Robert F. Heary

Gunshot wounds to the spine

BACKGROUND CONTEXTnThe incidence of violent crimes has risen over the past decade. With it, gunshot injuries have become increasingly more common in the civilian population. Among the most devastating injuries are gunshot wounds to the spine.nnnPURPOSEnThe purpose of this article is to provide a thorough review of the pathomechanics, diagnosis and treatment of gunshot wounds to the spine.nnnSTUDY DESIGN/SETTINGnLiterature review article.nnnCONCLUSIONSnTreatment of gunshot spine fractures differs from other mechanisms. Fractures are usually inherently stable and rarely require stabilization. In neurologically intact patients, there are few indications for surgery. Evidence of acute lead intoxication, an intracanal copper bullet or new onset neurologic deficit can justify operative decompression and/or bullet removal. Overzealous laminectomy can destabilize the spine and lead to late postoperative deformity. For complete and incomplete neural deficits at the cervical and thoracic levels, operative decompression is of little benefit and can lead to higher complication rates than nonsurgically managed patients. With gunshots to the T12 to L5 levels, better motor recovery has been reported after intracanal bullet removal versus nonoperative treatment. The use of steroids for gunshot paralysis has not improved the neurologic outcome and has resulted in a greater frequency of nonspinal complications. Although numerous recommendations exist, 7 to 14 days of broad-spectrum antibiosis has lead to the lowest rates of infection after transcolonic gunshots to the spine.

Steroids and gunshot wounds to the spine.

OBJECTIVEnThe second National Acute Spinal Cord Injury Study demonstrated that there were neurological benefits from spinal cord injury doses of methylprednisolone for blunt spinal cord injuries. In this review, we examined the relative risk/benefit ratio of intravenously treating spinal gunshot wound victims with steroids.nnnMETHODSnA retrospective review was conducted of 254 consecutive patients who were treated between 1979 and 1994 for gunshot wounds to the spine (C1-L1) and a spinal cord injury. Three subgroups were established based on the administration of the steroids methylprednisolone (National Acute Spinal Cord Injury Study 2 protocol), dexamethasone (initial dose, 10-100 mg), and no steroids. All patients who received steroids were initially treated at another hospital and then transferred. No patients received steroids at our institution. The data analyzed included neurological outcome and infectious and noninfectious complications.nnnRESULTSnNo statistically significant neurological benefits were demonstrable from the use of steroids (methylprednisolone, dexamethasone). Infectious complications were increased in both groups receiving steroids (not statistically significant). Gastrointestinal complications were significantly increased in the dexamethasone group (P = 0.021), and pancreatitis was significantly increased in the methylprednisolone group (P = 0.040). The mean duration of follow-up was 56.3 months.nnnCONCLUSIONnIn this retrospective, nonrandomized review, no neurological benefits were detectable from intravenously administered steroids after a gunshot wound to the spine. Both infectious and noninfectious complication rates were higher in the groups receiving steroids. Patients who sustain a spinal cord injury secondary to a gunshot wound to the spine should not be treated with steroids until the efficacy of such treatment is proven in a controlled study.

Candidal Pituitary Abscess: Case Report

We report a case of a culture-proven intrasellar Candida albicans abscess. A 36-year-old woman presented with a history of headaches, menstrual irregularities, and mild symptoms of diabetes insipidus. She was neurologically intact at the time of a transsphenoidal surgery for a presumed pituitary adenoma. An extensive work-up revealed that although the patient was seronegative for human immunodeficiency virus, she was immunocompromised with a T-cell dysfunction. Fungal abscesses of the pituitary gland have rarely been reported. This is the first documented case of a patient who is seronegative for human immunodeficiency virus who becomes infected by an ordinarily innocuous fungus, Candida albicans.

“en-bloc” vertebrectomy in the mobile lumbar spine

BACKGROUNDnPrimary tumors of the vertebral bodies have previously been treated with total or subtotal excision in a piecemeal fashion (intralesional excision). Radiation therapy has been used to help control tumor growth. Recurrence rates with an intralesional, piecemeal removal of vertebral tumors have been unacceptably high. This study describes a method to excise a lumbar vertebra en-bloc, and in the process, to perform a marginal (extralesional) resection of a primary tumor of the mobile lumbar spine that allows for a potential surgical cure.nnnMETHODSnA combined posterior-anterior procedure allows for an extralesional, marginal resection of the tumor and the involved vertebra. All posterior bony elements, including the pedicles and the adjacent intervertebral discs, are removed via a posterior approach. An anterior, retroperitoneal approach is then used to remove the vertebral body/tumor as a single specimen. The nerve roots at the involved levels are spared and the spine is instrumented and fused both posteriorly and anteriorly.nnnRESULTSnThree patients successfully had combined posterior-anterior resections of lumbar vertebral chordomas. No permanent neurological complications occurred. Overall morbidity of the procedure was acceptable. At 31-month follow-up, no tumor recurrence has been detected.nnnCONCLUSIONSnEn-bloc resection of a primary vertebral tumor of the lumbar spine is technically demanding, but potentially curative. The alternative approaches-intralesional excision, radiation therapy, or a combination-are unable to cure these tumors. Long-term, 10-year follow-up will be necessary to confirm whether this en-bloc approach provides a surgical cure.

Decision making in adult deformity.

