Journal of neurosurgery. Spine
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Gunshot wounds (GSWs) to the cervical spine have been examined in a limited number of case series, and operative management of this traumatic disease has been sparsely discussed. The current literature supports and the authors hypothesize that patients without neurological deficit need neither surgical fusion nor decompression. Patients with GSWs and neurological deficits, however, pose a greater management challenge. The authors have compiled the experience of the R Adams Cowley Shock Trauma Center in Baltimore, Maryland, over the past 12 years, creating the largest series of such injuries, with a total number of 40 civilian patients needing neurosurgical evaluation. The current analysis examines presenting bone injury, surgical indication, presenting neurological examination, and neurological outcome. In this study, the authors characterize the incidence, severity, and recovery potential of cervical GSWs. The rate of unstable fractures requiring surgical intervention is documented. A detailed discussion of surgical indications with a treatment algorithm for cervical instability is offered. ⋯ Spinal cord injury from GSWs often results in severe neurological deficits. In this series, 30% of these patients with deficits required intervention for instability. This is the first series that thoroughly documents AIS improvement in this patient population. Adherence to the proposed treatment algorithm may optimize neurological outcome and spine stability.
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A number of imaging techniques have been introduced to minimize the risk of pedicle screw placement. Intraoperative CT has been recently introduced to assist in spinal instrumentation. The aim of this study was to study the effectiveness of intraoperative CT in enhancing the safety and accuracy of pedicle screw placement. ⋯ The authors describe one of the first North American experiences using intraoperative CT scanning to confirm the placement of pedicle screws. Compared with a similar cohort of patients from their institution who had pedicle screws inserted via the free-hand technique with postoperative CT, the authors found that the intraoperative CT lowers the threshold for pedicle screw revision, resulting in a statistically higher rate of screw revision in the thoracic and lumbar spine (p < 0.0001). During their 2.5-year experience with the intraoperative CT, the authors did not find a reduction in rates of reoperation for misplaced pedicle screws.
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Multicenter Study
Outcomes following attempted en bloc resection of cervical chordomas in the C-1 and C-2 region versus the subaxial region: a multiinstitutional experience.
Chordomas involving the mobile spine are ideally managed via en bloc resection with reconstruction to optimize local control and possibly offer cure. In the cervical spine, local anatomy poses unique challenges, limiting the feasibility of aggressive resection. The authors present a multi-institutional series of 16 cases of cervical chordomas removed en bloc. Particular attention was paid to clinical outcome, complications, and recurrence. In addition, outcomes were assessed according to position of tumor at the C1-2 level versus the subaxial (SA) spine (C3-7). ⋯ Compared with en bloc resection of chordomas involving the subaxial cervical spine, en bloc resection of chordomas involving the upper cervical spine (C1-2) is associated with poorer outcomes, such as less favorable margins, higher rates of complications, and increased tumor recurrence. Data from this cohort do not support a statistically significant difference in survival for patients with C1-2 versus subaxial disease, but larger studies are needed to further study survival differences.
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Cervical arthroplasty has been accepted as a viable option for surgical management of cervical spondylosis or degenerative disc disease (DDD). The best candidates for cervical arthroplasty are young patients who have radiculopathy caused by herniated disc with competent facet joints. However, it remains uncertain whether arthroplasty is equally effective for patients who have cervical myelopathy caused by DDD. The aim of this study was to compare the outcomes of arthroplasty for patients with cervical spondylotic myelopathy (CSM) and patients with radiculopathy without CSM. ⋯ The severity of myelopathy improves after cervical arthroplasty in patients with CSM caused by DDD. At 3-year follow-up, the clinical and radiographic outcomes of cervical arthroplasty in DDD patients with CSM are similar to those patients who have only cervical radiculopathy. Therefore, cervical arthroplasty is a viable option for patients with CSM caused by DDD who require anterior surgery. However, comparison with the standard surgical treatment of anterior cervical discectomy and fusion is necessary to corroborate the outcomes of arthroplasty for CSM.
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Cervical laminoplasty is an effective procedure for decompressing the spinal cord at multiple levels, but restriction of neck motion is one of the well-known complications of the procedure. Although many authors have reported on cervical range of motion (ROM) after laminoplasty, they have focused mainly on 2D flexion and extension on lateral radiographs, not on 3D motion (including coupled motion) nor on precise intervertebral motion. The purpose of this study was to clarify the 3D kinematic changes in the cervical spine after laminoplasty performed to treat cervical spondylotic myelopathy. ⋯ In this first accurate documentation of 3D segmental kinematic changes after laminoplasty, Oc-T1 ROM, which represented total cervical ROM, did not change significantly during either flexion-extension or rotation by 6 months after laminoplasty despite a significant decrease in C2-7 flexion-extension ROM. This is thought to be partially because of a compensatory increase in segmental ROM at the upper cervical spine (Oc-C2).