain. Incidental degenerative changes were seen in 37%—which did not affect their acute management. FEF were positive for possible ligamentous injury in 5 patients (1.4%). Two of these patients had negative magnetic resonance images and the other three had collars removed within 3 wk as the findings were ultimately determined to be degenerative.

Conclusions

In the current era, where cervical CT has universally supplanted initial plain films, FEF appear to be of little value in the evaluation of persistent neck pain. Their use should be excluded from cervical spine clearance protocols in neurologically intact, awake patients.     

Sticking our neck out: is magnetic resonance imaging needed to clear an obtunded patient's cervical spine?

Background

Evaluating the cervical spine in the obtunded trauma patient is a subject fraught with controversy. Some authors assert that a negative computed tomography (CT) scan is sufficient. Others argue that CT alone misses occult unstable injuries, and magnetic resonance imaging (MRI) will alter treatment. This study examines the data in an urban, county trauma center to determine if a negative cervical spine CT scan is sufficient to clear the obtunded trauma patient.

Methods

Records of all consecutive patients admitted to a level 1 trauma center from January 2000 to December 2011 were retrospectively analyzed. Patients directly admitted to the intensive care unit with a Glasgow Coma Scale score ≤13, contemporaneous CT and MRI, and a negative CT reading were included. The results of the cervical spine MRI were analyzed.

Results

A total of 309 patients had both CT and MRI, 107 (35%) of whom had negative CTs. Mean time between CT and MRI was 16 d. Of those patients, seven (7%) had positive acute traumatic findings on MRI. Findings included ligamentous injury, subluxation, and fracture. However, only two of these patients required surgical intervention. None had unstable injuries.

Conclusions

In the obtunded trauma patient with a negative cervical spine CT, obtaining an MRI does not appear to significantly alter management, and no unstable injuries were missed on CT scan. This should be taken into consideration given the current efforts at cost-containment in the health care system. It is one of the larger studies published to date.     

Chronic expanding hematoma after spinal surgery

Background context

Chronic expanding hematoma after spinal surgery is extremely rare, with no case previously reported in the literature.

Purpose

To report a rare case of a chronic expanding hematoma of the spine that occurred 24 years after thoracic laminectomy and spinal cord tumor resection.

Study design

Case report.

Methods

A 71-year-old man presented with a spinal mass located approximately at the level of the sixth thoracic vertebral body. The patient had undergone thoracic laminectomy with tumor resection 24 years previously. The mass had appeared 5 years after this and had gradually enlarged over 19 years.

Results

The tumor was resected en bloc. The lamina and spinous processes had been partially eroded by the tumor at the fifth and sixth thoracic vertebrae, but the dura was intact. Histopathologic examination confirmed the diagnosis of chronic expanding hematoma. The hematoma had not recurred at the 1-year follow-up.

Conclusion

We report herein an extremely rare case of chronic expanding hematoma after spinal surgery. This entity may be considered a late complication after surgery regardless of the number of years that have passed since the index surgery.     

Facet joint contact pressure is not significantly affected by ProDisc cervical disc arthroplasty in sagittal bending: a single-level cadaveric study

Background context

Total disc arthroplasty is a motion-preserving spinal procedure that has been investigated for its impact on spinal motions and adjacent-level degeneration. However, the effects of disc arthroplasty on facet joint biomechanics remain undefined despite the critical role of these posterior elements on guiding and limiting spinal motion.

Purpose

The goal was to measure the pressure in the facet joint in cadaveric human cervical spines subjected to sagittal bending before and after implantation of the ProDisc-C (Synthes Spine Company, L.P, West Chester, PA, USA).

Study design

A biomechanical study was performed using cadaveric human cervical spines during sagittal bending in the intact and implanted conditions.

Methods

Seven C2–T1 osteoligamentous cadaveric cervical spines were instrumented with a transducer to measure the C5–C6 facet pressure profiles during physiological sagittal bending, before and after implantation of a ProDisc-C at that level. Rotations of the index segment and global cervical spine were also quantified.

Results

The mean C5–C6 range of motion significantly increased (p=.009) from 9.6°±5.1° in the intact condition to 16.2°±3.6° after implantation. However, despite such changes in rotation, there was no significant difference in the facet contact pressure during extension between the intact (64±30 kPa) and implanted (44±55 kPa) conditions. Similarly, there was no difference in facet pressure developed during flexion.

Conclusions

Although implantation of a ProDisc-C arthroplasty device at the C5–C6 level increases angular rotations, it does not significantly alter the local facet pressure at the index level in flexion or extension. Using a technique that preserves the capsular ligament, this study provides the first direct measurement of cervical facet pressure in a disc arthroplasty condition.     

Ischemic stroke after cervical spine injury: analysis of 11,005 patients using the Japanese Diagnosis Procedure Combination database

Background context

The incidence and relevant risk of ischemic stroke after cervical spine trauma remain unknown.

Purpose

To examine the incidence of ischemic stroke during hospitalization in patients with cervical spine injury, and analyze the impact of different types of cervical spine injuries on the occurrence of ischemic stroke.

Study design

Retrospective analysis of data abstracted from the Diagnosis Procedure Combination database, a nationally representative database in Japan.

Patient sample

We included all patients hospitalized for any of the following traumas: fracture of cervical spine (International Classification of Diseases, 10th Revision codes: S120, S121, S122, S127, S129); dislocation of cervical spine (S131, S133); and cervical spinal cord injury (SCI) (S141).

