John P. Kostuik

Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes.

Study Design. A meta-analysis of surgical outcomes of cauda equina syndrome secondary to lumbar disc herniation. Objectives. To determine the relationship between time to decompression after onset of cauda equina syndrome and clinical outcome, and to identify preoperative variables that were associated with outcomes. Summary of Background Data. The timing of surgical decompression for cauda equina syndrome is controversial. Although most surgeons recommend emergent decompression, results in certain studies show that delayed surgery may provide a satisfactory outcome. Methods. A meta-analysis was performed to determine the correlation between timing of decompression and clinical outcome. One hundred four citations were reviewed, and 42 met the inclusion criteria. Preoperative and postoperative data were recorded. Length of time to surgery was broken down into five groups: less than 24 hours, 24–48 hours, 2–10 days, 11 days to 1 month, and more than 1 month. Logistic regression was used to determine the association between preoperative variables and postoperative outcomes. Results. Outcomes were analyzed in 322 patients. Preoperative chronic back pain was associated with poorer outcomes in urinary and rectal function, and preoperative rectal dysfunction was associated with worsened outcome in urinary continence. In addition, increasing age was associated with poorer postoperative sexual function. No significant improvement in surgical outcome was identified with intervention less than 24 hours from the onset of cauda equina syndrome compared with patients treated within 24–48 hours. Similarly, no difference in outcome occurred in patients treated more than 48 hours after the onset of symptoms. Significant differences, however, were found in resolution of sensory and motor deficits as well as urinary and rectal function in patients treated within 48 hours compared with those treated more than 48 hours after onset of symptoms. Conclusions. There was a significant advantage to treating patients within 48 hours versus more than 48 hours after the onset of cauda equina syndrome. A significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patientswho underwent decompression within 48 hours versus after 48 hours.

Anterior cervical fusion : Outcome analysis of patients fused with and without anterior cervical plates

The purpose of this study was to assess the role of the anterior cervical plate in the treatment of cervical spondylosis. Forty-three patients surgically treated for cervical spondylosis were reviewed. The technique for discectomy and fusion was the same for both groups (Smith-Robinson with autologous iliac crest bone graft). Group I consisted of 25 consecutive patients treated with anterior cervical discectomy, autograft fusion, and anterior cervical plate fixation (Morscher titanium hollow screw plate system). Group II consisted of 18 consecutive patients treated without plate fixation. The overall clinical results in this study were not improved with the use of anterior cervical plate fixation (Fishers exact test, p > 0.05). The fusion rate of one-level cervical fusions was not improved with anterior cervical plate fixation (Fishers exact test, p > 0.05). The overall graft complication rate (pseudoarthrosis plus delayed union plus graft collapse) in multilevel fusions was decreased with anterior cervical plate fixation (Fishers exact test, p < 0.01). The cost effectiveness and risk versus benefit of anterior cervical plate fixation in the surgical treatment of cervical spondylosis require further investigation.

Design of an intervertebral disc prosthesis.

This article presents criteria for the design of a lumbar intervertebral disc prosthesis that take into consideration issues of endurance, materials behavior, geometry, kinetics, motion constraints, fixation to bone, and safety. The criteria and design philosophies discussed are generally applicable in the synthesis of any new implant system. Specifications of the design of a disc prosthesis are presented along with an evaluation of the design based on some of the preliminary test data.

