Rex A.W. Marco

Thoracolumbar Burst Fractures Treated with Posterior Decompression and Pedicle Screw Instrumentation Supplemented with Balloon-Assisted Vertebroplasty and Calcium Phosphate Reconstruction

BACKGROUND The treatment of unstable thoracolumbar burst fractures with short-segment posterior spinal instrumentation without anterior column reconstruction is associated with a high rate of screw breakage and progressive loss of reduction. The purpose of the present study was to evaluate the functional, neurologic, and radiographic results following transpedicular, balloon-assisted fracture reduction with anterior column reconstruction with use of calcium phosphate bone cement combined with short-segment posterior instrumentation and a laminectomy. METHODS A consecutive series of thirty-eight patients with an unstable thoracolumbar burst fracture with or without neurologic deficit were managed with transpedicular, balloon-assisted fracture reduction, calcium phosphate bone cement reconstruction, and short-segment spinal instrumentation from 2002 to 2005. Twenty-eight of the thirty-eight patients were followed for a minimum of two years. Demographic data, neurologic function, segmental kyphosis, the fracture severity score, canal compromise, the Short Form-36 score, the Oswestry Disability Index score, and treatment-related complications were evaluated prospectively. RESULTS All thirteen patients with incomplete neurologic deficits had improvement by at least one Frankel grade. The mean kyphotic angulation improved from 17 degrees preoperatively to 7 degrees at the time of the latest follow-up, and the loss of vertebral body height improved from a mean of 42% preoperatively to 14% at the time of the latest follow-up. Screw breakage occurred in two patients, and pseudarthrosis occurred in one patient. CONCLUSIONS The present study demonstrates that excellent reduction of unstable thoracolumbar burst fractures with and without associated neurologic deficits can be maintained with use of short-segment instrumentation and a transpedicular balloon-assisted reduction combined with anterior column reconstruction with calcium phosphate bone cement performed through a single posterior incision. The resultant circumferential stabilization combined with a decompressive laminectomy led to maintained or improved neurologic function in all patients with neurologic deficits, with a low rate of instrumentation failure and loss of correction.

The Effect of Compressive Axial Preload on the Flexibility of the Thoracolumbar Spine

Study Design: An in vitro flexibility study of the human thoracolumbar spine under compressive preload. Objective. To attain kinematics descriptive of the thoracolumbar spine in vitro by applying a pure bending moment under a range of physiologic compressive preloads. Summary of Background Data. Many studies on the mechanical behavior of the spine under pure moment have been conducted; however, little is known regarding variations in the range of motion of the thoracolumbar spine attributable to simulated body weight and other physiologic load conditions. Methods. Five fresh human cadaveric thoracolumbar spine specimens (T9–L3) were used. Five compressive axial preloads ranging from 75 to 975 N were applied to each specimen along the spinal curvature through four adjustable brackets attached to each vertebral body. Flexibility measurements were taken by applying a maximum of 5 Nm pure bending moment to the specimen in flexion and extension. The flexibilities in flexion and extension for each loading case were compared. Results. The thoracolumbar spine supported compressive preloads as much as 975 N without damage or instability in the sagittal plane when the preload was applied along the natural curvature of the spine through estimated centers of rotation. The flexibility in bending (flexion/extension) of the ligamentous thoracolumbar spine decreased with increasing compressive preload. Conclusion. A higher bending stiffness was reached after the compressive load exceeded 500 N. Such knowledge could be used to establish better testing guidelines for implant evaluation and more realistic loading conditions.

Osteochondroma of the sacrum: a case report and review of the literature.

