Perry A. Ball

Four-level cervical corpectomy

Study Design. Retrospective analysis of 31 cases of cervical spondylotic myelopathy treated by four‐level subaxial cervical corpectomy. Objective. To determine whether extremes of anterior decompression and fusion have inordinate or unique levels of morbidity. Summary of Background Data. There is a paucity of data on experience with four‐level corpectomy. However, counsel against such surgery can be found. Materials and Methods. The records and studies of 31 consecutive cases of cervical spondylotic myelopathy, treated by four‐level corpectomy, were retrospectively analyzed. Patients in 26 cases were observed longer than 2 years. No hardware was used in the procedures. External orthosis, worn for 6 months, was a Philadelphia‐type collar in 25 patients and a halo vest in 6. Results. Three patients died within 3 weeks of surgery (9.7%). Delayed radiculopathy occurred in four patients after surgery, three had acute graft complications, and one had pseudomeningocele, for a morbidity rate of 25.8%. There was no infection or worsened myelopathy. Conclusions. No unique morbidity is associated with extremes of subaxial decompression when compared with surgery of lesser extent.

Critical care of spinal cord injury.

Study Design. Review article. Objectives. To review the pathophysiology and management of the pulmonary and hemodynamic derangements that occur after acute spinal cord injury. Summary of Background Data. Acute spinal cord injury is often associated with alterations in pulmonary and cardiovascular function that require treatment in the intensive care unit. Methods. Review of published reports. Results/Conclusion. Careful attention to the support of the pulmonary and cardiovascular systems can reduce the morbidity associated with acute spinal cord injury. Pulmonary function decreases markedly in the immediate postinjury period but improves in the subsequent weeks, allowing most patients with injury levels at C4 and below to be weaned from ventilatory support. Bradycardia and hypotension often accompany acute spinal cord injury, and management strategies are reviewed. The prophylaxis and diagnosis of thromboembolic disease are reviewed.

SPORT: Does incidental durotomy affect long-term outcomes in cases of Spinal Stenosis?

BACKGROUND Incidental durotomy is a familiar encounter during surgery for lumbar spinal stenosis. The impact of durotomy on long-term outcomes remains a matter of debate. OBJECTIVE To determine the impact of durotomy on the long-term outcomes of patients in the Spine Patient Outcomes Research Trial (SPORT). METHODS The SPORT cohort participants with a confirmed diagnosis of spinal stenosis, without associated spondylolisthesis, undergoing standard, first-time, open decompressive laminectomy, with or without fusion, were followed up from baseline at 6 weeks, and 3, 6, and 12 months and yearly thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean follow-up among all analyzed patients was 43.8 months. RESULTS Four hundred nine patients underwent first-time open laminectomy with or without fusion. Thirty-seven of these patients (9%) had an incidental durotomy. No significant differences were observed with or without durotomy in age; sex; race; body mass index; the prevalence of smoking, diabetes mellitus, and hypertension; decompression level; number of levels decompressed; or whether an additional fusion was performed. The durotomy group had significantly increased operative duration, operative blood loss, and inpatient stay. There were, however, no differences in incidence of nerve root injury, mortality, additional surgeries, or primary outcomes (Short Form-36 Bodily Pain or Physical Function scores or Oswestry Disability Index) at yearly follow-ups to 4 years. CONCLUSIONS Incidental durotomy during first-time lumbar laminectomy for spinal stenosis did not impact long-term outcomes in affected patients.

Outcomes after incidental durotomy during first-time lumbar discectomy.

OBJECT Incidental durotomy is an infrequent but well-recognized complication during lumbar disc surgery. The effect of a durotomy on long-term outcomes is, however, controversial. The authors sought to examine whether the occurrence of durotomy during surgery impacts long-term clinical outcome. METHODS Spine Patient Outcomes Research Trial (SPORT) participants who had a confirmed diagnosis of intervertebral disc herniation and were undergoing standard first-time open discectomy were followed up at 6 weeks and at 3, 6, and 12 months after surgery and annually thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean (± SD) duration of follow-up among all of the intervertebral disc herniation patients whose data were analyzed was 41.5 ± 14.5 months (41.4 months in those with no durotomy vs 40.2 months in those with durotomy, p < 0.68). The median duration of follow-up among all of these patients was 47 months (range 1-95 months). RESULTS A total of 799 patients underwent first-time lumbar discectomy. There was an incidental durotomy in 25 (3.1%) of these cases. There were no significant differences between the durotomy and no-durotomy groups with respect to age, sex, race, body mass index, herniation level or type, or the prevalence of smoking, diabetes, or hypertension. When outcome differences between the groups were analyzed, the durotomy group was found to have significantly increased operative duration, operative blood loss, and length of inpatient stay. However, there were no significant differences in incidence rates for nerve root injury, postoperative mortality, additional surgeries, or SF-36 scores for Bodily Pain or Physical Function, or Oswestry Disability Index scores at 1, 2, 3, or 4 years. CONCLUSIONS Incidental durotomy during first-time lumbar discectomy does not appear to impact long-term outcome in affected patients.

