Christopher G. Furey

Influence of anterior cervical plate design on Dysphagia : a 2-year prospective longitudinal follow-up study

Objective: To compare the incidence, prevalence, and rate of improvement of dysphagia in patients undergoing anterior cervical spine surgery with two different anterior instrumentation designs. Methods: The study subjects were 156 consecutive patients undergoing anterior cervical spine surgery with plate fixation. We compared the incidence of dysphagia among the two different plate groups both produced by the same manufacturer (Medtronic Danek); the Atlantis plate has thicker and wider plate dimensions than the Zephir plate. Dysphagia evaluations were performed prospectively by telephone interviews at 1, 2, 6, 12, and 24 months following the procedure. Risk factors such as gender, revision surgery, and number of surgical levels were compared between the groups and were not statistically different. Results: Overall incidences of dysphagia were 49%, 37%, 20%, 15.4%, and 11% at 1, 2, 6, 12, and 24 months, respectively. Severe and disabling dysphagia is reported to be a relatively uncommon complication of anterior cervical surgery. However, a significant number of patients report mild to moderate discomfort including double-swallowing and catching sensation. Except at the 2-month follow-up point, the Atlantis plate group had higher incidences of dysphagia than the Zephir group at all time points (57% vs 50%, 36% vs 4%, 23% vs 14%, 17% vs 7%, 14% vs 0% at 1, 2, 6, 12, and 24 months, respectively). The Atlantis plate group had a 14% incidence of dysphagia at 2 years compared with the Zephir group, which had a 0% incidence at 2 years (P < 0.04). For primary surgeries, there was a higher incidence of dysphagia at all time points in the Atlantis group when compared with the Zephir group (58% vs 43%, 35% vs 30%, 22% vs 10%, 17% vs 0%, and 13% vs 0% at 1, 2, 6, 12, and 24 months, respectively) (P < 0.04 at 1 year). A regression analysis was performed. The resulting formulas predict the permanent rate of dysphagia for the Atlantis group is 13.6% and for the Zephir group is 3.58%. Conclusions: The use of a smaller and smoother profile plate such as the Zephir does reduce the incidence of dysphagia as compared with a slightly larger and less smooth plate such as the Atlantis.

Risk factors for delayed extubation after single-stage, multi-level anterior cervical decompression and posterior fusion.

Airway difficulties after single-stage, multilevel anterior and posterior cervical surgery are potentially life-threatening complications. Although extubation delays can occur, overnight intubation can reduce the risk of postoperative airway emergencies. Our protocol was as follows: all patients were kept intubated overnight in an intensive care unit and examined by the intensive care unit staff each morning. Readiness for extubation was based on the cuff-leak test, and extubation done on patients beyond the first postoperative day was considered delayed. Eleven patients were extubated on the first postoperative day (group 1), and 11 extubated beyond day 1 (group 2). No airway emergencies occurred. Patient factors—age, weight, smoking, medical comorbidities, American Society of Anesthesiologist class—were not significantly related to extubation delay. There were no differences between groups in the number of anterior and posterior levels or anterior and posterior operative times. Delayed extubation was significantly related to total operative time (8.2 hours vs. 10.6 hours), volume of crystalloid replacement (3627 cm3 vs. 6218 cm3) and intraoperative blood transfused (0.7 units vs. 3.1 units); approaching significance was increased blood loss (1238 mL vs. 2820 mL). We have found intraoperative factors—operative time, crystalloid volume, blood loss and replacement—rather than patient characteristics, to be risk factors for delayed extubation. Good communication with anesthesia staff and careful attention to postoperative airway management is essential after single-stage, multilevel anterior cervical decompression and posterior fusion.

Ketorolac use for postoperative pain management following lumbar decompression surgery: a prospective, randomized, double-blinded, placebo-controlled trial.

Study Design. Prospective randomized double-blind placebo-controlled study. Objective. The objective of this study was to assess the efficacy of Ketorolac in reducing postoperative pain and morphine requirements following primary multilevel lumbar decompression surgery. Summary of Background Data. The use of opioid medications following surgical interventions can be complicated by related side effects such as respiratory depression, somnolence, urinary retention, and delayed time to oral intake. The use of Ketorolac, a potent nonopioid, nonsteroidal anti-inflammatory drug, is an attractive alternative to morphine as many of the opioid-related side effects can be avoided. Methods. After Institutional Review Board approval, 25 patients who underwent a primary multilevel lumbar decompression procedure were randomly assigned to receive either Ketorolac or placebo in a double-blinded fashion. After surgery, all patients were allowed to receive intravenous morphine on an as needed basis. Morphine requirements were then recorded immediately postoperative, at 6, 12, and at 24 hours postoperative. A patient’s overall hospital course morphine requirement was also assessed. Patient postoperative pain levels were determined using the Visual Analog Pain Scale and were documented at 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. Morphine equivalent requirements were significantly less at all predetermined time points in addition to the overall hospital morphine requirement in patients randomized to receive Ketorolac. Visual Analog Pain Scores were significantly lower in patients randomized to receive Ketorolac immediately postoperative in addition to 4, 12, and 16 hours postoperative. There were no identifiable postoperative complications associated with the use of Ketorolac. Conclusion. Intravenous Ketorolac seems to be a safe and effective analgesic agent following multilevel lumbar decompressive laminectomy. Patients can expect lowermorphine requirements and better pain scores throughout their postoperative course.