Study Design. A case report and review of the literature. Objectives. To describe the en bloc excision and postoperative outcome of an osteochondroma of the sacrum compressing the neural elements, as well as review the literature on solitary osteochondroma involving the sacrum. Summary of Background Data. Osteochondroma is the most common primary benign bone tumor. However, this tumor rarely involves the spine and even more rarely involves the sacrum. To the best of our knowledge, en bloc excision of a solitary osteochondroma of the sacrum has not been previously reported. Methods. An 11-year-old male presented with disabling radicular pain in the right lower extremity. Radiologic studies showed a lesion occurring from the sacral lamina that was compressing the S2 nerve root. The tumor was excised en bloc through a posterior approach. The cavitary defect within the sacrum was reconstructed with crushed cancellous allograft and demineralized bone matrix putty. A literature review of solitary sacral osteochondroma was conducted of the English-based medical literature. Results. Histologic studies showed the tumor to be an osteochondroma. After surgery, pain was completely relieved, and neurologic function was normal. At the last follow-up, the sacroiliac joint remained intact, and there was no evidence of local recurrence. A literature review revealed 4 previous cases addressing osteochondroma of the sacrum. Conclusions. Osteochondroma is a rare primary benign bone tumor that can occur in the sacrum. Local contamination and, therefore, the likelihood of local recurrence, are decreased when an en bloc, as opposed to an intralesional, excision is performed.

En bloc excisions of chordomas in the cervical spine: review of five consecutive cases with more than 4-year follow-up.

Study Design. Retrospective case series of five consecutive patients. Objective. To determine the oncological outcomes and morbidity rates after en bloc excisions of cervical chordomas. Summary of Background Data. Studies have demonstrated that en bloc surgical excision of chordoma with negative margins results in improved local disease control and survival compared with intralesional resections. Chordomas arising from the cervical spine are rare and they present unique challenges for en bloc tumor excision. We present a series of five consecutive cases of cervical chordoma managed with en bloc tumor excision, which represents one of the largest surgical experiences of cervical chordomas reported to date. Methods. A retrospective review of our institutional spine tumor database identified five consecutive patients who underwent en bloc tumor excision for cervical spine chordoma from 2000 to 2007. We analyze their surgical margins, perioperative complications, tumor recurrence rate, and survival. Results. Our review demonstrated that dysphagia and cervicalgia were the most common presenting symptoms for cervical chordoma. The mean age of diagnosis in this cohort was 52.4 years and our mean follow-up is 54.7 months. All five patients required multistage procedures to achieve en bloc tumor excision. Independent analysis of the surgical margins by the pathologists revealed that marginal en bloc excisions were achieved in all five patients. Our 30-day perioperative complication was significant for one case of transient radiculopathy with paresis and one wound infection. Other long-term complications included three cases with pseudoarthrosis with instrumentation failures requiring surgical revisions. There were no neurological or cerebrovascular complications. The mean disease-free survival after en bloc spondylectomy for cervical chordoma was 84.2 months in this cohort. Conclusion. En bloc excision of chordoma, whether wide or marginal, is the most ideal for treatment to prolong disease-free survival. En bloc excisions of chordomas in the cervical spine are technically complex procedures but can be performed with acceptable safety and perioperative morbidity.Retrospective case series of five consecutive patients. To determine the oncological outcomes and morbidity rates after en bloc excisions of cervical chordomas. Studies have demonstrated that en bloc surgical excision of chordoma with negative margins results in improved local disease control and survival compared with intralesional resections. Chordomas arising from the cervical spine are rare and they present unique challenges for en bloc tumor excision. We present a series of five consecutive cases of cervical chordoma managed with en bloc tumor excision, which represents one of the largest surgical experiences of cervical chordomas reported to date. A retrospective review of our institutional spine tumor database identified five consecutive patients who underwent en bloc tumor excision for cervical spine chordoma from 2000 to 2007. We analyze their surgical margins, perioperative complications, tumor recurrence rate, and survival. Our review demonstrated that dysphagia and cervicalgia were the most common presenting symptoms for cervical chordoma. The mean age of diagnosis in this cohort was 52.4 years and our mean follow-up is 54.7 months. All five patients required multistage procedures to achieve en bloc tumor excision. Independent analysis of the surgical margins by the pathologists revealed that marginal en bloc excisions were achieved in all five patients. Our 30-day perioperative complication was significant for one case of transient radiculopathy with paresis and one wound infection. Other long-term complications included three cases with pseudoarthrosis with instrumentation failures requiring surgical revisions. There were no neurological or cerebrovascular complications. The mean disease-free survival after en bloc spondylectomy for cervical chordoma was 84.2 months in this cohort. En bloc excision of chordoma, whether wide or marginal, is the most ideal for treatment to prolong disease-free survival. En bloc excisions of chordomas in the cervical spine are technically complex procedures but can be performed with acceptable safety and perioperative morbidity.

