Frank J. Eismont

Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing.

Eighteen neurologically intact patients with burst fractures at the thoracolumbar junction were treated with early ambulation in a total contact orthosis. No attempt was made to reduce the associated deformity. Selection criteria excluded patients with posterior column disruption. Hospital stay averaged 10 days. Follow-up averaged 19 months. Mean kyphosis was 19 at time of injury and 20 at follow-up. At follow-up, 15 patients rated their pain as little or none. Seventeen patients had little or no restriction of activity. Follow-up computed tomography (CT) scans obtained in eight patients showed significant resorption of retropulsed bone. No deterioration of neurologic function developed in any patient. In patients with intact posterior elements and thoracolumbar burst fractures, early mobilization in a total contact TLSO can lead to satisfactory functional results. Prolonged bed rest was not required in this series. The authors attribute the good results of nonoperative management to the exclusion of patients with posterior column disruption.

Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets. Case report.

The occurrence of a clinically significant anterior herniation of a cervical disc in association with an injury to the posterior ligaments and subluxation or dislocation of facets (zygapophyseal joints) has received sparse attention in the orthopaedic and neurosurgical literatur&358’3”5. Similarly, inadequate attention has been paid to the fact that the neurological status of a patient might worsen with increasing protrusion of the disc as the posterior displacement of the facets is corrected2’3’6. In July 1980, a patient who had dislocation of the facet joints at the sixth and seventh cervical levels and hemiation of the disc between those two vertebrae was treated at our institution, and the result was catastrophic. Since that time, we have been alert to the possibility that a herniation of a cervical disc might accompany the posterior injury. We encountered the cases of five additional patients who had these concomitant injuries. At the Jackson Memorial Hospital in Miami, Florida, from July 1980 to August 1987, we operated on sixty-eight patients who had an acute injury to the cervical posterior ligaments associated with subluxation or dislocation, or both, of facet joints. Our routine, in general, is as follows. Traction with Gardner-Wells skull-tongs is applied initially to every patient who has a posterior cervical injury. We attempt a closed reduction by gradually increasing traction. We monitor the situation with serial roentgenograms. We do not attempt a manipulative reduction. As long as the neurological status does not deteriorate, we use this method of reduction for as long as seventy-two hours and with as much as twenty-three kilograms (fifty pounds) of traction. A myelogram or a computerized tomography or magnetic resonance-imaging scan (or, often, more than one of these studies) is made during that interval to reveal whether there is hemiation of a disc. If there is no such herniation, posterior cervical wiring and arthrodesis is done after a closed reduction. If the subluxated or dislocated facet was not reduced with skull-tong traction, we perform an operative

Cervical sagittal spinal canal size in spine injury.

This study investigated the relationship between cervical spine sagittal canal diameter and neurologic injury in cases of spinal fracture-dislocation. A group of 98 patients with such injuries was reviewed; 45 had no neurologic deficits, 39 had incomplete quadriplegia, and 14 had complete quadriplegia. Spinal canal sagittal diameter was measured in all, and large diameter and small canals were defined. Small diameter canals were correlated significantly with neurologic injury, while large diameter canals allowed protection from neurologic injury in cervical fracture dislocation.

Oncologic and functional outcome following sacrectomy for sacral chordoma.

