Edward D. Simmons

Spinal stenosis with scoliosis

A retrospective review was carried out on 40 patients who met the criteria of 1) having a significant lumbar scoliosis associated with spinal stenosis, with symptoms of neurogenic claudication; and 2) having been treated with posterior decompression and pedicular screw fixation techniques. The average age of the patients was 61.5 years (range, 38–77 years), and 25 of the 40 patients were female. Eighty-eight percent of the patients had significant back pain in addition to lower extremity pain. All patients had pedicular screw fixation at all levels. Zielke instrumentation was used in 24 patients, Cotrel-Dubousset instrumentation in 8 patients, and Texas Scottish Rite Hospital instrumentation in the remaining 8 patients. After surgery, there was marked improvement in regard to pain status: 34 patients (83%) had severe pain before surgery, with 38 patients (93%) reporting mild or no pain at follow-up. Average length of follow-up was 44 months (range, 24–61 months). There were no deaths and no instrument-related failures or pseudarthroses noted in this series. A mean correction of the deformity of 19° was obtained. Average scoliosis was 37° before surgery and 18° at follow-up.

Familial predisposition for degenerative disc disease : A case control study

Study Design This case‐control study was undertaken to determine if relatives of patients who had been admitted for surgery for degenerative disc disease‐related problems were at increased risk for lower back pain or sciatica. Objectives To determine if familial factors play a role in placing a person at risk for development of degenerative disc disease of the lumbar spine. Summary of Background Data It is known that smoking and various occupational factors can place a person at risk for degenerative disc disease problems. It is not known if a familial predisposition may also exist. Methods The family members and relatives of 65 patients who had undergone surgery for lumbar degenerative disc disease were interviewed with a standardized questionnaire and compared with a control group of 67 patients who had been admitted to hospital for non‐spine‐related orthopedic procedures. The same interview and standardized questionnaire was used for both groups by a single observer. Results In the study group of 65 patients who had undergone surgery for degenerative disc disease, 44.6% were noted to have a positive family history, whereas 25.4% of the patients in the control group had a positive family history. Eighteen and one‐half percent of relatives in the study group had a history of having spinal surgery, compared with only 4.5% of the control group. Conclusions The results indicate that a familial predisposition to degenerative disc disease can exist along with other risk factors.

Reliability of roentgenogram evaluation of pedicle screw position.

Study Design. This was a human cadaver study of the accuracy of biplanar roentgenography in determining pedicle screw position. Objective. To determine the independent accuracy of radiologic evaluation of screw placement and to determine if there are any particular screw malpositions that are more likely to produce a false sense of acceptable screw position. Summary of Background Data. Other investigators have reported the correlation between radiologic evaluation and anatomic dissection. However, in those studies the radiologic evaluation was not independent of the surgeons placing the screws. There has been no comment in the literature regarding particular screw malpositions that would lead the surgeon into a false sense of successful screw placement. Methods. Pedicle screws were placed in cadaver spines, and biplanar roentgenograms of the specimens were evaluated by independent observers. The results of the roentgenogram evaluation then were compared to those of the anatomic dissection. Results. The accuracy of roentgenogram evaluation varied from 73% to 83%, depending on the experience of the surgeon grading the roentgenograms. Screws misplaced medially into the spinal canal are more likely to give the surgeon a false sense of successful screw placement. Conclusions. The surgeon must not rely solely on the roentgenograms, but instead continue to use tactile sensory skills, anatomic knowledge, and additional modalities such as electromyography monitoring.

Thirty-six years experience of cervical extension osteotomy in ankylosing spondylitis: techniques and outcomes.

Study Design. A retrospective review of the cervical extension osteotomy in the past 36 years for the treatment of flexion deformity of patients with ankylosing spondylitis was conducted. Objectives. To review the conventional and current surgical techniques of cervical extension osteotomy in ankylosing spondylitis and to evaluate the clinical outcomes. Summary of Background Data. Cervical osteotomy is a challenging procedure in the correction of flexion deformity in ankylosing spondylitis. Some authors prefer using general anesthesia and prone position for their surgery, and some, including the authors, use the sitting position. Methods. A review of 131 cases of cervical spine osteotomy was carried out. The accumulation of 131 cases was classified into two phases: 114 cases from 1967 to 1997 (conventional technique group) by our senior author and 17 cases from 1997 to 2003 (current technique group) by our first author. Patient follow-up was obtained by a combination of retrospective chart review and telephone interview by 2 independent physicians. The flexion deformity was measured before surgery and after surgery using chin-brow to vertical angle. Results. There were 114 patients in the conventional group and 17 patients in the current group. The average preoperative and postoperative angle was 56° and 4°, respectively, in the conventional group and 49° and 12°, respectively, in the current group. Conclusions. The sitting position with local anesthesia is safe and allows for correction of deformity in a controlled manner. The increased lateral resection area reduces the possibility of nerve root impingement and provides ample room for the spinal cord. The cranial halo can also be adjusted after surgery to modify the head/neck position and can be adjusted to alleviate any C8 nerve root impingement. The procedure demands great attention to detail to minimize risk.

