George B. Jacobs

Frameless stereotactic guidance for surgery of the upper cervical spine.

OBJECTIVE The goal was to evaluate and describe the use of a frameless, computed tomography-guided, stereotactic technique in complex procedures involving the craniocervical junction. METHODS Eleven procedures, including transoral odontoid resection, posterior atlantoaxial fusion with transarticular C1-C2 screw fixation, and spinal tumor resection, were performed in the preceding 26 months. In each case, frameless stereotaxy was used to plan the incision, to define resection margins, and to determine the appropriate orientation of instrumentation. RESULTS There were no intraoperative complications noted. Each patient underwent adequate resection of the pathological lesion and satisfactory placement of instrumentation. The stereotactic system provided detailed anatomic visualization, which increased the confidence of the surgeon during the procedure. The system limited the need for extensive surgical exposure, reduced fluoroscopy time, and decreased the risk of neurovascular injury. CONCLUSION Frameless stereotaxy provided the surgeon with intraoperative information regarding the extent of bone and soft tissue resection. It provided a multidimensional view of anatomic relationships in the operative field, which significantly increased surgical accuracy and safety.

Persistently electrified pedicle stimulation instruments in spinal instrumentation. Technique and protocol development.

STUDY DESIGN A prospective review was done of a new intraoperative technique developed to detect and prevent neurologic compromise during pedicle screw insertion. OBJECTIVES To describe in sufficient detail the technique of persistently electrified pedicle stimulation instruments, so that this technique will be available generally to all clinical neurophysiologists and spine surgeons; and to demonstrate the use, typical results, interpretation, and protocol of the technique. SUMMARY AND BACKGROUND DATA Fusion techniques that use pedicle instrumentation have the potential to cause nerve root injury. Several authors have proposed imaging and neurophysiologic methods to improve outcome. The present method represents a significant theoretical departure and advance from previously reported methods. METHODS All relevant instruments used during pedicle instrumentation were converted easily, inexpensively, and quickly into monopolar stimulators with appropriate stimulus voltages to identify broaches of pedicle bone via evoked-electromyograms from relevant muscle groups. RESULTS The persistently electrified pedicle stimulation instrument technique provided accurate intraoperative neurophysiologic information concerning pedicle, integrity in the patients studied. The protocol is standardized and adaptable easily, inexpensively, and quickly to most clinical applications. CONCLUSIONS The persistently electrified pedicle stimulation instrument technique described here is useful for monitoring instrumented lumbar fusion procedures. The use of this protocol may help confirm intraosseous placement of pedicle screws and prevent neurologic injury.

Disc Space Infections in Children

Intractable low back pain in children is often due to disc space infections. The clinical presentation, diagnostic workup, and treatment of four cases are presented. Symptoms often occur well before radiographic findings are evident. The diagnosis can only be made by a high degree of suspicion and repeated X-rays. Antecedent causes, such as urinary infection or intravenous administration of narcotics were lacking in this group. Fever or a preceding febrile illness was often, but not invariably, present. Percutaneous biopsies were not usually helpful. Myelography in each instance was normal. Bed rest reduced but did not alleviate the back pain. The institution of appropriate antibiotic therapy resulted in a prompt diminution of pain.

Consequences and potential problems of operating room outbursts and temper tantrums by surgeons.

Background: Anecdotal tales of colorful temper tantrums and outbursts by surgeons directed at operating room nurses and at times other health care providers, like residents and fellows, are part of the history of surgery and include not only verbal abuse but also instrument throwing and real harassment. Our Editor-in-Chief, Dr. Nancy Epstein, has made the literature review of “Are there truly any risks and consequences when spine surgeons mistreat their predominantly female OR nursing staff/colleagues, and what can we do about it?,” an assigned topic for members of the editorial board as part of a new category entitled Ethical Note for our journal. This is a topic long overdue and I chose to research it. Methods: There is no medical literature to review dealing with nurse abuse. To research this topic, one has to involve business, industry, educational institutions, compliance standards and practices, and existing state and federal laws. I asked Dr. Rosanne Wille to co-author this paper since, as the former Dean of Nursing and then Provost and Senior Vice President for Academic Affairs at a major higher educational institution, she had personal experience with compliance regulations and both sexual harassment and employment discrimination complaints, to make this review meaningful. Results: A review of the existing business practices and both state and federal laws strongly suggests that although there has not been any specific legal complaint that is part of the public record, any surgeon who chooses to act out his or her frustration and nervous energy demands by abusing co-workers on the health care team, and in this case specifically operating room personnel, is taking a chance of making legal history with financial outcomes which only an actual trial can predict or determine. Even more serious outcomes of an out-of-control temper tantrum and disruptive behavior can terminate, after multiple hearings and appeals, in adverse decisions affecting hospital privileges. Conclusions: Surgeons who abuse other health care workers are in violation of institutional bylaws and compliance regulations and create a hostile environment at work which adversely affects efficient productivity and violates specific State and Federal laws which prohibit discrimination based on race, color, sex, religion, or national origin.

Anatomy of the Brain and Skull

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