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1.  Endonasal Access to the Upper Cervical Spine, Part One: Radiographic Morphometric Analysis 
Objectives To determine the anatomical relationships that may influence endonasal access to the upper cervical spine.
Setting We retrospectively analyzed computed tomography of 100 patients at a single institution.
Participants Participants included adults with imaging of the hard palate, clivus, and cervical spine without evidence of fracture, severe spondylosis, or previous instrumentation.
Main Outcome Measures Morphometric analyses of hard palate length and both distance and angle between the hard palate and odontoid process were based on radiographic measurements. Descriptive zones were assigned to cervical spine levels, and endoscopic visualization was simulated with projected lines at 0, 30, and 45 degrees from the hard palate to the cervical spine.
Results We found an inverse relationship between hard palate length and the lowest zone of the cervical spine potentially visualized by nasal endoscopy. The distance between the posterior tip of the hard palate and the odontoid tip, and the angle formed between the two, directly influenced the lowest possible cervical exposure.
Conclusions Radiographic relationships between hard palate length, distance to the odontoid, and the angle formed between the two predict the limits of endonasal access to the cervical spine. These results are supported by cadaveric data in Part Two of this study.
PMCID: PMC3709930  PMID: 24436909
cervical spine; endoscopic; minimally invasive; morphometric; odontoidectomy; transnasal
2.  Research in spinal surgery: Evaluation and practice of evidence-based medicine 
World Journal of Orthopedics  2014;5(2):89-93.
Evidence-based medicine (EBM) is a common concept among medical practitioners, yet unique challenges arise when EBM is applied to spinal surgery. Due to the relative rarity of certain spinal disorders, and a lack of management equipoise, randomized controlled trials may be difficult to execute. Despite this, responsibility rests with spinal surgeons to design high quality studies in order to justify certain treatment modalities. The authors therefore review the tenets of implementing evidence-based research, through the lens of spinal disorders. The process of EBM begins with asking the correct question. An appropriate study is then designed based on the research question. Understanding study designs allows the spinal surgeon to assess the level of evidence provided. Validated outcome measurements allow clinicians to communicate the success of treatment strategies, and will increase the quality of a given study design. Importantly, one must recognize that the randomized controlled trial is not always the optimal study design for a given research question. Rather, prospective observational cohort studies may be more appropriate in certain circumstances, and would provide superior generalizability. Despite the challenges involved with EBM, it is the future of medicine. These issues surrounding EBM are important for spinal surgeons, as well as health policy makers and editorial boards, to have familiarity.
PMCID: PMC4017311  PMID: 24829870
Evidence-based medicine; Spinal surgery; Trial design; Research; Methodology
3.  A Prospective, Multicenter, Phase I Matched-Comparison Group Trial of Safety, Pharmacokinetics, and Preliminary Efficacy of Riluzole in Patients with Traumatic Spinal Cord Injury 
Journal of Neurotrauma  2014;31(3):239-255.
A prospective, multicenter phase I trial was undertaken by the North American Clinical Trials Network (NACTN) to investigate the pharmacokinetics and safety of, as well as obtain pilot data on, the effects of riluzole on neurological outcome in acute spinal cord injury (SCI). Thirty-six patients, with ASIA impairment grades A–C (28 cervical and 8 thoracic) were enrolled at 6 NACTN sites between April 2010 and June 2011. Patients received 50 mg of riluzole PO/NG twice-daily, within 12 h of SCI, for 14 days. Peak and trough plasma concentrations were quantified on days 3 and 14. Peak plasma concentration (Cmax) and systemic exposure to riluzole varied significantly between patients. On the same dose basis, Cmax did not reach levels comparable to those in patients with amyotrophic lateral sclerosis. Riluzole plasma levels were significantly higher on day 3 than on day 14, resulting from a lower clearance and a smaller volume of distribution on day 3. Rates of medical complications, adverse events, and progression of neurological status were evaluated by comparison with matched patients in the NACTN SCI Registry. Medical complications in riluzole-treated patients occurred with incidences similar to those in patients in the comparison group. Mild-to-moderate increase in liver enzyme and bilirubin levels were found in 14–70% of patients for different enzymes. Three patients had borderline severe elevations of enzymes. No patient had elevated bilirubin on day 14 of administration of riluzole. There were no serious adverse events related to riluzole and no deaths. The mean motor score of 24 cervical injury riluzole-treated patients gained 31.2 points from admission to 90 days, compared to 15.7 points for 26 registry patients, a 15.5-point difference (p=0.021). Patients with cervical injuries treated with riluzole had more-robust conversions of impairment grades to higher grades than the comparison group.