The results of surgical treatment for adult scoliosis.

This study was done to define and characterize those adult patients with scoliosis who will have problems of pain and/or progression leading to a surgical procedure and to review the results of these surgical procedures. The authors reviewed the cases of 49 adult patients who had undergone surgical treatment for scoliosis (average follow-up, 34 months; range, 24-140 months). The patients were categorized according to age, which allowed analysis of the data comparing age and the incidence and level of pain, age versus the degree of curvature, and age versus the incidence of progression. The relative incidence of pain and progression as indications for surgery were found to vary with respect to age. In the younger groups, progression was more often the indication for surgery than in the older groups. The Younger groups also had larger curves than did the older groups, on average. The degree of pain was not found to correlate with the magnitude of the deformity. Surgical Complications occurred in 20 patients; however, 14 of these were minor complications during the perioperative period, which did result in any sequelae. Surgical treatment can be done with a relatively low serious complication rate and good results in terms of pain relief and reasonable correction of the deformity.

Radiographic assessment for patients with low back pain.

Guidelines for radiographs of the lumbar spine are established. In general, radiographs are not believed to be necessary for a first episode of low back pain present for less than 7 weeks. Exceptions to this include various medical or physical findings, which are listed. In general, anteroposterior and lateral views only should be done initially. Indications for other views are discussed.

Value of Magnetic Resonance Imaging and Discography in Determining the Level of Cervical Discectomy and Fusion

Study Design. The correlation between magnetic resonance imaging and discography of the cervical spine in degenerative disc disease was studied. In addition, the results of cervical discectomy and fusion were evaluated. Objectives. To compare the value of cervical magnetic resonance imaging versus discography in selecting the level for discectomy and fusion and to evaluate the surgical outcome. Summary of Background Data. The value of magnetic resonance imaging and discography in patients with cervical discogenic pain is less clear. Also, the status of a hypointense signal (dark) cervical disc and/or a small herniated disc on magnetic resonance imaging has not been determined. Methods. The magnetic resonance imaging studies and discography followed by computed tomography in 55 patients with cervical discogenic pain were evaluated. Surgical planning was based on the complete information of clinical symptoms, magnetic resonance imaging, and discography as well as computed tomography discography. Anterior cervical discectomy and keystone fusion was performed. Postoperative pain relief was assessed by the patients, and the follow-up radiographs were viewed by an independent reviewer. The overall surgical outcome was evaluated using Odom’s criteria. Results. There were 161 disc levels that successfully underwent cervical discography with 79 positive levels. A positive discography result was found in 63% of dark (hypointense signal) discs and 45% of speckled discs. Fifty-nine percent of small herniated discs and 59% of torn discs had a positive discography, respectively. There were 100 abnormal cervical discs on magnetic resonance imaging. Magnetic resonance imaging had a false-positive rate of 51% and a false-negative rate of 27%. Successful cervical fusion was achieved in 95% of patients, and the overall satisfactory result was 76%. Conclusions. Magnetic resonance imaging can identify most of the painful discs but still has relatively high false-negative and false-positive rates. There is a high chance that hypointense signal and small herniated discs are the pain generators, but they are not always symptomatic. Discography can save the levels from being unnecessarily fused. The combination of clinical symptoms, magnetic resonance imaging, and discography provides the most information for decision making and can improve the management of cervical discogenic pain.

Magnetic resonance imaging : use in patients with low back or radicular pain

With the current emphasis on cost containment, it is important to order the single best diagnostic test when clinical uncertainties must be resolved. Magnetic resonance imaging is currently the optimal imaging modality to provide the maximum amount of information when evaluating patients with suspected spinal disorders. A comprehensive magnetic resonance imaging study is needed along with a subspecialty interpretation to provide the greatest amount of useful clinical information.

CERVICAL DEFORMITY: Rationale for Selecting the Appropriate Fusion Technique (Anterior, Posterior, and 360 Degree)

This article examines cervical deformities and their treatments, such as iatrogenic deformities, posttraumatic deformities, ankylosing spondylitis, rheumatoid arthritis, degenerative subaxial spondylolisthesis, myopathy, infectious spondylitis, and tumors. Congenital scoliosis and kyphosis and torticollis and rotatory atlanto-axial subluxation also are discussed.

THORACIC AND LUMBAR DEFORMITY: Rationale for Selecting the Appropriate Fusion Technique (Anterior, Posterior, and 360 Degree)

The rationale of anterior versus posterior, or combined fusion is discussed with regards to different clinical diagnoses and situations. Factors involved in the decision-making process include stability, magnitude of deformity, rigidity of deformity, neurologic considerations, bone quality, and medical/metabolic factors. Careful preoperative assessment and planning are required as well as consideration for the patients overall well being.