Spinal stabilization of vertebral column tumors

An analysis of indications, techniques, results of stabilization and decompression of 100 consecutive spinal tumour cases was carried out. Localized metastatic disease is best operated anteriorly. Primary malignancies are best treated with en bioc resection. Pain relief in metastatic disease is achieved by rigid stabilization. The unstable spine secondary to benign or malignant disease often requires stabilization for alleviation of pain; 132 stabilization procedures were performed in 100 patients. There were nine benign and 91 malignant tumors Including 71 metastatlc. Indications for stabilization were pathological fracture or following decompression. Anterior approaches including implant stabilization were used in those with metastatic disease limited to one to two levels or where significant kyphosls existed. Posterolateral decompression with Luque rod stabilization was indicated where disease was more widespread. In metastatlc disease acrylic cement was used both anteriorly and posteriorly together with implant stabilization. Eighty-one percent had good to excellent relief of pain; 68 patients had neurological deficits. Significant neurological return was achieved in 40% of posterior decompressions and 71% of anterior decompressions in metastatic disease. All patients with benign tumors have solid fusions. In malignant disease the use of cement provided stability without loss of fixation in 87 of 91 procedures. Complications were 4% Infection and failure of two Harrington rods without wiring, one Luque rod and two anterior constructs. The average longevity of patients treated for metastatlc disease was 11.3 months.

Anterior fixation for burst fractures of the thoracic and lumbar spine with or without neurological involvement.

This report details the use of the anterior approach for burst fractures of the thoracic and lumbar spine. The indication for dural decompression is acute neurological injury arising from significant canal intrusion. The use of anterior fixation devices, and in particular the anterior Kostuik-Harrington system, generally eliminates the necessity for a posterior approach. Anterior surgery has been performed in 80 cases for burst injuries of the thoracic and lumbar spine. Fifty-seven of these were paraparetic. While there were two cases of nonunion and 11 screw breakages, there were no early or late vascular or neurological complications. Average neurological recovery was 1.6 grades on the Frankel scale. All incomplete paraplegics recovered at least one grade. All complete paraplegics (four) failed to show any recovery.

The Incidence of Low-Back Pain in Adult Scoliosis

To date no knowledge of the incidence of scoliosis in adults and its relationship to low-back pain is available. In order to arrive at an understanding of low-back pain in adult scoliosis, a study of 5000 intravenous pyelograms was performed. The incidence of lumbar and thoracolumbar curves was 2.9%. One hundred and fifty-nine of the 189 patients found to have scoliosis were contacted. The incidence of back pain was 59% (similar to that in the general population). Back pain was subdivided into mild (44%), moderate (49%), or severe (7%). The curve was subdivided into three categories: 10-24°, 25-44°, and 45+°. Of the 82 idiopathic curves with pain, 64 were in group 1, 15 in group 2, and 3 in group 3. Forty-three percent had mild pain, 50% had moderate pain, and 7% had severe pain. As the degree of curvature increased, the severity of pain increased, especially for curves of more than 45°. Patients without back pain tended to have smaller curves. The presence of facet sclerosis correlated with a history of pain in 64%. There was a high correlation between radiologic changes at the curve apex and pain. Age bore no relationship to the incidence of pain.

Combined single stage anterior and posterior osteotomy for correction of iatrogenic lumbar kyphosis.

Fifty-four patients were treated by a standardized single stage anterior opening wedge and a posterior closing extension wedge osteotomy for back pain associated with postoperative loss of lumbar lordosis (iatrogenic flat back syndrome). Presenting complaints were fatigue, pain and a stooped posture. Etiological factors were, in descending order of frequency, distraction instrumentation with the lower end at the L5 or S1 vertebra, thoracolumbar junction kyphosis greater than 15°, especially if associated with a hypokyphotic thoracic spine, and degenerative changes above and below a previous fusion. Kostuik-Harrington Instrumentation was used anteriorly for the opening wedge and Dwyer cables and screws together with a midline plate were used posteriorly for the closing extension osteotomy. Malunion occurred in three patients, one requiring recorrection. Pain relief occurred in 48 (90%). Neurological complications occurred in two patients, one with permanent deficient. Follow-up averaged 4 years. Average preosteotomy lordosis L1–S1 was 21.5° and was restored to 49° (equal to the lordosis before the initial surgery) for an average correction of 29°, (range 24° to 63°). Prevention of this complication can be accomplished by maintaining normal lordosis at the time of initial surgery

Spinal fusions to the sacrum in adults with scoliosis.