Atypical teratoid/rhabdoid tumor of the spine in an adult: case report and review of the literature

Atypical teratoid/rhabdoid tumors (AT/RTs) are rare, malignant brain tumors which occur almost exclusively in infants and young children. There have been only 17 cases of AT/RT in adults reported in the medical literature and the rarity of this tumor makes the diagnosis in adults difficult. We describe a case of an AT/RT of the spinal cord in an adult. A 43-year old woman presented with neck and left upper extremity pain. An MRI demonstrated a mass lesion in the dorsal spinal cord extending from C4 to C6. The patient underwent a C3 through C7 laminectomy. In consultation with senior pathologists at other institutions, the lesion was initially diagnosed as a rhabdoid meningioma. Molecular genetic studies revealed monosomy 22 and loss of expression of the INI1 gene in 22q11.2. Subsequently, immunohistochemical studies revealed the absence of INI1 gene expression in the malignant cells, supporting the diagnosis of AT/RT. The patient underwent three additional surgical procedures for recurrent disease throughout the neuraxis secondary to leptomeningeal spread of the tumor. Despite aggressive surgical resection, adjuvant chemotherapy and radiation therapy, the patient succumbed to the disease two and a half years after her initial presentation. An unrestricted autopsy was performed. To our knowledge, this is the first case of a spinal atypical teratoid/rhabdoid tumor in an adult fully documented with molecular, immunohistochemical, cytogenetic and autopsy findings.

Sensitivity of prevertebral soft tissue measurement at C3 for detection of cervical spine fractures and dislocations

A prevertebral soft tissue measurement exceeding 4 to 5 mm at C3 on a lateral spine radiograph is considered to be evidence of cervical spine injury. The objective of this study was to determine the sensitivity of the prevertebral soft tissue measurement at C3 in patients with proven cervical spine fractures or dislocations and to determine if this measurement correlates with the location or mechanism of injury. Consecutive patients 16 years of age or older who were admitted from July 1988 to June 1995 to a tertiary referral hospital with a discharge diagnosis of cervical spine fracture or dislocation were retrospectively studied. Patients were excluded if an interpretable lateral cervical radiograph taken within 24 hours of the injury was unavailable, medical records were unavailable or incomplete, the injury was caused by penetrating trauma or attempted hanging, or retropharyngeal air was present on the lateral radiograph. For each study patient, the earliest available lateral radiograph was obtained, and the prevertebral soft tissue measurement at the inferior aspect of C3 was recorded. All medical records and reports of imaging studies were reviewed. Two hundred thirty-two patients were identified and 21 were excluded, leaving 212 study patients. Injuries were classified as high (C1 to C2), low (C3 to C7), anterior, or posterior. For each patient the mechanism of injury was inferred from the fracture pattern according to established criteria. For all patients the sensitivity of a prevertebral soft tissue measurement at C3 of > 4 mm was 66% (95% confidence interval [CI] 59, 72). For C1 to C2 (n = 71) and C3 to C7 (n = 138) injuries, the sensitivities were 64% (95% CI 56, 78) and 64% (95% CI 56, 72), respectively. For anterior (n = 95) and posterior (n = 70) injuries the sensitivities were 64% (95% CI 54, 74) and 64% (95% CI 52, 75), respectively. There was no statistically significant difference in the prevertebral soft tissue measurement at C3 for high versus low injury, anterior versus posterior injury, or mechanism of injury. These results show that the prevertebral soft tissue measurement at C3 is an insensitive marker of cervical spine fracture or dislocation and does not correlate with the location or mechanism of injury.

Surgery for lumbar degenerative spondylolisthesis in Spine Patient Outcomes Research Trial: does incidental durotomy affect outcome?

