Courtney W. Brown

Is there an optimal patient stance for obtaining a lateral 36" radiograph? A critical comparison of three techniques.

Study Design. Scoliosis patients were prospectively x-rayed in three positions with independent analysis. Objectives. To determine if one positioning technique provides superior visualization of critical landmarks (C7, T2, T12, L5–S1) and to determine any position dependent variations in regional measures or sagittal balance. Summary of Background Data. Different techniques for positioning patient’s arms are used for 36” lateral radiograph with no data on relative effects. Methods. A total of 25 scoliosis patients were prospectively studied with 36” lateral radiographs in three positions varying arm location (straight out, partially flexed, and the ”clavicle“ position). Films were analyzed independently by three surgeons. Vertebral landmarks were scored for clarity; and lordosis, kyphosis, and global balance were analyzed. Statistical analysis was done with a General Estimating Equations model. Results. The overall visualization score for the clavicle position was superior to either the 60° or 90° positions (clavicle vs. 60°, P < 0.0001; clavicle vs. 90°, P < 0.0003). Analysis of vertebral landmarks showed significantly better visualization of T2 with clavicle versus 90° (P < 0.047), better visualization of T12 with clavicle versus either 60° (P < 0.006) or 90° (P < 0.049), and better visualization of L5-S1 with clavicle versus 90° (P < 0.02). Regional measures showed no differences, but sagittal balance was significantly more positive in the 60° position than either clavicle (P < 0.04) or 90° (P < 0.015). Conclusions. The clavicle position for obtaining lateral 36” radiographs produces significantly better overall visualization of critical vertebral landmarks. Regional measures do not differ between the three positions, but global balance is more positive with the 60° position. Clinically, the clavicle position may result in more accurate radiographic measures and may minimize repeated radiograph exposures.

Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization

Study Design A retrospective study to review the results of unstable thoracolumbar burst fractures managed with casting or bracing and early ambulation in neurologically healthy patients. Objectives To determine the clinical outcome of patients with unstable burst fractures of the thoracolumbar spine treated without surgery, and to identify any variables that may adversely influence the final outcome. Summary of Background Data The management of unstable fractures of the thoracolumbar spine as described by Bedbrook involves a period of recumbency for 6–8 weeks followed by gradual mobilization. Newer techniques of surgical stabilization of the fracture and decompression of the neural elements have become popular because immediate stability of the spine is created and because the need for prolonged bedrest and hospitalization is eliminated. There have been only three reports in the literature describing the nonoperative management of these fractures with early mobilization; some authors believe that this is appropriate only if the posterior column is intact. The results reported in the literature of nonoperative management of thoracolumbar burst fractures have indicated that this is an effective method of management. Methods A retrospective review of 26 patients with unstable burst fractures in the thoracolumbar region (T11‐L2) was performed; follow‐up evaluation was obtained from 24 patients. Clinical follow‐up examination was performed by the use of a questionnaire in which the patients were asked to rate their pain, ability to work, ability to perform in recreational activities, and their overall satisfaction with treatment. Results Mean follow‐up time for the 24 patients was 34.3 months. Mean duration of hospitalization was 8.2 days; those patients who did not have injuries other than their spine fracture had a mean hospitalization time of 5.9 days. Kyphotic deformity could be corrected with hyperextension casting but tended to recur during the course of mobilization and healing. No correlation was found between kyphosis and clinical outcome. At final follow‐up evaluation, 19 patients (79%) had little or no pain; 18 patients (75%) had returned to work; 18 (75%) stated that they had little or no restrictions in their ability to work, and 16 (67%) stated that they had little or no restrictions in their ability to participate in recreational activities. Only one patient (4%) reported being dissatisfied with the initial nonoperative treatment of his spine fracture. Ten patients were found to have evidence of spinous process widening on plain films; there was no significant difference in the clinical or radiographic outcome of these 10 patients when compared with the 14 others who did not have interspinous widening. Conclusions Nonoperative management of thoracolumbar burst fractures with hyperextension casting or bracing was proven to be a safe and effective method of treatment in selected patients. Clinical results were favorable; no neurologic deterioration was observed; hospitalization times were minimized, and patient satisfaction was high. The authors do not believe that ligamentous injury of the posterior column is a contraindication to nonoperative management of thoracolumbar burst fractures.

The natural history of thoracic disc herniation.

Fifty-five patients with 72 thoracic disc herniations were retrospectively reviewed in an effort to ascertain the natural history of this disease. The treatment programs given to these patients were evaluated, and 15 (27%) of the 55 patients eventually required surgery. The majority, however, did not require surgery and have continued to perform activities of daily living, some even participating in vigorous sports activities (eg, skiing) without any apparent neurologic consequences. Thoracic disc herniations, similar to cervical and lumbar disc herniations, do not always lead to major neurologic compromise. A less aggressive surgical approach therefore can be considered.

Neuropathic (charcot) Arthropathy of the Spine After Traumatic Spinal Paraplegia

Neuropathic (Charcot) arthropathy of the spine is a relatively rare problem that, nonetheless, must be considered in the differential diagnosis of any patient with degeneration of one or more levels of the spine associated with diminished or absent protective sensation. This study presents 15 patients in whom Charcot arthropathy of the spine developed after traumatic paraplegia. Eight were successfully treated with surgical fusion, and the remaining seven were treated nonoperatively. By the use of combined anterior and posterior fusion with extensive debridement, autogenous grafting, and posterior instrumentation, successful fusion can be achieved in patients with Charcot arthropathy of the spine. However, the surgical technique is demanding, the rehabilitation must be carefully supervised, and the postoperative complication rate remains high. The possibility of developing secondary levels of arthropathy below a previously successful fusion must be considered.

