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1.  Functional Outcomes, Morbidity, Mortality, and Fracture Healing in 58 Consecutive Patients with Geriatric Odontoid Fracture Treated with Cervical Collar or Posterior Fusion 
Global Spine Journal  2013;3(1):21-32.
Controversy exists as to the most effective management option for elderly patients with type II odontoid fractures. The purpose of this study is to evaluate outcomes associated with rigid cervical collar and posterior fusion surgery. Patients with ≥ 50% odontoid displacement were treated with posterior fusion surgery including C1–2 (PSF group, n = 25, average age = 80 years). Patients with < 50% odontoid displacement were treated with a rigid cervical collar for 12 weeks (collar group, n = 33, average age = 83 years). These inhomogeneous groups were followed for an average of 14 months. Fracture healing rates were higher in the operative group (28% versus 6%). Neck Disability Index scores were slightly lower in the nonoperative group (13 versus 18.3, p = 0.23). Analogue pain scores were also slightly lower in the nonoperative group (1.3 versus 1.9, p = 0.26). The mortality rate was 12.5% in the collar group and 20% in the operative group. Complications were higher in the operative group (24% versus 6%). Rates of type II odontoid facture healing and stability appear to be higher in geriatric patients treated with posterior fusion surgery. Fracture healing and stability did not correlate with improved outcomes with respect to levels of pain, function, and satisfaction. Mortality and complication rates are lower in those patients with lesser-displaced fractures who are treated with a cervical collar and early mobilization.
doi:10.1055/s-0033-1337122
PMCID: PMC3854588  PMID: 24436848
odontoid; fracture; geriatric; operative; nonoperative; management
2.  Prophylactic intraoperative powdered vancomycin and postoperative deep spinal wound infection: 1,512 consecutive surgical cases over a 6-year period 
European Spine Journal  2011;21(Suppl 4):476-482.
Purpose
The purpose of this study is to evaluate the effect of intraoperative powdered vancomycin on the rates of postoperative deep spinal wound infection. The use of intraoperative powdered vancomycin as a prophylactic measure in an attempt to reduce the incidence of postoperative spinal wound infection has not been sufficiently evaluated in the existing literature. A retrospective review of a large clinical database was performed to determine the rates of deep wound infection associated with the use of intraoperative operative site powdered vancomycin.
Materials and methods
During the period from 2005 to 2010, 1,512 consecutive spinal surgery cases were performed by the same fellowship-trained spinal surgeon (RWM) at a level 1 trauma-university medical center. One gram of powdered vancomycin was placed in all surgical sites prior to wound closure. Eight hundred forty-nine cases were uninstrumented, 478 cases were instrumented posterior thoracic or lumbar, 12 were instrumented anterior thoracic or lumbar, 126 were instrumented anterior cervical, and 47 were instrumented posterior cervical cases. Fifty-eight cases were combined anterior and posterior surgery and 87 were revision surgeries. A retrospective operative database and medical record review was performed to evaluate for evidence of postoperative deep wound infection.
Results
15 of the 1,512 patients (0.99%) were identified as having evidence of postoperative deep wound infection. At least one pre-existing risk factor for deep infection was present in 8/15 pts (54%). Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) were the most commonly identified organisms (11/15 cases). The rate of deep wound infection was 1.20% (8/663) for instrumented spinal surgeries, and 0.82% (7/849) for uninstrumented surgeries. Deep infection occurred in only 1.23% (4/324) of multilevel instrumented posterior spinal fusions, 1.37% (1/73) of open PLIF procedures, and 1.23% (1/81) of single-level instrumented posterior fusions. Deep infection was not observed in any patient who had uninstrumented spinal fusion (0/64). The deep infection rate for revision surgeries was 1.15% (1/87) and 0.55% (1/183) for trauma surgery. Increased rates of complications related to powdered vancomycin use were not identified in this series. Conclusion
In this series of 1,512 consecutive spinal surgeries, the use of 1 g of powdered intraoperative vancomycin placed in the wound prior to wound closure appears to associated with a low rate deep spinal wound infection for both instrumented and uninstrumented cases. Rates of deep infection for instrumented fusion surgery, trauma, and revision surgery appear to be among the lowest reported in the existing literature. Further investigation of this prophylactic adjunctive measure is warranted.
doi:10.1007/s00586-011-2104-z
PMCID: PMC3369056  PMID: 22160172
Operative site vancomycin; Intraoperative vancomycin; Postoperative spinal operative site infection; Spinal surgery infection prophylaxis
3.  Rigid cervical collar treatment for geriatric type II odontoid fractures 
European Spine Journal  2011;21(5):855-862.
Purpose
To evaluate fracture healing, functional outcomes, complications, and mortality associated with rigid cervical collars.
Methods
Thirty-four patients with <50% odontoid displacement were treated with a rigid cervical collar for 12 weeks (Average age = 84 years). Outcome scores were compared with a group of 40 age-matched control subjects (Average age 79.3).
Results
At average 14.9-month follow-up, only 6% demonstrated radiographic evidence of fracture healing and 70% had mobile odontoid nonunion. NDI scores indicated only mild disability, pain scores were low, and neither differed significantly from age-matched controls. Mobile odontoid nonunion was not associated with higher levels of disability or neck pain. Mortality rate was 11.8%. Treatment complications occurred in 6% of patients.