PMCID: PMC3904533  PMID: 23859435
clinical trial; neuroprotection; riluzole; spinal cord injury
4.  Spinal Cord Injury Resulting From Injury Missed on CT Scan: The Danger of Relying on CT Alone for Collar Removal 
Strict criteria have been used before removing cervical collars in patients with injuries who have midline pain or are unable to be reliably examined. This sometimes leads to prolonged immobilization in cervical collars or use of MRI to rule out injury. Several studies suggest a collar may be removed in the absence of fractures, dislocation, or pathologic subluxation on a cervical CT scan. This may avoid the morbidity of prolonged cervical immobilization or cost of advanced imaging study but risks devastating consequences from missing injuries.
Case Description
We report a patient with a cervical spinal cord injury after removal of a collar after a CT scan was misinterpreted as normal. Retrospective review of the CT showed subtle signs of widening between the spinous processes of the injured level, a finding easily missed without the use of further imaging studies.
Literature Review
Several articles suggest cervical collars may be safely removed from awake and alert patients and in patients who cannot be reliably examined after a negative CT scan without the need for further imaging.
Purposes and Clinical Relevance
CT scans are excellent at detecting bony injuries but not ligamentous injuries. Removing cervical collars based on CT scans alone may be expeditious, but some injuries may be missed without further imaging. Our case demonstrates the catastrophic consequences of missing a cervical spine injury and emphasizes the need for maintaining the cervical collar in high-risk patients until proper imaging can be obtained.
PMCID: PMC3348314  PMID: 22395870
5.  CT and MRI-based Diagnosis of Craniocervical Dislocations: The Role of the Occipitoatlantal Ligament 
Craniocervical dislocations are rare, potentially devastating injuries. A diagnosis of craniocervical dislocations may be delayed as a result of their low incidence and paucity of diagnostic criteria based on CT and MRI. Delay in diagnosis may contribute to neurological injury from secondary displacement resulting from instability. The purpose of this study was to define CT and MRI-based diagnostic criteria for craniocervical dislocations to facilitate early injury recognition and stabilization.
Using CT and MRI, we (1) described the bony articular displacements characterize craniocervical injuries; (2) described the ligamentous injuries that characterize craniocervical injuries; and (3) determined whether neurologic injuries were associated with bony or ligamentous injury.
Using a prospectively collected spinal cord injury database, we identified 18 patients with acute, traumatic occipitocervical injuries. We reviewed CT scans and MR images to document the height of the occipitoatlantal and atlantoaxial joints and integrity of craniocervical ligaments. Medical records were reviewed for neurological status. The primary measurements were number of patients with articular displacement, location of bony displacement, and number of patients with ligamentous injury.
Thirteen of 18 patients had displacement outside the normal range. Six patients demonstrated displacement of both occipitoatlantal and atlantoaxial joints, whereas five patients presented with displacement through the atlantoaxial joints only. Two patients had an abnormal basion-dental interval only. Of 17 patients with MR images, the cruciate ligament was injured in 11 patients, indeterminate in four, and intact in two. All five patients with occipitoatlantal articular displacement had injury to the occipitoatlantal capsule. No patient had occipitoatlantal capsular injury without occipitoatlantal articular displacement. Three cases of complete spinal cord injury were found after occipitoatlantal-atlantoaxial dislocations. Three patients with occipitoatlantal-atlantoaxial dislocations were neurologically intact. The five patients with atlantoaxial dislocations and patients without displacement or ligamentous injury were neurologically intact. Five patients had cruciate ligament rupture or indeterminate injury but no joint diastasis.
The occipitoatlantal joint capsules stabilize the occipitoatlantal joint; disruption of the occipitoatlantal capsule may suggest the presence of instability. Based on these findings, we identified two distinct injury patterns: isolated atlantoaxial injuries (Type I) and combined occipitoatlantal-atlantoaxial injuries (Type II). Occipitoatlantal joint capsule integrity differentiated these subsets and Type II injuries had a higher percentage of complete spinal cord injuries on presentation.
PMCID: PMC3348326  PMID: 22033875
6.  Cervical instability presenting as thoracic pain: Case report and literature review 
Study design
Case report.
To report a case of cervical instability from an os odontoideum that presented as posterior thoracic pain and to present a review of the literature.
Thoracic posterior paraspinal spasms and pain are common chief complaints in individuals with spinal abnormalities.
