Kevin W. Rolfe

Accuracy of percutaneous lumbar pedicle screw placement using the oblique or “owl's-eye” view and novel guidance technology

OBJECT This study was conducted to assess the in vivo safety and accuracy of percutaneous lumbar pedicle screw placement using the owls-eye view of the pedicle axis and a new guidance technology system that facilitates orientation of the C-arm into the appropriate fluoroscopic view and the pedicle cannulation tool in the corresponding trajectory. METHODS A total of 326 percutaneous pedicle screws were placed from L-3 to S-1 in 85 consecutive adult patients. Placement was performed using simple coaxial imaging of the pedicle with the owls-eye fluoroscopic view. NeuroVision, a new guidance system using accelerometer technology, helped align the C-arm trajectory into the owls-eye view and the cannulation tool in the same trajectory. Postoperative fine-cut CT scans were acquired to assess screw position. Medical records were reviewed for complications. RESULTS Five of 326 screws breached a pedicle cortex—all breaches were less than 2 mm—for an accuracy rate of 98.47%. Five screws violated an adjacent facet joint. All were at the S-1 superior facet and included in a fusion. No screw violated an adjacent mobile facet or disc space. There were no cases of new or worsening neurological symptoms or deficits for an overall clinical accuracy of 100%. CONCLUSIONS The owls-eye technique of coaxial pedicle imaging with the C-arm fluoroscopy, facilitated by NeuroVision, is a safe and accurate means by which to place percutaneous pedicle screws for degenerative conditions of the lumbar spine. This is the largest series reported to use the oblique or owls-eye projection for percutaneous pedicle screw insertion. The accuracy of percutaneous screw insertion with this technique meets or exceeds that of other reported clinical series or techniques.

Scoliosis and interspinous decompression with the X-STOP: prospective minimum 1-year outcomes in lumbar spinal stenosis.

BACKGROUND CONTEXT The X-STOP interspinous decompression device, as a treatment for neurogenic intermittent claudication (NIC) because of lumbar spinal stenosis (LSS), has been shown to be superior to nonoperative control treatment. Current Food and Drug Administration labeling limits X-STOP use to NIC patients with a maximum of 25° concomitant lumbar scoliosis. This value was arrived at arbitrarily by the device developers and is untested. PURPOSE To determine X-STOP utility for NIC in patients with concomitant lumbar scoliosis. STUDY DESIGN A prospective, single institution, clinical outcome study comparing patients with scoliosis with patients without scoliosis who underwent X-STOP interspinous decompression for NIC because of LSS. PATIENT SAMPLE A cohort of 179 consecutive patients, 63 with scoliosis (Cobb angle 11° or more) and 116 without scoliosis, with symptoms attributable to NIC treated between January 2006 and May 2007, were included in the study. OUTCOME MEASURES All patients completed self-reported preoperative and minimum 1-year postoperative outcome forms. Functional measures included Oswestry Disability Index (ODI), visual analog scale (VAS) pain score, and maximum walking and standing times in minutes. Three questions measured patient satisfaction: How satisfied were you with the procedure (very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied); Would you have the procedure again? (yes or no); Would you recommend the procedure to a friend? (yes or no). METHODS Before analysis, the 179 consecutive X-STOP patients were divided into three groups: Group 1 (controls without scoliosis, n=116); Group 2 (low scoliosis: 11-25°, n=41), and Group 3 (high scoliosis: 26° or more, n=22). The three groups were not statistically different for any preoperative functional scores. Groups were analyzed for pre- to postoperative functional change and level of satisfaction. Segmental scoliosis at the treated level was also analyzed. RESULTS Fifty-six percent of Group 1 and Group 2 patients, but only 18% of Group 3 patients, achieved the success criterion of an ODI improvement of 15 or more points (Group 3 the outlier, p=.004). The satisfaction rate was Group 1, 76%; Group 2, 78%; Group 3, 59% (Group 3 the outlier, p=.0001). On average, all three groups improved for each outcome: Group 1 (ODI 17.3, VAS 2.0, standing time 39 minutes, and walking time 43 minutes), Group 2 (ODI 20.0, VAS 1.9, standing time 65 minutes, and walking time 64 minutes), Group 3 (ODI 7.2, VAS 0.9, standing time 18 minutes, and walking time 16 minutes). There was no statistical relationship between any outcome and segmental scoliosis. CONCLUSIONS The outcome success rate for the X-STOP procedure to treat NIC is lower in patients with overall lumbar scoliosis more than 25° but is unaltered by segmental scoliosis at the affected level. Although patients and surgeons must be aware that the presence of more than 25° of scoliosis portends less favorable results with X-STOP implantation for NIC because of LSS, success in these patients is not precluded, and selection of treatment must be put into the context of individual patient risk and other treatment options.

