Journal of neurosurgery. Spine
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In patients with cervical spondylotic myelopathy (CSM), ventral disease and loss of cervical lordosis are considered to be relative indications for anterior surgery. However, anterior decompression and fusion operations may be associated with an increased risk of swallowing difficulty and an increased risk of nonunion when extensive decompression is performed. The authors reviewed cases involving patients with CSM treated via an anterior approach, paying special attention to neurological outcome, fusion rates, and complications. ⋯ Significant improvement in Nurick grade can be achieved in patients who undergo anterior surgery for cervical myelopathy for primarily ventral disease or loss of cervical lordosis. In selected high-risk patients who undergo multilevel ventral decompression, supplemental posterior fixation and arthrodesis allows for low rates of construct failure with acceptable added morbidity.
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The vertebral artery (VA) often takes a protrusive course posterolaterally over the posterior arch of the atlas. In this study, the authors attempted to quantify this posterolateral protrusion of the VA. ⋯ When there was no dominant side, mean distances from the most protrusive part of the VA to the posterior arch of the atlas were 6.73 +/- 2.35 mm (right) and 6.8 +/- 2.15 mm (left). When the left side of the VA was dominant, the distance on the left side (8.46 +/- 2.00 mm) was significantly larger than that of the right side (6.64 +/- 2.0 mm). When compared by age group (< or = 30 years, 31-60 years, and > or = 61 years), there were no significant differences in the extent of the protrusion. When there was no dominant side, the mean distances from the most protrusive part of the VA to the midline were 30.73 +/- 2.51 mm (right side) and 30.79 +/- 2.47 mm (left side). When the left side of the VA was dominant, the distance on the left side (32.68 +/- 2.03 mm) was significantly larger than that on the right side (29.87 +/- 2.53 mm). The distance from the midline to the intersection of the VA and inner cortex of the posterior arch of the atlas was approximately 12 mm, irrespective of the side of VA dominance. The distance from the midline to the intersection of the VA and outer cortex of the posterior arch was approximately 20 mm on both sides. Anatomical variations and anomalies were found as follows: bony bridge formation over the groove for the VA on the posterior arch of C-1 (9.3%), an extracranial origin of the posterior inferior cerebellar artery (8.2%), and a VA passing beneath the posterior arch of the atlas (1.8%). Conclusions There may be significant variation in the location and branches of the VA that may place the vessel at risk during surgical intervention. If concern is noted about the vulnerability of the VA or its branches during surgery, preoperative evaluation by CT angiography should be considered.
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Pseudarthrosis and construct failure following single-level anterior cervical discectomy, fusion, and plate placement (ACDFP) rarely occur. Routine postoperative anteroposterior and lateral radiographs may be an inconvenience to patients and expose them to additional and potentially unnecessary radiation. No standard exists to define when patients should obtain radiographs following an ACDFP. The authors hypothesize that routinely obtaining static anteroposterior and lateral radiographs in patients who recently underwent a single-level ACDFP without new axial neck pain or other neurological complaints or symptoms is unwarranted and does not alter the long-term treatment of the patient. ⋯ Pseudarthrosis and construct failure following single-level ACDFP occur rarely, and patients with new symptoms following surgery are as likely to have normal radiographic findings as they are to have abnormalities identified on their postoperative plain radiographs. Routinely obtaining postoperative radiographs at regular intervals in asymptomatic patients following single-level ACDFP does not appear to be warranted.
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Sarcomas of the spine are a challenging problem due to their frequent and extensive involvement of multiple spinal segments and high recurrence rates. Gross-total resection to negative margins, with preservation of neurological function and palliation of pain, is the surgical goal and may be achieved using either intralesional resection or en bloc excision. The authors report outcomes of surgery for primary and metastatic sarcomas of the mobile spine in a large patient series. ⋯ Surgery for primary or metastatic sarcoma of the spine is associated with an improvement in neurological function and palliation of pain. The results of this study show a significant difference in patient survival for primary versus metastatic spine sarcomas. The results do not show a statistically significant benefit in survival or local recurrence rates for en bloc versus intralesional resections for either metastatic or primary sarcomas of the spine, but this may be due to the small number of patients undergoing en bloc resections.
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Case Reports
Spine-shortening vertebral osteotomy in a patient with tethered cord syndrome and a vertebral fracture. Case report.
The authors report a rare case of tethered cord syndrome with low-placed conus medullaris complicated by a vertebral fracture that was successfully treated by a spine-shortening vertebral osteotomy. The patient was a 57-year-old woman whose neurological condition worsened after a T-12 vertebral fracture because a fracture fragment and the associated local kyphotic deformity directly compressed the tethered spinal cord. ⋯ Two years after the surgery, the patient's neurological symptoms were resolved. The bone union was complete with no loss of correction.