A 19-year-old man presented with posterior thoracic pain for nearly 1 year following a college sports-related injury (lacrosse). Computed tomography and magnetic resonance imaging did not reveal any significant thoracic or lumbar spinal cord or nerve root pathology, but did reveal an incidental finding of an os odontoideum.
Surgical stabilization of the atlantoaxial instability resulting from the os odontoideum resulted in complete resolution of the patient's thoracic pain.
Thoracic back pain without a clear thoracic spine etiology warrants further workup to rule out the possibility of spinal instability.
PMCID: PMC3304558  PMID: 22525325
Atlantoaxial instability; Os odontoideum; Surgery; Spinal; Pain; Thoracic; Injuries; Sports
7.  Thoracic Fracture through a Prior Instrumented Arthrodesis in a Patient with Ankylosing Spondylitis without Hardware Loosening: A Case Report 
Global Spine Journal  2011;1(1):23-26.
The objective of this article is to report a case of a patient with ankylosing spondylitis who sustained a fracture through a prior solid arthrodesis without loosening or changing posterior instrumentation. There have been few cases reported of a patient with ankylosing spondylitis suffering a fracture through a prior instrumented arthrodesis. None have noted the instrumentation remaining intact with the fracture through the middle of the construct. The surgeon must be aware of this possibility to avoid spinal instability that may lead to a neurological deficit. We retrospectively reviewed the case. A review of the literature was performed through a PubMed search. A patient was found to have a fracture within a prior construct despite the presence of a posterior instrumentation. The mechanism of failure was a three-column spine fracture with “bending” of the rods. This patient was treated with a revision posterior/anterior instrumentation and fusion with placement of larger-diameter rods for added stiffness. Fractures through a prior instrumented arthrodesis are rare but still can occur in the ankylosing spondylitis patient. Given the higher risk of epidural hematoma and neurological compromise in this patient population, the surgeon must keep this on the differential diagnosis when treating patients with a prior instrumented arthrodesis.
PMCID: PMC3864410  PMID: 24353934
ankylosing spondylitis; postoperative complication; spinal arthrodesis
8.  A Clinical Prediction Model for Long-Term Functional Outcome after Traumatic Spinal Cord Injury Based on Acute Clinical and Imaging Factors 
Journal of Neurotrauma  2012;29(13):2263-2271.
To improve clinicians' ability to predict outcome after spinal cord injury (SCI) and to help classify patients within clinical trials, we have created a novel prediction model relating acute clinical and imaging information to functional outcome at 1 year. Data were obtained from two large prospective SCI datasets. Functional independence measure (FIM) motor score at 1 year follow-up was the primary outcome, and functional independence (score ≥6 for each FIM motor item) was the secondary outcome. A linear regression model was created with the primary outcome modeled relative to clinical and imaging predictors obtained within 3 days of injury. A logistic model was then created using the dichotomized secondary outcome and the same predictor variables. Model validation was performed using a bootstrap resampling procedure. Of 729 patients, 376 met the inclusion criteria. The mean FIM motor score at 1 year was 62.9 (±28.6). Better functional status was predicted by less severe initial American Spinal Injury Association (ASIA) Impairment Scale grade, and by an ASIA motor score >50 at admission. In contrast, older age and magnetic resonance imaging (MRI) signal characteristics consistent with spinal cord edema or hemorrhage predicted worse functional outcome. The linear model predicting FIM motor score demonstrated an R-square of 0.52 in the original dataset, and 0.52 (95% CI 0.52,0.53) across the 200 bootstraps. Functional independence was achieved by 148 patients (39.4%). For the logistic model, the area under the curve was 0.93 in the original dataset, and 0.92 (95% CI 0.92,0.93) across the bootstraps, indicating excellent predictive discrimination. These models will have important clinical impact to guide decision making and to counsel patients and families.
PMCID: PMC3430477  PMID: 22709268
clinical prediction model; functional outcome; spinal cord injury
9.  Can clinical and radiological findings predict surgery for lumbar disc herniation? A systematic literature review 
Study design: Systematic review.
Objective or clinical question: What clinical and radiological findings in patients with lumbar-herniated nucleus pulposus can serve as predictors of surgical intervention?
Methods: Articles published between January 1975 and August 2011 were systematically reviewed using Pubmed, Cochrane, National Guideline Clearinghouse Databases, and bibliographies of key articles. Each article was subject to quality rating and was analyzed by two independent reviewers.