Steroids and Risk Factors for Airway Compromise in Multilevel Cervical Corpectomy Patients: A Prospective, Randomized, Double-blind Study

Study Design. Prospective, randomized, double-blind study. Objective. To evaluate intravenous corticosteroids in preventing delayed extubation after multilevel corpectomy and strut graft reconstructive procedures and to identify risk factors for delayed extubation in these patients. Summary of Background Data. We performed a prospective, randomized double-blind study in patients undergoing multilevel cervical corpectomy procedures. Our hypothesis was that high-dose perioperative steroids would decrease edema and thus decrease the incidence of delayed extubation. Methods. We studied patients undergoing 2- or 3-level anterior cervical corpectomy procedures with anterior strut graft reconstruction. Sixty-six patients were randomized to receive 3 doses of either intravenous dexamethasone (n = 35) or saline (n = 31). The first dose was given before the incision, with subsequent doses given 8 and 16 hours later. Patients remained intubated until postoperative day 1, at which time a cuff leak test was performed by the anesthesiology attending. If a leak was present, the patient was extubated. If not, the test was repeated each postoperative day until a leak was present, indicating a patent airway. Results. Five of 35 (14%) in the steroid group and 6 of 31 (19%) in the saline group required delayed extubation (P = 0.22). There were no statistical differences in preoperative parameters of age, gender, diagnosis, smoking history, BMI, number of operative levels, or preoperative American Society of Anesthesiologists rating between the 2 groups. Similarly there were no differences between the groups for duration of anesthesia, intraoperative colloids or crystalloids, intraoperative blood loss, or intraoperative urine output. The data for both groups were pooled to evaluate risk factors for delayed extubation. The only statistically significant risk factor for delayed extubation in this study was female gender (P = 0.0001). Conclusion. Based on our data, we cannot recommend intravenous dexamethasone for prevention of delayed extubation after multilevel anterior cervical corpectomy and strut grafting procedures.

A multimodal approach for postoperative pain management after lumbar decompression surgery: a prospective, randomized study.

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.

Tandem stenosis: a cadaveric study in osseous morphology

BACKGROUND Tandem stenosis is the occurrence of concurrent cervical and lumbar stenosis. The prevalence has been estimated to be from 5% to 25%. Symptomatic tandem stenosis can present with a confusing scenario of both neurogenic claudication and myelopathy symptoms. PURPOSE The purpose of this study was to determine 1) the prevalence of anatomic tandem stenosis in a cadaveric population, 2) if there was an associative relationship between lumbar and cervical stenosis, and 3) the positive predictive values of stenosis in one area for stenosis in the other. STUDY DESIGN We obtained 440 skeletally mature skeletons and examined the cervical and lumbar spines from the Hamann Todd Collection in the Cleveland Museum of Natural History. METHODS For the cervical spine, we measured the mid-sagittal canal diameter using digital calipers for every level from C3 through C7. The minimum full central sagittal diameter was recorded for each level. For the lumbar spine, we measured the minimum full mid-sagittal canal diameter for every level from L1 through L5, using digital calipers. Stenosis was defined as a mid-sagittal canal diameter of less than 12 mm at at least one level. After analysis of this data, a second analysis was performed after correcting the data for contemporary body size and radiographic manifestation. RESULTS The prevalence of tandem stenosis ranged from 0.9% to 5.4% in this population. The association of cervical and lumbar stenosis was found to be statistically significant (p < .05). Stenosis in one part of the spine positively predicts for stenosis in the other area of the spine 15.3% to 32.4% of the time. CONCLUSION Tandem stenosis should be considered when evaluating a patient with mixed claudication and myeloradiculopathy symptoms.

Tumoral calcinosis in the cervical spine in a patient with CREST syndrome. A case report.

T umoral calcinosis is characterized by tumor-like periarticular deposits of calcium, and it commonly presents as a growing calcific mass in the soft tissue surrounding major joints1-6. It may be associated with bone erosion and destruction and may have a mass effect on neurovascular structures7-9. Tumoral calcinosis can be a component of CREST syndrome, an acronym for calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. Spinal and paraspinal tumoral calcinosis has been reported to involve both the vertebral bodies and the posterior elements of the cervical, thoracic, and lumbar spine6,10-18. To our knowledge, tumoral calcinosis of the cervical spine as a component of CREST syndrome has been reported in only three patients7,8,10. The diagnosis of tumoral calcinosis in the spine is difficult because of its rarity and its ability to mimic a neoplasm or infectious cause6,14,16,19. Neurologic deficits by mass effect can occur and may manifest as radiculopathy and/or myelopathy7-10,18. Moreover, it has been shown that tumoral calcinosis of the spine has presented diagnostic dilemmas to clinicians, radiologists, and pathologists because of a lack of familiarity with the entity16. We report the clinical presentation, radiographic findings, histopathologic results, and the surgical management of tumoral calcinosis of the cervical spine in a patient with CREST syndrome. Our patient is unique in that there was radiographic evidence of rapid progression of bone erosion and crystal deposition involving the posterior elements and paraspinal tissues within a one-year period. In addition, an anomalous, single vertebral artery on the affected side supplied the basilar artery system. The patient was informed that data concerning the case would be submitted for …

Weight Loss in Overweight and Obese Patients Following Successful Lumbar Decompression

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.