Outcome measures

Outcome measures included all-cause in-hospital mortality and incidence of ischemic stroke (I63) during hospitalization.

Methods

We analyzed the effects of age, sex, comorbidities, smoking status, spinal surgery, consciousness level at admission, and type of cervical spine injury on outcomes.

Results

We identified 11,005 patients with cervical spine injury (8,031 men, 2,974 women; mean [standard deviation] age, 63.5 [18] years). According to the types of cervical spine injury, we stratified the patients into three groups: cervical fracture and/or dislocation without SCI (2,363 patients); cervical fracture and/or dislocation associated with SCI (1,283 patients); and cervical SCI without fracture and/or dislocation (7,359 patients). Overall, ischemic stroke occurred in 115 (1.0%) patients during hospitalization (median length of stay, 26 days). In-hospital death occurred in 456 (4.1%) patients. Multivariate analyses showed that ischemic stroke after cervical spine injury was significantly associated with age, diabetes, and consciousness level at admission. The highest in-hospital mortality was observed in patients with cervical fracture and/or dislocation associated with SCI (7.6%), followed by cervical SCI without fracture and/or dislocation (4.0%), and cervical fracture and/or dislocation without SCI (2.6%). Unlike mortality, risks of stroke did not vary significantly among the three groups.

Conclusions

This analysis revealed that ischemic stroke after cervical spine injury was not uncommon and was associated with increased mortality and morbidity. Occurrence of ischemic stroke was significantly associated with age, comorbidities such as diabetes, and consciousness level at admission, but not with the type of spine injury.     

Progressive severe kyphosis as a complication of multilevel cervical percutaneous facet neurotomy: a case report

Background context

Percutaneous facet neurotomy is a procedure commonly used for the treatment of pain thought to originate from zygoapophyseal joint dysfunction. Some practitioners have also used this technique to treat cervicogenic headache. Previously reported complications for this procedure have been minimal and have included dysthesias and local pain.

Study design

Case report.

Methods

Bilateral multilevel cervical percutaneous facet neurotomies were used to treat a patient suffering from a chronic headache and neck pain that had failed to respond to extensive medical management.

Results

Within days of completing the bilateral facet neurotomies, the patient developed head drop. Subsequent electromyography revealed denervation of the patient's paraspinous muscles. Initially the patient was managed conservatively in a cervical collar with the hope that he would recover some function. After few years, the patient developed fixed kyphotic deformity. Correction of the patient's deformity required multilevel anterior cervical discectomy and fusion followed by posterior instrumented fusion.

Conclusions

When performing multilevel percutaneous cervical facet neurotomies, there is a risk of paraspinous muscle denervation, and subsequent kyphotic deformity may occur. The likelihood of this rare and previously unreported complication can probably be reduced by proper needle positioning and by minimizing the number of levels at which the procedure is performed.     

Complications,outcomes, and need for fusion after minimally invasive posterior cervical foraminotomy and microdiscectomy

Background context

Posterior cervical foraminotomy (PCF) with or without microdiscectomy (posterior cervical discectomy [PCD]) is a frequently used surgical technique for cervical radiculopathy secondary to foraminal stenosis or a laterally located herniated disc. Currently, these procedures are being performed with increasing frequency using advanced minimally invasive techniques. Although the safety and efficacy of minimally invasive PCF/PCD (MI-PCF/PCD) have been established, reports on long-term outcome and need for secondary surgical intervention at the index or adjacent level are lacking.

Purpose

To determine the rates of complications, long-term outcomes, and need for secondary surgical intervention at the index or adjacent level after MI-PCF and microdiscectomy.

Study design

Retrospective analysis of a prospective cohort.

Patient sample

Seventy patients treated with MI-PCF and/or MI-PCD for cervical radiculopathy.

Outcome measures

Visual Analog Scale for neck/arm (VAS_N/A) pain and Neck Disability Index (NDI).

Methods

Ninety-seven patients underwent MI-PCF with or without MI-PCD between 2002 and 2011. Adequate prospective follow-up was available for 70 patients (95 cervical levels). The primary outcome assessed was need for secondary surgical intervention at the index or adjacent level. The secondary outcomes assessed included complications and improvements in NDI and VAS_N/A scores. All complications were reviewed. Mixed-model analyses of variance with random subject effects and autoregressive first-order correlation structures were used to test for differences among NDI, VAS_A, and VAS_N measurements made over time while accounting for the correlation among repeated observations within a patient. All statistical hypothesis tests were conducted at the 5% level of significance.

Results

Patients were followed for a mean of 32.1 months. Of 70 patients operated, there were 3 (4.3%) complications (1 cerebrospinal fluid leak, 1 postoperative wound hematoma, and 1 radiculitis), none of which required a secondary operative intervention. Five patients required an anterior cervical discectomy and fusion (eight total levels fused) on average 44.4 months after the index surgery. Of those, five (5.3%) were at the index level and three (2.1%) were at adjacent levels. Neck Disability Index scores improved significantly (p<.0001) immediately postoperatively and continued to decrease gradually with time. Visual Analog Scale for neck/arm scores improved significantly (p<.0001) from baseline immediately postoperatively but tended to plateau with time.

Conclusions

Minimally invasive PCF with or without MI-PCD is an excellent alternative for cervical radiculopathy secondary to foraminal stenosis or a laterally located herniated disc. There is a low rate (1.1% per index level per year) of future index site fusion and a very low rate (0.9% per adjacent level per year) of adjacent-level disease requiring surgery.