BACKGROUND Sacral chordoma is a rare, low to intermediate-grade tumor that poses substantial challenges in terms of timely diagnosis and adequate treatment. Few studies have examined the oncologic and functional outcomes of patients treated for sacral chordoma. METHODS The clinical records of sixteen patients who had undergone sacrectomy for chordoma between 1985 and 2001 were evaluated retrospectively. All patients underwent resection by means of a sequential combined anterior and posterior approach. Patients were followed clinically at six-month intervals following recovery from the index surgical procedure. The disease onset, treatment, hospital stay, recurrence rates, survival, adjuvant therapy, functional outcome measures, and complications were evaluated. RESULTS The average age at the time of diagnosis was sixty-one years. The mean tumor size was 15.2 cm in diameter, and all patients had a resection involving S1 or S2. The mean duration of follow-up was sixty-six months, and the tumor recurred in twelve of the sixteen patients. The mean time to metastasis was fifty months. Four patients were clinically disease-free at a mean follow-up of 94.5 months, while five patients died as a result of progressive local or metastatic disease at a mean follow-up of 31.4 months. Only one patient had normal bowel and bladder control postoperatively, and only three were able to walk without assistive devices. Eight patients had wound complications, and one patient had a deep-vein thrombosis. With the numbers available, neither negative margins at the time of initial tumor resection nor adjuvant radiation therapy had a significant impact on survival or local recurrence. More cephalad levels of resection were associated with significantly worse bowel (p = 0.01) and bladder (p = 0.01) control. Complications were frequent and were more common with a larger tumor size at the time of presentation (p = 0.034). CONCLUSIONS The treatment of sacral chordoma is an arduous clinical undertaking that requires a multidisciplinary approach and attention to detail from the outset. Despite aggressive well-planned surgical management and adherence to strict surveillance protocols, frequent recurrence and the late onset of metastatic disease are to be expected in a substantial proportion of patients, especially those with a very large chordoma or one at a more cephalad level. Adequate surgical treatment results in substantial functional impairment and numerous complications; however, it does offer the possibility of long-term disease-free survival. We advocate an attempt at complete resection, when there is still a possibility of cure, and aggressive treatment of local recurrences. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Anterior decompression, structural bone grafting, and Caspar plate stabilization for unstable cervical spine fractures and/or dislocations.

Fourteen patients who sustained acute cervical spine fractures and/or dislocations with associated posterior ligamentous disruption had anterior decompressoions, structural bone grafting, and anterior Caspar plate stabilization. Whit an average 30–month follow–up, no patient has had loss of fixation. Despite criticism raised from biomechanical testing, the Caspar anterior plate system (Aesculape, Tuttlingen, Germany) may be added to structural bone grafting of unstable cervical fractures and/or dislocations, Yielding an in vivosolid construct, which obviates the need for simultaneous posterior stabilization.

Efficacy of five cervical orthoses in restricting cervical motion : A comparison study

Study Design. Twenty volunteers, 10 men and 10 women, with clinically and radiographically normal cervical spines were studied. Objectives. To evaluate the effectiveness of five cervical orthoses in their ability to restrict cervical motion in flexion, extension, lateral tilt, rotation, and interverte bral motion. Summary of Background Data. The five cervical orthoses evaluated were the Philadelphia collar (Philadelphia Collar Co., Philadelphia, PA), Aspen (International Healthcare Devices, Long Beach, CA), Stifneck (Laerdal, Armonk, NY), Miami J (Jerome Medical, Moorestown, NJ), and NecLoc (Jerome Medical, Moorestown, NJ) orthoses. Together these five orthoses comprise 80% of the rigid cervical and extrication devices in current use. Methods. The normal and unrestricted ranges of active cervical motion in flexion, extension, and lateral tilt were measured in each subject and compared with the motion permitted in each of the five cervical orthoses. Lateral radiographs of the cervical spine in the neutral position and at maximum flexion and extension were obtained. Measurements of flexion, extension, and combined flexion-extension were determined for the cervical spine as a whole as measured from the occiput to the seventh cervical vertebra and at each intervertebral cervical level. Lateral tilt was measured on an anteroposterior radiograph at the extreme of motion. Rotation was measured using a compass goniometer. Each volunteer served as his own control for the radiographic and goniometric measurements. Results and Conclusion. The NecLoc cervical orthosis demonstrated statistically superior restriction of cervical motion in flexion, extension, rotation, and lateral tilt in comparison with the other four orthoses studied in healthy volunteers. The Miami J cervical orthosis was the next most restrictive orthosis and was superior to the Philadelphia Collar and Aspen orthosis in all parameters of motion.