Results: From 123 citations, 21 underwent full-text review. Four studies met inclusion criteria. Only baseline disability as measured by the Roland Disability Index (RDI) or the Oswestry Disability Index (ODI) was consistently associated with a greater likelihood of having discectomy surgery across multiple studies. With the current literature, we were not able to find an association between surgery and several characteristics including smoking status, body mass index, neurological deficit, positive straight leg testing, and level of herniation.
Conclusions: From the limited data available, it appears that individual radiographic and clinical features are not able to predict the likelihood of surgical intervention. Higher baseline disability measurements (Oswestry and Roland) did correlate, however, with surgical treatment.
PMCID: PMC3503512  PMID: 23236305
10.  Traumatic cervical spinal cord injury with “negative” cervical spine CT scan 
BMJ Case Reports  2010;2010:bcr12.2009.2525.
A 46-year-old man fell four steps, striking his neck and having associated neck pain and discomfort. He was evaluated at a local emergency department and reported no neurological deficit but focal mid cervical tenderness. Radiographs and computed tomography (CT) scan were “negative” for cervical spine fracture, dislocation or pre-vertebral soft tissue swelling. He was discharged home in a cervical collar with a scheduled outpatient follow-up. Over the proceeding hours neurologic deterioration occurred, including hand and lower limb weakness with the inability to urinate. The patient returned to the local emergency room and was transferred to a tertiary care hospital where examination revealed C5ASIAB deficits. Repeat high resolution CT scan of the cervical spine with reformatted images was unremarkable for osseous fractures except some loss of definition in the posterior cervical musculature. Emergency magnetic resonance imaging MRI revealed a subluxation of C5/6 right facet (not evident on CT) with disruption of the posterior longitudinal ligament, ligamentum flavum, and disc space with abnormal T2 weighted spinal cord hyperintense signal at C5/6. He underwent emergency C5–C6 anterior and posterior decompression and fusion. One week later an examination showed improved C5ASIAD. This case reveals the difficulty of assessing the cervical spine for instability and potential limitations of current management schemes.
PMCID: PMC3027880  PMID: 22389654
11.  Early versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: Results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) 
PLoS ONE  2012;7(2):e32037.
There is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (<24 hours after injury) versus late (≥24 hours after injury) decompressive surgery after traumatic cervical SCI.
We performed a multicenter, international, prospective cohort study (Surgical Timing in Acute Spinal Cord Injury Study: STASCIS) in adults aged 16–80 with cervical SCI. Enrolment occurred between 2002 and 2009 at 6 North American centers. The primary outcome was ordinal change in ASIA Impairment Scale (AIS) grade at 6 months follow-up. Secondary outcomes included assessments of complications rates and mortality.
A total of 313 patients with acute cervical SCI were enrolled. Of these, 182 underwent early surgery, at a mean of 14.2(±5.4) hours, with the remaining 131 having late surgery, at a mean of 48.3(±29.3) hours. Of the 222 patients with follow-up available at 6 months post injury, 19.8% of patients undergoing early surgery showed a ≥2 grade improvement in AIS compared to 8.8% in the late decompression group (OR = 2.57, 95% CI:1.11,5.97). In the multivariate analysis, adjusted for preoperative neurological status and steroid administration, the odds of at least a 2 grade AIS improvement were 2.8 times higher amongst those who underwent early surgery as compared to those who underwent late surgery (OR = 2.83, 95% CI:1.10,7.28). During the 30 day post injury period, there was 1 mortality in both of the surgical groups. Complications occurred in 24.2% of early surgery patients and 30.5% of late surgery patients (p = 0.21).
Decompression prior to 24 hours after SCI can be performed safely and is associated with improved neurologic outcome, defined as at least a 2 grade AIS improvement at 6 months follow-up.
PMCID: PMC3285644  PMID: 22384132
12.  Impact of total disc arthroplasty on the surgical management of lumbar degenerative disc disease: Analysis of the Nationwide Inpatient Sample from 2000 to 2008 
Spinal fusion is the most rapidly increasing type of lumbar spine surgery for various lumbar degenerative pathologies. The surgical treatment of lumbar spine degenerative disc disease may involve decompression, stabilization, or arthroplasty procedures. Lumbar disc athroplasty is a recent technological advance in the field of lumbar surgery. This study seeks to determine the clinical impact of anterior lumbar disc replacement on the surgical treatment of lumbar spine degenerative pathology. This is a retrospective assessment of the Nationwide Inpatient Sample (NIS).