Understanding Bony Safety Zones in the Posterior Iliac Crest : An Anatomic Study From the Hamann-Todd Collection

Study Design. Morphometric analysis of the human ilia obtained from the Hamann-Todd Collection at Cleveland Museum of Natural History. Objective. To identify whether gender and pelvis size affect the distances between anatomic landmarks of the posterior pelvis. Summary of Background Data. The iliac crest bone harvest is commonly performed in orthopedic, neurosurgic, and maxillofacial surgery. Morbidity from the bone graft harvest is well described (Arrington et al, Clin Orthop Relat Res 1996:300–9; Ebraheim et al, J Am Acad Orthop Surg 2001;9:210–8; Hu and Bohlman, Clin Orthop Relat Res 1994;208–13; Kahn, Clin Orthop Relat Res 1979;204–7; Kurz et al, Spine 1989;14:1324–31; Lim et al, Spine 1996;21:2376–8; Sasso et al, J Bone Joint Surg Am 1998;80:631–5; St. John et al, A J Orthop (Belle Mead NJ) 2003;32:18–23; Summers and Eisenstein, J Bone Joint Surg Br 1989;71:677–80). Several studies have advanced our understanding of the bony, vascular, and neurologic anatomy of the posterior iliac crest (Ebraheim et al, J Am Acad Orthop Surg 2001;9:210–8; Xu et al, Spine 1996;21:1017–20). There is no literature documenting the measurement of this region on a large, statistically significant scale. Methods. An anatomic study was undertaken using the Hamann-Todd collection. The bilateral human ilia were examined from 50 men and 50 women between 18 and 80 years of age. Age, gender, and side were recorded. Four parameters were recorded: the shortest distance from the posterior superior iliac spine to the sciatic notch (PN), the shortest distance from posterior superior iliac spine to the sacroiliac joint (PS), the anterior-posterior length of the sciatic notch (P90), and the maximum length of the sacroiliac joint (SI). Results. The right and left ilia were compared, and no significant difference was found. The mean for all 4 measurements was slightly larger in men and statistically significant (PN: men 43.7 ± 4.6 mm vs. women 39.7 ± 5.8 mm; PS: 21.5 ± 7.8 mm vs. 16.9 ± 5.3 mm; P90: 16.7 ± 3.8 mm vs. 15.3 ± 3.6 mm; SI: 60.0 ± 5.9 mm vs. 55.2 ± 5.8 mm). The ranges and distribution of data within the ranges were compared. Men had higher maximum limits although the lower limits were similar (PN: men 28.7–62.7 mm vs. women 28.0–51.0 mm; PS: 7.3–43.3 mm vs. 4.7–34.3 mm; P90: 9–25.3 mm vs. 7.7–22.7 mm; SI: 42.3–69 mm vs. 50.0–79.0 mm). Conclusion. This study defines distances in the posterior iliac crest beyond which the risk of injuring important structures is present (2.80 cm for 100% of the population or 3.00 cm for ≥90%).

Postoperative magnetic resonance imaging assessment for potential compressive effects of retained posterior longitudinal ligament after anterior cervical fusions: a cross-sectional study.

Study Design. A cross-sectional study. Objective. To assess using postoperative magnetic resonance imaging whether the posterior longitudinal ligament (PLL) caused residual cord compression after anterior cervical decompression and fusion (ACDF) in a series of patients in whom the PLL was retained. Summary of Background Data. There is a lack of data evaluating the postoperative compressive effects of the PLL in patients undergoing ACDF providing guidance as to whether to remove or retain the PLL during discectomy to facilitate adequate decompression. Methods. Postoperative gadolinium enhanced magnetic resonance images were reviewed in a series of 33 patients who underwent ACDF for cervical radiculomyelopathy and who had persistent or recurrent postoperative symptoms. Patients with ossification of the posterior longitudinal ligament or with a herniated disc behind the PLL were excluded from this study. Results. There were no cases of discernible compression by the retained PLL identified on the magnetic resonance image (P < 0.001) as assessed by 2 independent reviewers. Four patients underwent subsequent revision surgery unrelated to the PLL. Conclusion. We were unable to demonstrate magnetic resonance imaging evidence to suggest that the retained PLL caused compression after ACDF in this patient cohort. Therefore we suggest that removing the PLL should be considered for reasons other than concern about residual compression.