Forty-five skeletally mature patients averaging 44.3 years of age had spinal fusions which extended to the sacrum for pain and/or progression of their scoliosis. The primary diagnosis was idiopathic scoliosis in 35 patients, congenital scoliosis in two patients, and paralytic scoliosis in eight patients. A single curve pattern was present in 41 patients and the remainder had double primary curves. Thirty-eight patients had single stage procedures and 35 of these were done posteriorly. There was an evolution in the type of posterior instrumentation used over the 12 years. Thirty-five patients (78%) had at least one significant postsurgical complication. Thirteen of 22 patients with loss of lordosis required corrective osteotomies. Other complications included pseudoarthrosis in ten patients and neurologic complications in five patients, four of which had complete recovery. Twenty-five patients required a total of 51 subsequent surgical procedures. Despite a 51 % initially poor result and a high complication rate, the final results were good or fair in 93% of the patients. This change was primarily the result of successful subsequent surgical procedures for correction of loss of lordosis and pseudoarthrosis. The adult scoliosis patient should be fused to the sacrum only if the lumbosacral disc is clearly a source of pain or the degree of pelvic obliquity makes it necessary in the paralytic curve. Every effort must be made to carefully preserve the patients lumbar lordosis. Better results were obtained by using segmental spinal fixation in the form of sublaminar wiring of double Luque rods.

Adolescent idiopathic scoliosis. Long-term effect of instrumentation extending to the lumbar spine.

We evaluated eighty-three patients in whom adolescent idiopathic scoliosis had been treated with a posterior spinal arthrodesis and Harrington instrumentation extending to the second, third, fourth, or fifth lumbar vertebra. All eighty-three patients completed a questionnaire, and fifty-five patients were also examined clinically and roentgenographically at a follow-up evaluation at an average of twelve years (range, ten to sixteen years). Twelve patients had a type-I curve; twenty-six, a type-II curve; sixteen, a type-III curve; and one, a type-IV curve, according to the classification of King et al. The preoperative Cobb angle of the primary curve averaged 60 degrees and ranged from 40 to 100 degrees. The curve was an average of 35 degrees (range, 15 to 65 degrees) at the most recent follow-up evaluation. Functional assessment with use of information from the questionnaire revealed an average spine score of 81 points (range, 18 to 99 points). On the basis of the score, thirty-five patients were considered to have had an excellent result; twenty, a good result; thirteen, a fair result; and fifteen, a poor result. Sixty-three (76 per cent) of the eighty-three patients had low-back pain compared with thirty (50 per cent) of sixty individuals who served as a control group. This difference was significant (p < 0.001; chi-square test). Eighteen patients (22 per cent) needed additional spinal procedures. Fourteen patients (17 per cent) did not think that the goals of the initial operation had been accomplished.(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior Spinal Cord Decompression for Lesions of the Thoracic and Lumbar Spine, Techniques, New Methods of Internal Fixation Results

Seventy-nine patients, 51 with a fresh neurologic deficit, underwent anterior spinal cord decompression, block bone grafting and anterior internal fixation. AO plates were used in nine patients, Dwyer cables in 15, anterior Harrington systems in 20, and solid Hall rods with Dwyer screws in 23. Cases included 13 tumors (six metastatic, five primary malignant, two benign), 15 late kyphotics (13 congenital and two old tuberculosis), 15 pyogenic (nontuberculous) infections, 32 fractures and four thoracic discs. Levels of decompression were from T5 to L5 with the majority (23) at L1. The neurologic deficit improved in 100% of those with incomplete paraplegia, and was graded according to the Frankel classification. None was made worse. Surgical indications were: progressive neurologic deficit in 51 patients, tumors in 13, correction of deformity in 55, failure of infection to respond to conservative measures in 15, cachexia in nine, (many patients had more than one indication). Bone grafts included 11 rib grafts, 24 block iliac grafts with ribs and 44 iliac block grafts. Complications included three nonunions, two common iliac vein lacerations, one death (pulmonary) and two post-thoractomy syndrome. The more recent use of an anterior Harrington distraction system allows for greater correction of kyphotic deformities and more rigid internal fixation which in time allows for early ambulation in a brace. Supplementary posterior fixation is generally no longer necessary except where more than one vertebral body is resected.