The NIS was searched for ICD-9 codes for lumbar and lumbosacral fusion (81.06), anterior lumbar interbody fusion (81.07), and posterolateral lumbar fusion (81.08), as well as for procedure codes for revision fusion surgery in the lumbar and lumbosacral spine (81.36, 81.37, and 81.38). To assess lumbar arthroplasty, procedure codes for the insertion or replacement of lumbar artificial discs (84.60, 84.65, and 84.68) were queried. Results were assayed from 2000 through 2008, the last year with available data. Analysis was done using the lme4 package in the R programming language for statistical computing.
A total of nearly 300,000 lumbar spine fusion procedures were reported in the NIS database from 2000 to 2008; assuming a representative cross-section of the US health care market, this models approximately 1.5 million procedures performed over this time period. In 2005, the first year of its widespread use, there were 911 lumbar arthroplasty procedures performed, representing 3% of posterolateral fusions performed in this year. Since introduction, the number of lumbar spine arthroplasty procedures has consistently declined, to 653 total procedures recorded in the NIS in 2008. From 2005 to 2008, lumbar arthroplasties comprised approximately 2% of lumbar posterolateral fusions. Arthroplasty patients were younger than posterior lumbar fusion patients (42.8 ± 11.5 vs. 55.9 ± 15.1 years, P < 0.0000001). The distribution of arthroplasty procedures was even between academic and private urban facilities (48.5% and 48.9%, respectively). While rates of posterolateral lumbar spine fusion steadily grew during the period (OR 1.06, 95% CI: 1.05-1.06, P < 0.0000001), rates of revision surgery and anterior spinal fusion remained static.
The impact of lumbar arthroplasty procedures has been minimal. Measured as a percentage of more common lumbar posterior arthrodesis procedures, lumbar arthroplasty comprises only approximately 2% of lumbar spine surgeries performed in the United States. Over the first 4 years following the Food and Drug Administration (FDA) approval, the frequency of lumbar disc arthroplasty has decreased while the number of all lumbar spinal fusions has increased.
PMCID: PMC3205497  PMID: 22059134
Artificial disc; lumbar spinal fusion; total disc replacement
13.  Spine Disorders: Medical and Surgical Management 
Mayo Clinic Proceedings  2011;86(1):302-e8.
PMCID: PMC3012642
14.  Dorsal Epidural Intervertebral Disk Herniation With Atypical Radiographic Findings: Case Report and Literature Review 
Intervertebral disk herniation is relatively common. Migration usually occurs in the ventral epidural space; rarely, disks migrate to the dorsal epidural space due to the natural anatomical barriers of the thecal sac.
Case report.
A 49-year-old man presented with 1 week of severe back pain with bilateral radiculopathy to the lateral aspect of his lower extremities and weakness of the ankle dorsiflexors and toe extensors. Lumbar spine magnetic resonance imaging with gadolinium revealed a peripheral enhancing dorsal epidural lesion with severe compression of the thecal sac. Initial differential diagnosis included spontaneous hematoma, synovial cyst, and epidural abscess. Posterior lumbar decompression was performed; intraoperatively, the lesion was identified as a large herniated disk fragment.
Dorsal migration of a herniated intervertebral disk is rare and may be difficult to definitively diagnose preoperatively. Dorsal disk migration may present in a variety of clinical scenarios and, as in this case, may mimic other epidural lesions on magnetic resonance imaging.
PMCID: PMC2920122  PMID: 20737802
Vertebral disk, herniation; Back pain, radiculopathy; Abscess, epidural; Hematoma, epidural; Laminectomy; Decompression, lumbar
15.  Vulnerability of the Femoral Nerve During Complex Anterior and Posterior Spinal Surgery 
Femoral nerve palsy is not a common adverse effect of lumbar spinal surgery.
To report 3 unique cases of femoral nerve neuropathy due to instrumentation and positioning during complex anterior and posterior spinal surgery.
Case series
All 3 patients demonstrated femoral nerve neuropathy. The first patient presented postoperatively but after 6 months, the palsy resolved. Femoral nerve malfunctioning was documented in the second and third patients intraoperatively; however, with rapid patient repositioning and removal of offending instrumentation, postoperative palsy was avoided.
Use of motor evoked potential monitoring of the femoral nerve during surgery is vital for the prevention of future neuropathies, an avoidable complication of spinal surgery.
PMCID: PMC2830684  PMID: 19777866
Lumbar spine; Surgery, spinal; Femoral nerve, palsy, iatrogenic; Nerve injury; Neuropathy, femoral; Lumbar fusion, anterior; Evoked potentials
16.  Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma 
Journal of Orthopaedic Science  2005;10(6):671-675.