Overutilization of bracing in the management of penetrating spinal cord injury from gunshot wounds.

OBJECTIVE Penetrating gunshot wounds (GSWs) to the spinal column are stable injuries and do not require spinal orthoses or bracing postinjury. Nonetheless, a high number of GSW-related spinal cord injury (SCI) patients are referred with a brace to national rehabilitation centers. Unnecessary bracing may encumber rehabilitation, create skin breakdown or pressure ulcers, and add excessive costs. The aim of this study was to confirm the stability of spinal column injuries from GSWs and quantify the overutilization rate of bracing based on long-term follow-up. METHODS This retrospective cohort study was performed at a nationally renowned rehabilitation center. In total, 487 GSW-related SCI patients were transferred for rehabilitation and identified over the last 14 years. Retrospective chart review and telephone interviews were conducted to identify patients who were braced at the initial treating institution and determine if late instability, deformity, or neurological deterioration resulted in secondary surgery or intervention. In addition, 396 unoperated patients were available for analysis after 91 patients were excluded for undergoing an initial destabilizing surgical dissection or laminectomy, thereby altering the natural history of the injury. All of these 396 patients who presented with a brace had bracing discontinued upon reaching the facility. RESULTS In total, 203 of 396 patients were transferred with a spinal brace, demonstrating an overutilization rate of 51%. No patients deteriorated neurologically or needed later surgery for spinal column deformity or instability attributable to the injury. All patients had stable injuries. The patterns of injury and severity of neurological injury did not vary between patients who were initially braced or unbraced. The average follow-up was 7.8 years (range 1-14 years) and the average age was 25 years (range 10-62 years). CONCLUSIONS The incidence of brace overutilization for penetrating GSW-related SCI was 51%. Long-term follow-up in this study confirmed that these injuries were stable and thus did not require bracing. No patients deteriorated neurologically, whether or not they were initially braced. The unnecessary use of spinal orthoses increases costs and patient morbidity. Reeducation and dissemination of this information is warranted.

Chronic Right Hand Pain

A 45-year-old seamstress presents to the clinic with a 4-year history of paresthesias of the volar right thumb, index, and middle finger with associated pain. Patient notes symptoms are worse at night. On examination, patient has decreased sensation on the volar thumb, index, and middle finger as well as the dorsal finger tips and a positive Tinel’s sign and Phalen’s test at the wrist. Strength in her abductor pollicis brevis is normal at 3/5 compared to the contralateral side and she has moderate thenar atrophy, but no hypothenar or intrinsic muscle atrophy. The hand is well perfused and there are no surgical or traumatic scars of the hand or wrist. She has no past medical history and no history of cancer.

Multiple Extremity Injuries After Motorcycle Accident

A 35-year-old male is involved in a motor vehicle accident and is brought in by paramedics complaining of severe pain in both legs and in his right arm. In the ED, the patient is awake and alert. He has an obvious deformity of his right mid-humerus. There are no open wounds in the arm. He has a noticeable wrist-drop on the right and is unable to dorsiflex the wrist or extend the metacarpophalangeal joints. Radial pulse on the right is 2+. On exam of his right leg, there is an obvious deformity of the right thigh as well as in the mid-tibia. There is a 2 cm laceration over his mid-shin, with visible bone exposed. Distal motor and sensory function in his right leg are intact, and pedal pulses are 2+. On the left he has a swollen knee with an obvious effusion. There is no tenderness or deformity in his left thigh or left lower leg. X-ray imaging confirms a right mid-shaft humerus fracture (shown below), a right femur fracture, and a right tibia and fibula fracture. X-rays of the left knee are negative.

Immediate Swelling After Trauma to the Knee

A 26-year-old otherwise healthy male presents to the clinic with right knee pain after a skiing accident 3 days ago. The patient landed awkwardly after attempting a jump. He experienced immediate right knee pain necessitating ski patrol to bring him down the mountain. The patient reports hearing a “popping” noise when landing. Shortly after he noticed swelling around his knee, but he was still able to bear weight on his leg. Today in clinic, the patient is able to ambulate with a single crutch on a slightly flexed knee without the knee buckling. On physical exam, a large effusion is present over his anterior knee. There is mild warmth and tenderness to palpation around the medial joint line. Muscle compartments in the leg are soft and pulses are 2+. Neurologic exam reveals normal motor and sensory function distal to the knee. The patient is able, but hesitant, to perform active or passive knee range of motion secondary to pain. There is increased knee laxity of 1 cm when an anterior force is applied to the tibia at 30° and 90°. There is no laxity with varus or valgus stress applied to the knee. Compression and axial rotation across the knee joint while extending it from a fully flexed position produces neither pain nor a palpable or audible snap.