Study Design. Retrospective review of a prospectively collected multi-institutional database. Objective. In the present analysis, we investigate the impact of incidental durotomy on outcome in patients undergoing surgery for lumbar degenerative spondylolisthesis. Summary of Background Data. Surgery for lumbar degenerative spondylolisthesis has several potential complications, one of the most common of which is incidental durotomy. The effect of incidental durotomy on outcome, however, remains uncertain. Methods. Spine Patient Outcomes Research Trial cohort participants with a confirmed diagnosis of lumbar degenerative spondylolisthesis undergoing standard first-time open decompressive laminectomy, with or without fusion, were followed from baseline at 6 weeks, at 3, 6, 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean (standard deviation [SD]) follow-up among all analyzed degenerative spondylolisthesis patients was 46.6 months (SD = 13.1) (no durotomy: 46.7 vs. had durotomy: 45.2, P = 0.49). The median (range) follow-up time among all analyzed degenerative spondylolisthesis patients was 47.6 months (SD = 2.5–84). Results. A 10.5% incidence of durotomy was detected among the 389 patients undergoing surgery. No significant differences were observed with or without durotomy in age, race, the prevalence of smoking, diabetes and hypertension, decompression level, number of levels, or whether a fusion was performed. There were no differences in incidence of nerve root injury, postoperative mortality, additional surgeries, 36-Item Short Form Health Survey (SF-36) scores of body pain or physical function, or Oswestry Disability Index at 1, 2, 3, and 4 years. Conclusion. Incidental durotomy during first-time surgery for lumbar degenerative spondylolisthesis does not appear to impact outcome in affected patients.

Variation in Outcomes Across Centers After Surgery for Lumbar Stenosis and Degenerative Spondylolisthesis in the Spine Patient Outcomes Research Trial

Study Design. Retrospective review of a prospectively collected database. Objective. To examine whether short- and long-term outcomes after surgery for lumbar stenosis (SPS) and degenerative spondylolisthesis (DS) vary across centers. Summary of Background Data. Surgery has been shown to be of benefit for both SPS and DS. For both conditions, surgery often consists of laminectomy with or without fusion. Potential differences in outcomes of these overlapping procedures across various surgical centers have not yet been investigated. Methods. Spine Patient Outcomes Research Trial cohort participants with a confirmed diagnosis of SPS or DS undergoing surgery were followed from baseline at 6 weeks, 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Baseline characteristics and short- and long-term outcomes were analyzed. Results. A total of 793 patients underwent surgery. Significant differences were found between centers with regard to patient race, body mass index, treatment preference, neurological deficit, stenosis location, severity, and number of stenotic levels. Significant differences were also found in operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and wound infection. When baseline differences were adjusted for, significant differences were still seen between centers in changes in patient functional outcome (Short Form-36 bodily pain and physical function, and Oswestry Disability Index) at 1 year after surgery. In addition, the cumulative adjusted change in the Oswestry Disability Index Score at 4 years significantly differed among centers, with Short Form-36 scores trending toward significance. Conclusion. There is a broad and statistically significant variation in short- and long-term outcomes after surgery for SPS and DS across various academic centers, when statistically significant baseline differences are adjusted for. The findings suggest that the choice of center affects outcome after these procedures, although further studies are required to investigate which center characteristics are most important.

Postoperative Mycoplasma hominis infections after neurosurgical intervention

OBJECT Mycoplasma hominis is a rare cause of infection after neurosurgical procedures. The Mycoplasma genus contains the smallest bacteria discovered to date. Mycoplasma are atypical bacteria that lack a cell wall, a feature that complicates both diagnosis and treatment. The Gram stain and some types of culture media fail to identify these organisms, and typical broad-spectrum antibiotic regimens are ineffective because they act on cell wall metabolism. Mycoplasma hominis commonly colonizes the genitourinary tract in a nonvirulent manner, but it has caused postoperative, postpartum, and posttraumatic infections in various organ systems. The authors present the case of a 17-year-old male with a postoperative intramedullary spinal cord abscess due to M. hominis and report the results of a literature review of M. hominis infections after neurosurgical procedures. Attention is given to time to diagnosis, risk factors for infection, ineffective antibiotic regimens, and final effective antibiotic regimens to provide pertinent information for the practicing neurosurgeon to diagnose and treat this rare occurrence. METHODS A PubMed search was performed to identify reports of M. hominis infections after neurosurgical procedures. RESULTS Eleven cases of postneurosurgical M. hominis infection were found. No other cases of intramedullary spinal cord abscess were found. Initial antibiotic coverage was inadequate in all cases, and diagnosis was delayed in all cases. Multiple surgical interventions were often needed. Once appropriate antibiotics were started, patients typically experienced rapid resolution of their neurological symptoms. In 27% of cases, a suspicious genitourinary source other than urinary catheterization was identified. CONCLUSIONS Postoperative M. hominis infections are rarely seen after neurosurgical procedures. They are typically responsive to appropriate antibiotic therapy. Mycoplasma infection may cause prolonged hospitalization and multiple returns to the operating room due to delay in diagnosis. Early clinical suspicion with appropriate antibiotic coverage could help prevent these significant complications.

Benign Nasal Polyposis Presenting as an Intracranial Mass: Case Report

An interesting case of benign nasal polyposis with intracranial extension and subsequent abscess formation is described. Its diagnosis and treatment are presented and the pathology is demonstrated. The literature related to this rare disease process is discussed in detail.