Contemporary understanding of the biomechanics, natural history, and methods of treating thoracolumbar spine injuries continues to evolve. Current classification schemes of these injuries, however, can be either too simplified or overly complex for clinical use.
The Spine Trauma Group was given a survey to identify similarities in treatment algorithms for common thoracolumbar injuries, as well as to identify characteristics of injury that played a key role in the decision-making process.
Based on the survey, the Spine Trauma Group has developed a classification system and an injury severity score (thoracolumbar injury classification and severity score, or TLICS), which may facilitate communication between physicians and serve as a guideline for treating these injuries. The classification system is based on the morphology of the injury, integrity of the posterior ligamentous complex, and neurological status of the patient. Points are assigned for each category, and the final total points suggest a possible treatment option.
The usefulness of this new system will have to be proven in future studies investigating inter- and intraobserver reliability, as well as long-term outcome studies for operative and nonoperative treatment methods.
PMCID: PMC2779435  PMID: 16307197
17.  Utility of Helical Computed Tomography in Differentiating Unilateral and Bilateral Facet Dislocations 
Diagnosis of cervical facet dislocation is difficult when relying on plain radiographs alone. This study evaluates the interobserver reliability of helical computed tomography (CT) in the assessment of cervical translational injuries, correlates the radiographic diagnosis with intraoperative observation, and examines the role of neurologic injury in the evaluation and diagnosis of these injuries.
Clinical histories and radiographic studies of 10 patients with cervical facet dislocations were presented to 25 surgeons. Participants classified cases as unilateral or bilateral facet dislocations after reviewing selected axial CT slices and sagittal reconstructions. Surgeons' interpretations were compared with intraoperative diagnosis. Participants interpreted the same radiographic studies with 3 different clinical scenarios: neurologically intact, incomplete, and complete spinal cord injury. Vertebral body translation from midsagittal CT was evaluated to confirm whether all unilateral facet dislocations had <25% translation.
Interrater κ coefficient showed moderate agreement between observers in classifying injuries as unilateral or bilateral (κ: 0.54–0.58), regardless of neurologic status. Percent agreement among observers varied from 50% to 100% for each individual case. Agreement was statistically higher for bilateral facet dislocation (85%) than for unilateral dislocations (78%), with 1 unilateral fracture showing nearly 50% translation on a midsagittal image.
The addition of helical CT to reconstruction enables spine surgeons to more reliably distinguish bilateral from unilateral cervical facet dislocations. Despite frequent occurrence of these injuries and presumed agreement on injury description, agreement may be improved by a more precise definition of facet dislocations and subluxations and thorough review of all imaging studies.
PMCID: PMC2647499  PMID: 19264048
Spine, cervical; Facet dislocation; Imaging; Computed tomography; Trauma, spinal
18.  Cervical Extradural Meningioma: Case Report and Literature Review 
Extradural lesions are most commonly metastatic neoplasms. Extradural meningioma accounts for 2.7 to 10% of spinal neoplasms and most commonly is found in the thoracic spine.
Case report.
A 45-year-old woman presented with posterior cervicothoracic pain for 8 months following a motor vehicle crash. Magnetic resonance imaging of the cervical spine revealed an enhancing epidural mass. Computerized tomography of the chest, abdomen, and pelvis revealed no systemic disease. Due to the lesion's unusual signal characteristics and location, an open surgical biopsy was completed, which revealed a psammomatous meningioma. Surgical decompression of the spinal cord and nerve roots was then performed. The resection was subtotal due to the extension of the tumor around the vertebral artery.
Meningiomas should be considered in the differential diagnosis of contrast-enhancing lesions in the cervical spine.
PMCID: PMC2565566  PMID: 18795481
Meningioma; psammomatous; Epidural tumor; Vertebrae, cervical
19.  Athletes returning to play after cervical spine or neurobrachial injury 
The treatment algorithms for athletes with spine injuries follow similar guidelines as those for non-athletes in terms of deciding between surgical intervention and non-operative management. However, the athlete has unique postoperative demands and the decision to “allow” an athlete to return to competitive sports after a spinal or plexus injury can be difficult. This article reviews the several studies, available guidelines and peer-reviewed publications to aid in the decisions to allow athletes to return to sports. A set of recommendations concerning return to play after a spinal injury is provided.
