Frederick L. Mansfield

Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression.

Study Design. A retrospective chart review was performed. Objective. To determine whether preoperative spinal radiation increases the number of major wound complications in patients with cancer who have symptomatic spinal cord compression. Summary of Background Data. Many factors have increased the number of patients hospitalized with symptomatic spinal cord compression after spinal irradiation. The surgical management of metastatic spinal cord compression may be complicated by preoperative radiation. Methods. A retrospective review of 123 patients admitted with symptomatic metastatic spinal cord compression from 1970 through 1996 was conducted. The final study population of 85 patients was separated into three treatment groups: 1) radiation only, 2) radiation followed by surgery, and 3) de novo surgery followed by radiation. Results. The major wound complication rate for patients who had radiation before surgical decompression and stabilization was 32%, or threefold, higher than the 12% observed in patients who had de novo surgery (P < 0.05). No other clinical factor or condition predicted the development of a major wound complication. Patients treated initially with surgery had superior functional outcomes in an analysis stratified by Frankel grade (P < 0.05). Of the ambulatory patients who underwent de novo surgery, 75% remained ambulatory and continent 30 days after treatment, whereas only 50% of those treated with radiation before surgery had similar outcomes. Conclusions. Spinal radiation before surgical decompression for metastatic spinal cord compression is associated with a significantly higher major wound complication rate. In addition, preoperative spinal irradiation might adversely affect the surgical outcome.

The efficacy of pedicle screw/plate fixation on lumbar/lumbosacral autogenous bone graft fusion in adult patients with degenerative spondylolisthesis.

A total of 18 patients with grade I or II degenerative spondylolisthesis fused three levels or fewer with autogenous bone graft were entered at three clinical sites. After 2 years, these patients were found to have a fusion rate of 89%. A statistical analysis of these results compared with those in the literature showed that patients with spondylolisthesis who underwent fusion with pedicle screw instrumentation were > 3 times more likely to fuse than comparable patients implanted without a pedicle screw/plate system. The pedicle screw/plate system used in this study was shown to be an effective method of facilitating lumbar or lumbosacral fusion with autogenous bone graft for adult patients with a primary indication of grade I or II degenerative spondylolisthesis.

Traumatic open anterior lumbosacral fracture dislocation. A report of two cases.

STUDY DESIGN Case presentation. OBJECTIVES To review the diagnosis and treatment of rare anterior lumbosacral fracture dislocations. SUMMARY OF BACKGROUND DATA The severity of closed anterior and open and closed posterior lumbosacral dislocations has been documented; however, there have been no reports of open anterior lumbosacral dislocations in the literature. Two patients are reported who experienced acute open anterior lumbosacral fracture dislocations. METHODS Review of the patient history and physical examination, radiologic review, operative techniques, and a review of the literature. RESULTS Fractures healed in both patients, with no major infections. Both patients had persistent neurologic deficits at last follow-up. CONCLUSIONS Open lumbosacral fracture dislocations are complex injuries that require diligence on the part of the surgeons involved the recognize the severity of the injury, to prevent or resolve any infectious process, to prevent further neurologic injury, and then to obtain and maintain alignment of the spine on the pelvis.

Long-term results of chymopapain injections.

A 10- to 14-year follow-up questionnaire of 146 patients treated for sciatica from a herniated nucleus pulposus by chymopapain (Discase) injection revealed a durable, satisfactory result in 66%. In the 102 patients rated as excellent or good, 5% required surgical discectomy 50-82 months after injection. One-, two-, and three-level injections were performed and the number of levels injected did not influence the success of the procedure or the subsequent need for open surgical intervention. There was no correlation shown between the incidence of job change or unemployment and the number of levels injected.

Biomechanical evaluation of the X-Stop device for surgical treatment of lumbar spinal stenosis.

Study Design: Controlled experimental study. Objective: To evaluate the kinematical effects of X-Stop device on the spinal process at the operated and the adjacent segments before and after X-Stop surgeries during various weight-bearing postures in elderly patients with lumbar spine stenosis. Summary of Background Data: The mechanism of interspinous process (ISP) devices is to directly distract the ISP of the implanted level to indirectly decompress the intervertebra foramen and spinal canal. Few studies have investigated the changes of ISP gap caused by X-Stop implantation using magnetic resonance imaging or radiography, but the effect of X-Stop surgery on the kinematics of spinous processes during functional activities is still unclear. Methods: Eight patients were tested before and, on average, 7 months after surgical implantation of the X-Stop devices using a combined computed tomography/magnetic resonance imaging and dual fluoroscopic imaging system during weight-bearing standing, flexion-extension, left-right bending, and left-right twisting positions of the torso. The shortest distances of the ISPs at the operated and the adjacent levels were measured using iterative closest point method and was dissected into vertical (gap) and horizontal (lateral translation) components. Results: At the operated levels, the shortest vertical ISP distances (gap) significantly (P<0.05) increased by 1.5 mm during standing, 1.2 mm during left twist, 1.3 mm during extension, and 1.1 mm during flexion, whereas they also increased yet not significantly (P>0.05) in right twist, left bend, and right bend after the X-Stop implantation. The lateral translations were not significantly affected. At both cephalad and caudad adjacent levels, the ISP distances (vertical and horizontal) were not significantly affected during all postures after X-Stop implantation. Conclusion: The findings of this study indicate that implantation of the X-Stop devices can effectively distract the ISP space at the diseased level without causing apparent kinematic changes at the adjacent segments during the studied postures.