Delayed presentation of cervical ligamentous instability without radiologic evidence.

Study Design. A case of delayed presentation of unstable cervical ligamentous injury without radiologic evidence is presented. Objectives. To report a rare case of delayed presentation of cervical ligamentous injury without radiologic evidence, and to discuss diagnosis, initial management, and techniques of operative stabilization. Summary of Background Data. The literature is reviewed. Methods. A 48-year-old man who sustained a nondisplaced unilateral C6 pillar fracture with no radiologic evidence of ligamentous injury returned for follow-up with radicular pain and bilateral perched facets at C5–C6. Results. Closed reduction of the cervical subluxation was performed via cervical traction, and subsequent surgical stabilization was undertaken with anterior cervical discectomy and instrumented arthrodesis of C5–C6 with structural interbody autograft. The patient wore a cervical brace for 6 weeks after surgery, and progressed to a stable fusion with pain resolution and no neurologic sequelae. Conclusions. This is a rare reported case of delayed presentation of an unstable ligamentous injury in a nondisplaced cervical pillar fracture without initial radiologic evidence of instability. If any reason to suspect ligamentous injury exists, workup with upright cervical lateral radiographs, flexion/extension radiographs, or magnetic resonance imaging should be obtained. Awake, closed reduction with cervical traction followed by surgical stabilization with an anterior discectomy and instrumented arthrodesis with structural autograft achieved stable fixation.

En bloc excisions of chordomas in the cervical spine

Study Design. Retrospective case series of five consecutive patients. Objective. To determine the oncological outcomes and morbidity rates after en bloc excisions of cervical chordomas. Summary of Background Data. Studies have demonstrated that en bloc surgical excision of chordoma with negative margins results in improved local disease control and survival compared with intralesional resections. Chordomas arising from the cervical spine are rare and they present unique challenges for en bloc tumor excision. We present a series of five consecutive cases of cervical chordoma managed with en bloc tumor excision, which represents one of the largest surgical experiences of cervical chordomas reported to date. Methods. A retrospective review of our institutional spine tumor database identified five consecutive patients who underwent en bloc tumor excision for cervical spine chordoma from 2000 to 2007. We analyze their surgical margins, perioperative complications, tumor recurrence rate, and survival. Results. Our review demonstrated that dysphagia and cervicalgia were the most common presenting symptoms for cervical chordoma. The mean age of diagnosis in this cohort was 52.4 years and our mean follow-up is 54.7 months. All five patients required multistage procedures to achieve en bloc tumor excision. Independent analysis of the surgical margins by the pathologists revealed that marginal en bloc excisions were achieved in all five patients. Our 30-day perioperative complication was significant for one case of transient radiculopathy with paresis and one wound infection. Other long-term complications included three cases with pseudoarthrosis with instrumentation failures requiring surgical revisions. There were no neurological or cerebrovascular complications. The mean disease-free survival after en bloc spondylectomy for cervical chordoma was 84.2 months in this cohort. Conclusion. En bloc excision of chordoma, whether wide or marginal, is the most ideal for treatment to prolong disease-free survival. En bloc excisions of chordomas in the cervical spine are technically complex procedures but can be performed with acceptable safety and perioperative morbidity.Retrospective case series of five consecutive patients. To determine the oncological outcomes and morbidity rates after en bloc excisions of cervical chordomas. Studies have demonstrated that en bloc surgical excision of chordoma with negative margins results in improved local disease control and survival compared with intralesional resections. Chordomas arising from the cervical spine are rare and they present unique challenges for en bloc tumor excision. We present a series of five consecutive cases of cervical chordoma managed with en bloc tumor excision, which represents one of the largest surgical experiences of cervical chordomas reported to date. A retrospective review of our institutional spine tumor database identified five consecutive patients who underwent en bloc tumor excision for cervical spine chordoma from 2000 to 2007. We analyze their surgical margins, perioperative complications, tumor recurrence rate, and survival. Our review demonstrated that dysphagia and cervicalgia were the most common presenting symptoms for cervical chordoma. The mean age of diagnosis in this cohort was 52.4 years and our mean follow-up is 54.7 months. All five patients required multistage procedures to achieve en bloc tumor excision. Independent analysis of the surgical margins by the pathologists revealed that marginal en bloc excisions were achieved in all five patients. Our 30-day perioperative complication was significant for one case of transient radiculopathy with paresis and one wound infection. Other long-term complications included three cases with pseudoarthrosis with instrumentation failures requiring surgical revisions. There were no neurological or cerebrovascular complications. The mean disease-free survival after en bloc spondylectomy for cervical chordoma was 84.2 months in this cohort. En bloc excision of chordoma, whether wide or marginal, is the most ideal for treatment to prolong disease-free survival. En bloc excisions of chordomas in the cervical spine are technically complex procedures but can be performed with acceptable safety and perioperative morbidity.