SPINAL DEFORMITY AFFECTS adults and adolescents in different ways. Adult deformity patients are skeletally mature and tend to have relatively fixed curves, whereas adolescent patients are skeletally immature with flexible curves. As a result, adult patients typically present with back pain and neurological concerns, whereas adolescents present with cosmetic complaints. The goals of surgery on the adult deformity patient are to treat pain and relieve neurological problems while maintaining or achieving three-dimensional balance. The absolute degree of coronal curve correction in an adult deformity patient is less important than maintaining good sagittal balance. Issues that must be addressed in the preoperative decision-making process include the approach to the surgery, the timing of the surgery, and the location of the end of the construct. Twenty years ago, anteroposterior surgery was the most common procedure used for adults with fixed curves; however, recent advances in technology and techniques have led to more frequent use of purely posterior approaches. The posterior approach allows for greater curve correction owing to two major advances in the surgical method: osteotomy techniques, which release fixed deformities, and pedicle screw instrumentation in the thoracolumbar spine, which achieves greater curve correction with fewer levels of fixation. The optimal timing of surgery and the levels to be treated remain open to debate. Each adult patients treatment must be individualized to achieve the best coronal correction possible while maintaining sagittal balance to preserve the three-dimensional balance of the spine.

Candidal Pituitary Abscess

We report a case of a culture-proven intrasellar Candida albicans abscess. A 36-year-old woman presented with a history of headaches, menstrual irregularities, and mild symptoms of diabetes insipidus. She was neurologically intact at the time of a transsphenoidal surgery for a presumed pituitary adenoma. An extensive work-up revealed that although the patient was seronegative for human immunodeficiency virus, she was immunocompromised with a T-cell dysfunction. Fungal abscesses of the pituitary gland have rarely been reported. This is the first documented case of a patient who is seronegative for human immunodeficiency virus who becomes infected by an ordinarily innocuous fungus, Candida albicans.

Bracing for scoliosis.

Bracing is the oldest treatment known for scoliotic spinal deformity. The relative advantages to the use of bracing have been directly related to the etiology of the deformity and the flexibility of the spine at the time that a decision is made regarding the use of a brace. In skeletally immature patients with adolescent idiopathic scoliosis, the advantages to bracing are clear. In many instances, prompt recognition and appropriate bracing can arrest the progression of this form of deformity, and, in so doing, the need for any surgery may be avoided completely. On the other hand, in skeletally mature adult deformity patients, bracing has almost no proven role in affecting the natural history of the disease. Likewise, infantile and congenital scoliosis routinely requires surgical correction to prevent curve progression. Lastly, although many surgeons use bracing in the postoperative management of patients with spinal deformity, the benefits of postoperative bracing remain debatable. By far, the best indication for bracing is treatment of the skeletally immature adolescent patient with an idiopathic flexible curve of less than 45 degrees magnitude.

Stackable carbon fiber cages for thoracolumbar interbody fusion after corpectomy: long-term outcome analysis.

BACKGROUND:Reconstruction of the thoracolumbar spine after corpectomy is a challenge for fractures, infections, and tumors. OBJECTIVE:To analyze fusion rates, clinical outcomes, and the percent of vertebral body coverage achieved by using stackable carbon fiber–reinforced polyetheretherketone cages in thoracolumbar corpectomies, and to measure the actual size of the cages and compare this measurement with the size of the vertebra(e) replaced by the cage. METHODS:A retrospective study of 40 patients who underwent thoracolumbar corpectomies was performed. Preoperative imaging included plain films, computed tomography scans, and magnetic resonance imaging. Postoperatively, plain films and computed tomography scans were obtained, and the width of decompression and cross-sectional area of the cage were measured. The ratio of the area of the cage to the calculated area of the replaced vertebral body was used to determine the percent of vertebral body coverage. RESULTS:The mean follow-up period was 43 months. Successful fusion was observed in 39 patients. One patient experienced cage subsidence with kyphosis. One additional patient incurred a neurological complication that was corrected without long-term consequence. The mean correction of sagittal alignment was 10°, and the mean width of bony decompression was 20 mm. The mean ratio of the area of the carbon fiber cage to the area of the resected vertebral body was 60%. CONCLUSION:Stackable carbon fiber cages are effective devices for achieving thoracolumbar fusions. No failures of the cages occurred over long-term follow-up. Excellent clinical and radiographic results were achieved by covering a mean of 60% of the vertebral body with the cage.

Rapid bony destruction with pyogenic vertebral osteomyelitis

We report the case of a previously healthy woman who had an extremely rapid progression of pyogenic vertebral osteomyelitis. The plain film radiographs from 1 month before admission, from the time of admission, and from her 1 year follow-up are presented. Although it is a well known fact that pyogenic vertebral osteomyelitis can evolve rapidly and that the radiographic images often lag behind the clinical symptoms, it is rare to find a case with such clear radiographic documentation. A film that was interpreted as having mild arthritic changes, 1 month before admission, progressed to one that demonstrates severe bony destruction with a kyphotic angulation of 90 degrees. The current methods of diagnosis and treatment of pyogenic vertebral osteomyelitis are reviewed.

The Use of Stem Cells’ Hematopoietic Stimulating Factors Therapy Following Spinal Cord Injury

Spinal cord injury (SCI) remains one of the most devestating conditions in medicine, particularily due to the loss of productive life years and the high economic burden it places on our society. There are limited therapeutic options available to reduce the morbidity and mortality related to SCI. However, recent work with stem cells in repairing SCI appears to be promising, making this one of the most exciting frontiers in medicine.A brief review of the mechanisms of SCI is presented. Stem cells from a variety of sources have shown effectiveness in improving motor function after SCI in animals. The pre-clinical use of stem cells in SCI and methods of delivery are discussed. The potential use of granulocyte-colony stimulating factor (G-CSF) to increase the number of stem cells engrafting at the site of injury in order to improve neurological and motor function recovery following SCI is introduced.G-CSF, through stimulation of lymphohemopoietic stem cells in peripheral blood, can potentially cause repopulation of the SCI region with neural progenitor cells. This allows for improved functional outcomes. More pre-clinical and translational research exploring this possibility is required.