Right Groin Pain and Limp

A 12-year-old African-American boy presents with right groin pain and a limp. He states that the pain is worse with walking and relieved by rest. The pain begins in his right groin and radiates to his right knee. The pain began about 1 month ago without antecedent trauma and has progressively worsened. He has no pain in any other joints or extremities. He denies any recent infections and reports no associated fevers, chills, or malaise. He participates in physical education at school, but is otherwise not involved in sports. He has no recent travel or camping trips and lives in an urban area. He takes no medications. There is no family history of joint problems. On physical examination, the patient is afebrile and appears to be moderately obese. The right lower extremity appears to be slightly externally rotated and he resists internal rotation. There is no leg length discrepancy. Neurologic and vascular exam are normal.

Spinal Column Injury at T11-T12 Causing C8 Tetraplegia Misdiagnosed as Spinal Cord Injury without Radiographic Abnormality in an Adult: A Case Report

Traumatic spinal cord injury is often assumed to occur locally as a result of an adjacent osteoligamentous disruption of the spinal column. When the spinal cord injury and the spinal column disruption are noncontiguous in location, without any imaging evidence of spinal column disruption near the cord injury, a diagnosis of spinal cord injury without radiographic abnormality (SCIWORA) or the more modern spinal cord injury without neuroradiographic abnormality (SCIWONA)1 often is made. The imaging component of SCIWONA includes magnetic resonance imaging (MRI) or other imaging beyond computed tomography (CT) or radiographs. Distraction injury mechanisms occurring without substantial local translation may cause these types of nonlocal injuries, thereby providing an adequate explanation without uncertainty. Misapplication of the SCIWORA or SCIWONA designation may lead to improper treatment. We report a case of violent osteoligamentous distraction at T11-T12 that caused spinal cord injury up to T1, resulting in complete tetraplegia at C8. An incorrect diagnosis of SCIWORA initially was applied, and, as a result, the treatment was incorrect. We present a review of the literature and mechanism, including a “taffy distraction” mechanism. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A sixty-five-year-old man was involved in a high-speed, sudden deceleration motor vehicle accident. He was extracted from the vehicle and transported to a level-I trauma center with a Glasgow Coma Score of 3. Resuscitative measures were immediately undertaken per the Advanced Trauma Life Support protocol, and full spine precautions were also taken. Complete neural-axis imaging with use of CT and MRI revealed a T11-T12 three-column distraction injury (Figs. 1-A and 1-B). Additional clinical findings included a nondisplaced left occipital condyle fracture, a hemothorax on the right, bilateral pulmonary emboli, multiple rib fractures, superior and inferior pubic rami fractures, a left acetabulum fracture, …

T2 Spinal Cord Injury Caused by Noncontiguous Traumatic C1-C2 Ligamentous Injury in a Young Child

Spinal injuries in young children involving a mechanism of distraction are often the result of a motor vehicle accident with sudden deceleration while the child is restrained in a forward-facing car seat (Fig. 1). The biomechanics of the pediatric spine, particularly in children under eight years of age, predispose to upper cervical spine injury. The atlantooccipital junction and the odontoid growth plate appear especially susceptible to distraction or distraction-flexion injuries, and rear-facing car seat regulations have been instituted in many countries to reduce the incidence of these injuries. Fig. 1 Illustration depicting flexion-distraction injury of the spine. The spinal column was unhinged at the C1-C2 level, allowing the remaining inertial energy of the head to be dissipated by the spinal cord via distraction (without translation) at a caudal noncontiguous level. The mechanism is akin to pulling taffy from two ends, with the brain suspended by the skull base of the head at one end being carried away from the car-seat shoulder anchor at the other end. The intervening neurologic tissue may stretch anywhere along its length. (Reproduced with permission from James Prinzivalli). Spinal cord injury is typically assumed to correspond to the level of spinal column disruption. This seems true for spinal column injuries with translation of the local vertebral elements and direct compression of the adjacent spinal cord, but not necessarily for distraction injury. The association of distraction-flexion C2 Salter-Harris type-I odontoid fractures with spinal cord stretch injury at the cervicothoracic junction, well away from the osteoligamentous disruption, is well described in the literature1. We report a case of atlantoaxial C1-C2 distraction injury without odontoid fracture, initially misdiagnosed as cervicothoracic spinal cord injury without radiographic abnormality (SCIWORA) causing a spinal cord injury at T2. A mechanism for the spinal cord injury occurring away from the osteoligamentous disruption and a …