en Bloc : Review of Five Consecutive Cases With More Than 4-year Follow-up Excisions of Chordomas in the Cervical Spine: Review of Five Consecutive Cases With More Than 4-year Follow-up

Study Design. Retrospective case series of five consecutive patients. Objective. To determine the oncological outcomes and morbidity rates after en bloc excisions of cervical chordomas. Summary of Background Data. Studies have demonstrated that en bloc surgical excision of chordoma with negative margins results in improved local disease control and survival compared with intralesional resections. Chordomas arising from the cervical spine are rare and they present unique challenges for en bloc tumor excision. We present a series of five consecutive cases of cervical chordoma managed with en bloc tumor excision, which represents one of the largest surgical experiences of cervical chordomas reported to date. Methods. A retrospective review of our institutional spine tumor database identified five consecutive patients who underwent en bloc tumor excision for cervical spine chordoma from 2000 to 2007. We analyze their surgical margins, perioperative complications, tumor recurrence rate, and survival. Results. Our review demonstrated that dysphagia and cervicalgia were the most common presenting symptoms for cervical chordoma. The mean age of diagnosis in this cohort was 52.4 years and our mean follow-up is 54.7 months. All five patients required multistage procedures to achieve en bloc tumor excision. Independent analysis of the surgical margins by the pathologists revealed that marginal en bloc excisions were achieved in all five patients. Our 30-day perioperative complication was significant for one case of transient radiculopathy with paresis and one wound infection. Other long-term complications included three cases with pseudoarthrosis with instrumentation failures requiring surgical revisions. There were no neurological or cerebrovascular complications. The mean disease-free survival after en bloc spondylectomy for cervical chordoma was 84.2 months in this cohort. Conclusion. En bloc excision of chordoma, whether wide or marginal, is the most ideal for treatment to prolong disease-free survival. En bloc excisions of chordomas in the cervical spine are technically complex procedures but can be performed with acceptable safety and perioperative morbidity.Retrospective case series of five consecutive patients. To determine the oncological outcomes and morbidity rates after en bloc excisions of cervical chordomas. Studies have demonstrated that en bloc surgical excision of chordoma with negative margins results in improved local disease control and survival compared with intralesional resections. Chordomas arising from the cervical spine are rare and they present unique challenges for en bloc tumor excision. We present a series of five consecutive cases of cervical chordoma managed with en bloc tumor excision, which represents one of the largest surgical experiences of cervical chordomas reported to date. A retrospective review of our institutional spine tumor database identified five consecutive patients who underwent en bloc tumor excision for cervical spine chordoma from 2000 to 2007. We analyze their surgical margins, perioperative complications, tumor recurrence rate, and survival. Our review demonstrated that dysphagia and cervicalgia were the most common presenting symptoms for cervical chordoma. The mean age of diagnosis in this cohort was 52.4 years and our mean follow-up is 54.7 months. All five patients required multistage procedures to achieve en bloc tumor excision. Independent analysis of the surgical margins by the pathologists revealed that marginal en bloc excisions were achieved in all five patients. Our 30-day perioperative complication was significant for one case of transient radiculopathy with paresis and one wound infection. Other long-term complications included three cases with pseudoarthrosis with instrumentation failures requiring surgical revisions. There were no neurological or cerebrovascular complications. The mean disease-free survival after en bloc spondylectomy for cervical chordoma was 84.2 months in this cohort. En bloc excision of chordoma, whether wide or marginal, is the most ideal for treatment to prolong disease-free survival. En bloc excisions of chordomas in the cervical spine are technically complex procedures but can be performed with acceptable safety and perioperative morbidity.