PMCID: PMC2682413  PMID: 19468903
Cervical; Return to sports; Spine; Injury; Neuropraxia
20.  Acute Cervical Fracture or Congenital Spinal Deformity 
There are few reports of developmental or congenital cervical spinal deformities. Such cases may be mistaken for traumatically induced fractures, and additional treatment may ensue.
A retrospective analysis was performed to identify patients with congenital cervical spine deformities. These patients were matched with a confirmed traumatic spinal fracture population with similar demographic features. Patients were analyzed for age, gender, imaging findings (plain roentgenograms including dynamic flexion and extension views, computed tomography scan, and MRI), neurologic status, and subjective complaints of pain.
Thirty-six individuals were included in the final analysis, 7 with congenital abnormalities and 29 with radiographically confirmed traumatic injuries. Patients with congenital abnormalities had significantly less soft-tissue swelling compared with the population with traumatic fractures (P < 0.001). Furthermore, those with congenital defects presented with lesser degrees of vertebral subluxation (0.29 mm vs 7.24 mm) (P < 0.0001) and without neurologic deficits (P < 0.0001).
Congenital abnormalities, though rare, can be mistaken for traumatic fractures of the spine. Physicians should note any evidence of soft-tissue swelling, neurologic deficits, degree of subluxation, and radiographic evidence of pedicle absence because these characteristics often provide insight into the specific etiology of the observed spinal deformity (congenital vs traumatic).
PMCID: PMC2435025  PMID: 18533417
Cervical spine; Fracture; Spine, congenital defect; Deformity, developmental; Spinal cord injuries, traumatic; Pedicle, absence
21.  Evaluation of Neurologic Deficit Without Apparent Cause: The Importance of a Multidisciplinary Approach 
A patient presenting with an acute neurologic deficit with no apparent etiology presents a diagnostic dilemma. A broad differential diagnosis must be entertained, considering both organic and psychiatric causes.
A case report and thorough literature review of acute paraplegia after a low-energy trauma without a discernible organic etiology.
Diagnostic imaging excluded any bony malalignment or fracture and any abnormality on magnetic resonance imaging. When no organic etiology was identified, a multidisciplinary approach using neurology, psychiatry, and physical medicine and rehabilitation services was applied. Neurophysiologic testing confirmed the absence of an organic disorder, and at this juncture, diagnostic efforts focused on identifying any psychiatric disorder to facilitate appropriate treatment for this individual. The final diagnosis was malingering.
The full psychiatric differential diagnosis should be considered in the evaluation of any patient with an atypical presentation of paralysis. A thorough clinical examination in combination with the appropriate diagnostic studies can confidently exclude an organic disorder. When considering a psychiatric disorder, the differential diagnosis should include conversion disorder and malingering, although each must remain a diagnosis of exclusion. Maintaining a broad differential diagnosis and involving multiple disciplines (neurology, psychiatry, social work, medical specialists) early in the evaluation of atypical paralysis may facilitate earlier diagnosis and initiation of treatment for the underlying etiology.
PMCID: PMC2141729  PMID: 18092568
Hysterical paralysis; Atypical paralysis; Conversion disorder; Malingering; Spinal cord injuries
22.  Incidence of fracture in adjacent levels in patients treated with balloon kyphoplasty: a review of the literature 
The available evidence suggests that the treatment of painful vertebral compression fractures (VCFs) secondary to osteoporosis or multiple myeloma, by cement augmentation with balloon kyphoplasty (BK), is both safe and effective. However, there is uncertainty in the literature concerning the potential of the procedure to influence the risk for adjacent segment fracture. The aim of this article is to review the available peer-reviewed literature, regarding adjacent vertebral body fractures after kyphoplasty augmentation.
PMCID: PMC2684154  PMID: 19468900
Kyphoplasty; Adjacent fracture; Vertebral body fracture; Vertebral compression fracture
23.  Percutaneous vertebral compression fracture management with polyethylene mesh-contained morcelized allograft bone 
Study design    A comprehensive systematic review of the literature. Objectives To assess the modern literature on the use of polyethylene mesh-contained morcelized allograft (PMCMA) bone for spinal fusion and vertebral compression fracture management. Summary of background data    There are presently no systematic reviews of PMCMA. Methods    A systematic literature review was performed within three databases (OVID, PubMed, and Google Scholar) using the following keyword search terms: vertebroplasty, kyphoplasty, vertebral compression fracture, percutaneous, polyethylene mesh, and osteoporosis. Results    The initial search identified 764 items, from which two pertinent technique-based articles were identified. There were no published scientific peer-reviewed or case series reporting the clinical results of this technique. The use of PMCMA in the management of vertebral compression fractures (VCFs) is similar to vertebroplasty and kyphoplasty. This novel, percutaneous system uses the properties of granular mechanics to establish a conforming, semirigid graft that is purportedly capable of withstanding physiologic loads. Discussion    PMCMA is a novel percutaneous technology for the management of VCF and possibly for use as a conforming interbody graft. The available published literature lacks outcome data of the use of PMCMA. Careful, independent research is needed to assess the viability of this technology and its long-term results.