Role of onlay grafting with minimal internal fixation for occipitocervical fusion in oncologic patients.

The choice of fixation for occipitocervical arthrodesis remains controversial, especially in oncologic patients who need further radiographic evaluation or postoperative radiotherapy. We studied the long-term outcome of 20 patients who underwent occipitocervical fusions using onlay corticocancellous bone graft and wiring, with postoperative halo vest immobilization. Eight of these patients had postoperative radiotherapy for spinal tumors (group I), and 12 patients had occipitocervical fusions for other pathologies that did not require postoperative radiotherapy (group II). All patients had solid arthrodeses; however, there was a difference in the average time to fusion between patients who received pre- or postoperative radiotherapy and those who did not (p = 0.11). At an average follow-up of 54.5 months (range 24-92 months) 15 of 20 patients (75%) had excellent or good outcomes. A high fusion rate can be expected with reasonable intraoperative or postoperative complications.

Epithelioid hemangioma of the spine: a case series of six patients and review of the literature.

BACKGROUND CONTEXT Epithelioid hemangioma (EH) of bone is a benign vascular tumor that can be locally aggressive. It rarely arises in the spine, and the optimum management of EH of the vertebrae is not well delineated. PURPOSE The report describes our experience treating six patients with EH of the spine in an effort to document the treatment of the rare spinal presentation. STUDY DESIGN This study is designed as a retrospective cohort study. PATIENT SAMPLE A continuous series of patients with the diagnosis of EH of the spine who presented at our institution. OUTCOME MEASURES The clinical and radiographic follow-up of the patient population is documented. METHODS The Bone Sarcoma Registry at our institution was used to obtain a list of all patients diagnosed with EH of the spine. Medical records, radiographs, and pathology reports were retrospectively reviewed in all cases. Only biopsy-proven cases were included. RESULTS The six patients included five men and one woman who ranged in age from 20 to 58 years (with an average age of 40 years). The follow-up available for all six patients ranged from 6 to 115 (average 46.8) months. All patients presented with lytic vertebral body lesions. Five patients presented with pain secondary to their tumor, and the tumor in the sixth patient was found incidentally during the workup for a herniated disc. Three patients required surgical management for instability secondary to the destructive nature of their tumors, and two other patients required emergent decompression secondary to spinal cord compression by the tumor. The sixth patient was treated expectantly after biopsy confirmation. Three patients received postoperative radiation therapy as gross tumor remained after surgery. Three patients had gross total resections and did not receive postoperative radiation. Preoperative embolization was used in four patients. One patient continued to have back pain after surgery and radiation and another continued to have ataxia after surgery and radiation. No tumor locally recurred or progressed. CONCLUSIONS Our data suggest that EH of the spine can be locally aggressive and lead to instability and cord compression. Surgery is required in such instances; however, observation should be considered in patients without instability or cord compression.

Prior abdominal surgery is associated with an increased risk of postoperative complications after anterior lumbar interbody fusion.

Study Design. Retrospective medical record review. Objective. The purpose of this study was to determine whether a history of abdominal/pelvic surgery confers an increased risk of retroperitoneal anterior approach–related complications when undergoing anterior lumbar interbody fusion. Summary of Background Data. As anterior lumbar interbody fusion gains popularity, both anterior retroperitoneal approach have become increasingly used. Methods. The records of 263 patients, who underwent infraumbilical retroperitoneal approach to the anterior aspect of the lower lumbar spine for a degenerative spine condition between 2007 and 2011 were retrospectively reviewed. Patients demographics, risk factors, preoperative diagnosis, surgical history, level of the anterior fusion, and perioperative complications were collected. Anterior retroperitoneal approach to the spine was carried out by a single general surgeon. Results. Ninety-seven patients (37%) developed at least 1 complication. Forty-nine percent of patients with a history of abdominal surgery developed a postoperative complication compared with 28% of patients without such history (RR = 1.747, P⩽ 0.001). After controlling for other factors such as age, sex, body mass index, diagnostic groups, and preoperative comorbidities (hypertension, diabetes, and smoking status), these differences remained statistically significant. When each type of complication was considered separately, there was a statistically significant difference in the incidence of general complications (RR = 2.384, P = 0.007), instrumentation-related complications (RR = 2.954, P = 0.010), and complications related to the anterior approach (RR = 1.797, P = 0.021). Conclusion. Anterior lumbar interbody fusion via a midline incision and a retroperitoneal approach was associated with 37% overall rate of complication. Patients with a history of abdominal or pelvic surgery are at a higher risk of developing general, instrumentation, and anterior approach–related complications. Level of Evidence: 4

A 34-year-old man with a destructive sacral lesion and a left gluteal mass

Presentation of Case A 34-year-old man was admitted to the hospital because of a painful left sacral and gluteal mass. There was a long history of low-back pain that was aggravated by lifting. X-ra...