Transthoracic disc excision and fusion for herniated thoracic discs

Transthoracic discectomy and fusion were performed on 19 patients for a central or central-lateral herniated thoracic disc. At initial visit, 14 patients had evidence of myelopathy, 5 had bowel or bladder dysfunction, and 13 had pain. Previous laminectomy in three patients compromised the result of later anterior decompression. Coexistent multiple sclerosis was diagnosed in two patients, who had an atypical postoperative course. The overall results of transthoracic discectomy and fusion in patients without prior laminectomy or coexistent multiple sclerosis were excellent in six, good in six, fair in one, and poor in one, demonstrating that it is a safe and effective procedure.

Traumatic occipitoatlantal dislocation.

Four patients with traumatic occipttoatlantal dlslocation are presented. The dislocations were the result of rapid deceleration motor vehicle accidents. The mechanism of injury was by hyperextenslon-rotation combined with a distraction force. Three patients sustained multiple Injuries. Neurologic findings were variable. One patient with complete cord transection and closed head trauma died 4 days after the injury. In the three surviving patients, the occlpitoatlantal dislocation was not diagnosed by the initial examiner. Prompt recognition and stabilization are essential to avoid further neurologic injury. Care must be taken not to increase the dislocation. A hato applied before operation facilitates reduction and allows posterior ocdpitoatiantal fusion to be performed tinder optimum conditions.

Fungal infections of the spine. Report of eleven patients with long-term follow-up.

BACKGROUND Fungal infections of the spine are noncaseating, acid-fast-negative infections that occur primarily as opportunistic infections in immunocompromised patients. We analyzed eleven patients with spinal osteomyelitis caused by a fungus, and we developed suggestions for treatment. METHODS All patients with a fungal infection of the spine treated by the authors over a sixteen-year period at three teaching institutions were evaluated. There was a total of eleven patients. Medical records and roentgenograms were available for every patient. Long-term follow-up of the nine surviving patients was performed by direct examination by the authors or by the patients primary physician. RESULTS For ten of the eleven patients, the average delay in the diagnosis was ninety-nine days. Nine patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. The sources of the spinal infections included direct implantation from trauma (one patient), hematogenous spread (four patients), and local extension (two patients). The infection followed elective spine surgery in three patients, and the cause was unknown in one. Paralysis secondary to the spine infection developed in eight patients. Ten patients were treated with surgical debridement. All eleven patients were treated with systemic antifungal medications for a minimum of six weeks. One patient died of generalized sepsis at thirty-three days, and another patient died of gastrointestinal hemorrhage at five months. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients. CONCLUSIONS Treatment of fungal spondylitis is often delayed because of difficulty with the diagnosis. Delay in the diagnosis led to poorer results in terms of neurologic recovery in our study. Performing fungal cultures whenever a spinal infection is suspected might hasten the diagnosis. Patients should be given a guarded prognosis and informed of the many possible complications of the disease.

Surgical options for the treatment of cervical spondylotic myelopathy

Cervical spondylotic myelopathy is a disease of the cervical spinal cord that results from circumferential compression of the degenerative cervical spine, often in a congenitally narrow spinal canal. Surgical recommendations must be based on patient characteristics, symptoms, function, and neuroradiologic findings. ACDF is an excellent option for one- or two-level spondylosis without retrovertebral disease. Anterior corpectomy and strut grafting may provide an improved decompression and is ideal for patients with kyphosis or neck pain. Laminectomy historically yields poor results from late deformity and late neurologic deterioration but yields improved results with good surgical technique. Laminoplasty was developed to address cervical stenosis of three or more segments and compares favorable with anterior corpectomy and fusion for neurologic recovery. Laminoplasty has a lower complication rate than corpectomy and strut grafting but has a higher incidence of postoperative axial symptoms.