PMCID: PMC2684215  PMID: 19468877
Vertebral compression fracture; Vertebroplasty; Kyphoplasty; Percutaneous; Polyethylene mesh; Osteoporosis
24.  Whiplash: diagnosis, treatment, and associated injuries 
Study design Focused review of the current literature. Objective To identify and synthesize the most current data pertaining to the diagnosis and treatment of whiplash and whiplash-associated disorders (WAD), and to report on whiplash-related injuries. Methods A search of OVID Medline (1996–January 2007) and the Cochrane database of systematic reviews was performed using the keywords whiplash and WAD. Articles under subheadings for pathology, diagnosis, treatment, and epidemiology were chosen for review after identification by the authors. Results A total of 485 articles in the English language literature were identified. Thirty-six articles pertained to the diagnosis, treatment, epidemiology of whiplash, and WAD, and were eligible for focused review. From these, 21 primary and 15 secondary sources were identified for full review. In addition, five articles were found that focused on whiplash associated cervical injuries. These five articles were also primary sources. Conclusions Whiplash is a common injury associated most often with motor vehicle accidents. It may present with a variety of clinical manifestations, collectively termed WAD. Whiplash is an important cause of chronic disability. Many controversies exist regarding the diagnosis and treatment of whiplash injuries. The multifactorial etiology, believed to underly whiplash injuries, make management highly variable between patients. Radiographic evidence of injury often cannot be identified in the acute phase. Recent studies suggest early mobilization may lead to improved outcomes. Ligamentous and bony injuries may go undetected at initial presentation leading to delayed diagnosis and inappropriate therapies.
PMCID: PMC2684148  PMID: 19468901
Whiplash; Whiplash associated disorders (WAD); Cervical spine injury
25.  Regional variability in use of a novel assessment of thoracolumbar spine fractures: United States versus international surgeons 
Considerable variability exists in clinical approaches to thoracolumbar fractures. Controversy in evaluation and nomenclature contribute to this confusion, with significant differences found between physicians, between different specialties, and in different geographic regions. A new classification system for thoracolumbar injuries, the Thoracolumbar Injury Severity Score (TLISS), was recently described by Vaccaro. No assessment of regional differences has been described. We report regional variability in use of the TLISS system between United States and non-US surgeons.
Twenty-eight spine surgeons (8 neurosurgeons and 20 orthopedic surgeons) reviewed 56 clinical thoracolumbar injury case histories, which included pertinent imaging studies. Cases were classified and scored using the TLISS system. After a three month period, the case histories were re-ordered and the physicians repeated the exercise; 22 physicians completed both surveys and were used to assess intra-rater reliability. The reliability and treatment validity of the TLISS was assessed. Surgeons were grouped into US (n = 15) and non-US (n = 13) cohorts. Inter-rater (both within and between different geographic groups) and intra-rater reliability was assessed by percent agreement, Cohen's kappa, kappa with linear weighting, and Spearman's rank-order correlation.
Non-US surgeons were found to have greater inter-rater reliability in injury mechanism, while agreement on neurological status and posterior ligamentous complex integrity tended to be higher among US surgeons. Inter-rater agreement on management was moderate, although it tended to be higher in US-surgeons. Inter-rater agreement between US and non-US surgeons was similar to within group inter-rater agreement for all categories. While intra-rater agreement for mechanism tended to be higher among US surgeons, intra-rater reliability for neurological status and PLC was slightly higher among non-US surgeons. Intra-rater reliability for management was substantial in both US and non-US surgeons. The TLISS incorporates generally accepted features of spinal injury assessment into a simple patient evaluation tool. The management recommendation of the treatment algorithm component of the TLISS shows good inter-rater and substantial intra-rater reliability in both non-US and US based spine surgeons. The TLISS may improve communication between health providers and may contribute to more efficient management of thoracolumbar injuries.
PMCID: PMC2045082  PMID: 17825106

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