Acquired spinal stenosis secondary to an expanding thoracic vertebral hemangioma

Intraosseous hemangioma is a slow-growing primary benign neoplasm of capillary, cavernous, or venous origin. The most common type is the cavernous hemangioma, composed of large thin-walled vessels and sinuses lined by endothelial cells. Although found in any bone, hemangioma is most common in the vertebrae, where it represents 2–3% of all radiographically detectable spinal tumors. Most spinal hemangiomas are solitary, asymptomatic lesions o the vertebral body, with 10–15% showing concomitant involvement of the posterior elements.31 Rarely, the lesion is located to the posterior arch.7,10 An unusual case of an expanding vertebral hemangioma isolated to the posterior elements of T9 is presented.

Stabilization of thoracic spine fractures resulting in complete paraplegia. A long-term retrospective analysis.

Study Design. The impact of surgical stabilization on initial rehabilitation and complications in patients with traumatic thoracic level paraplegia was investigated. One hundred thirteen patient records were retrospectively reviewed. Summary of Background Data. Forty-six patients had been treated with surgical stabilization and fusion. Nineteen patients had been treated by laminectomy alone. Forty-eight patients had been treated nonoperatively. The most common mechanism of injury was a motor vehicle accident (52.6%). The mean follow-up was 8.4 years. Methods. All inpatient and outpatient records at Craig Hospital were reviewed for patients who had sustained a thoracic spine fracture (T2–T9) that resulted in complete paraplegia (Frankel A). All patients were followed for a minimum of 5 years. Data were collected regarding initial length of inpatient rehabilitation, as well as early and late complications that affected rehabilitation and function during follow-up. This information was analyzed by treatment group. Results. There was a statistically significant difference in the length of initial rehabilitation days between the surgically stabilized group and the laminectomy-only group. There was a trend toward fewer in-patient rehabilitation days between the surgically stabilized group and the nonoperatively treated group. The surgically treated group had twice as many complications as the nonoperative group. Conclusions. The surgical stabilization of thoracic (T2–T9) spine fractures with complete paraplegia tends to decrease initial rehabilitation days but is associated with increased overall complications. The treatment of this patient group clearly must be individualized.

Hypomagnesemia in postoperative spine fusion patients.

Study Design This was a retrospective review of 49 consecutive patient charts and a prospective study of 44 consecutive patients who underwent spinal fusion. Objective To determine the incidence and clinical significance of hypomagnesemia after spinal fusion. Summary of Background Data Hypomagnesemia may be seen in 61% of patients in postoperative intensive care and may be associated with increased mortality. However, symptomatic hypomagnesemia is rare. Methods A retrospective review of the charts of 49 consecutive patients who underwent spine fusion was completed to determine postoperative magnesium levels. Twenty‐seven patients with postoperative hypomagnesemia received routine magnesium replacement regardless of symptoms. Forty‐four patients who underwent spine fusion were studied prospectively for post‐operative hypomagnesemia. Prospectively studied observational patients who developed hypomagnesemia were treated only when clinical signs or symptoms of magnesium deficiency occurred. Results Postoperative hypomagnesemia occurred in 28 of 49 retrospectively studied patients who underwent spine fusion (57%) and 38 of 44 prospectively studied patients who underwent spine fusion (86%). Symptoms associated with hypomagnesemia developed in three of 44 prospectively studied and two of 49 retrospectively studied patients who underwent spine fusion (7% and 4%, respectively). The combined incidence for symptomatic hypomagnesemia was five of 93 patients (5.4%). The majority of patients from the prospective study with postoperative hypomagnesemia were asymptomatic, and their magnesium levels returned to normal within 4 days, with or without treatment. Conclusions This study confirmed a high incidence of hypomagnesemia in patients who underwent spine fusion, although only 5.4% developed clinical signs or symptoms of magnesium deficiency. The cause of hypomagnesemia remains speculative.

Multifocal metachronous epidural abscesses of the spine. A case report.

Study Design A retrospective case report of a patient who had a lumbar epidural abscess treated surgically who then developed a cervical epidural abscess that also required surgical treatment. Objectives To describe a patient in whom treatment of a single epidural abscess with surgery and antibiotics was not sufficient to eradicate the systemic infection. Summary of Background Data Epidural abscesses are most commonly seen after invasive procedures that violate the epidural space. Epidural abscesses are usually a solitary event occurring in only one location and are usually treatable with surgical drainage and parenteral antibiotics. Methods An elderly patient presented with neck and shoulder pain and fever. Evaluation revealed degenerative disease of the cervical spine. Within a week, she developed a cauda equina syndrome secondary to a lumbar epidural abscess. The abscess was drained and intravenous antibiotics were given. Seventeen days later, while still receiving antibiotics, she developed a cervical epidural abscess which also required surgical drainage. Results The patient showed gradual improvement in her neurologic status. No recurrence of either epidural abscess was observed. Conclusions An epidural abscess may represent a serious systemic infection that requires aggressive treatment. Close follow‐up is necessary to ensure that the infection has been eradicated and that no recurrent abscess has formed in the same or a different location. Aggressive antibiotic treatment is also strongly recommended.