Conclusions
Odontoid nonunion and instability are high in geriatric patients treated with a rigid cervical collar. Fracture healing and stability did not correlate with improved outcomes. Outcomes did not differ significantly from age-matched cohorts.
doi:10.1007/s00586-011-2069-y
PMCID: PMC3337899  PMID: 22094387
Type II odontoid fracture; Cervical collar; Nonoperative management; Geriatric spine patients
5.  C1 lateral mass screw placement with intentional sacrifice of the C2 ganglion: functional outcomes and morbidity in elderly patients 
European Spine Journal  2010;19(8):1318-1324.
Placement of C1 lateral mass screws may be facilitated by intentional C2 root sacrifice. Functional outcomes and morbidity following intentional sacrifice of the C2 root have not been reported in the literature. The objective is to find out if intentional C2 nerve root sacrifice affects functional outcomes and operative morbidity in patients undergoing posterior cervical fusion with C1 lateral mass screws. The study is a case report. Twenty-two consecutive elderly patients (10 males, 12 females with an average age of 77 years) with C1–2 instability were treated with posterior cervical fusion using C1 lateral mass screw placement. Five patients had preservation of the bilateral C2 nerve roots (PRES group) and 18 patients had intentional sacrifice of the bilateral C2 nerve root (SAC group). Operative times, blood loss, hospital length of stay, and complications were recorded for each patient. Functional outcomes, pain, and satisfaction scores were compared between the two groups at the time of ultimate follow-up. Average follow-up time was 19.3 months (range 6–66). The SAC group demonstrated significantly decreased operative time (109.4 vs. 187 min) and a trend towards decreased blood loss (344 vs. 1,030 mL). At ultimate follow-up both groups experienced similar mild disability with no significant difference in NDI scores, analog pain, and satisfaction scores. No patient had C2 root dysesthesia, swallowing, or speech difficulty. In this small case series, intentional sacrifice of the bilateral C2 nerve root ganglion resulted in less operative time and decreased blood loss in elderly patents undergoing C1–2 posterior fusion with the Harms technique. Functional outcome, pain and satisfaction scores were not adversely affected when this technique was used in elderly patients.
doi:10.1007/s00586-010-1452-4
PMCID: PMC2989185  PMID: 20496037
Posterior cervical fusion; Sacrifice; C2 nerve root; Atlantoaxial; Instability
6.  Cervical Fracture With Transient Tetraplegia in a Youth Football Player: Case Report and Review of the Literature 
Background/Objective:
Serious cervical spinal injuries in organized youth football are rare. Cervical fracture with neurologic injury is rarely reported in organized youth football players with no pre-existing risk fractures for transient tetraplegia.
Methods:
Case report and literature review.
Results:
After being improperly tackled by an opponent of significantly larger body size, a player sustained a C7 posterior cervical fracture with transient tetraplegia. He was immobilized in a cervical collar and sent to a level 1 trauma center for evaluation. Initial examination showed bilateral paresthesia of the limbs with normal motor function (ASIA D). Initial radiographs of the cervical spine showed a displaced extension-compression fracture of the C7 spinous process. Magnetic resonance imaging of the cervical spine showed edema in the spinal cord in the region of the injury along with significant posterior injury. Imaging studies showed normal volumetric measurements of the spinal canal and no pre-existing risk factors for spinal stenosis or spinal cord injury. Radiographs showed that cervical fracture was healed at 9-month follow-up examination. At 1-year follow-up, the patient was asymptomatic. Radiographs showed healed fracture with no residual instability and full range of cervical spine motion on flexion–extension views.
Conclusions:
This case underscores the potential for serious cervical spinal injuries in organized youth sports when players are physically overmatched, and improper tackling technique is used.
PMCID: PMC2869276  PMID: 20486536
Youth football; Sports injuries; Spinal injury; Cervical; Tetraplegia, transient; Neurapraxia; Fracture, cervical, hyperextension; Spinal stenosis, congenital
7.  Extensive Postoperative Epidural Hematoma After Full Anticoagulation: Case Report and Review of the Literature 
Background/Objective:
A 67-year-old man with degenerative lumbar spinal stenosis and a medical history significant for coronary artery disease underwent routine lumbar surgical decompression. The objective of this study was to report a case of postoperative epidural hematoma associated with the use of emergent anticoagulation, including the dangers associated with spinal decompression and early postoperative anticoagulation.
Methods:
Case report.
Findings:
After anticoagulation therapy for postoperative myocardial ischemia, the patient developed paresis with ascending abdominal paraesthesias. Immediate decompression of the surgical wound was carried out at the bedside. Magnetic resonance imaging revealed a massive spinal epidural hematoma extending from the middle of the cervical spine to the sacrum. Emergent cervical, thoracic, and revision lumbar laminectomy without fusion was performed to decompress the spinal canal and evacuate the hematoma.
Results:
Motor and sensory function returned to normal by 14 days postoperatively, but bowel and bladder function continued to be impaired. Postoperative radiographs showed that coronal and sagittal spinal alignment did not change significantly after extensive laminectomy.
Conclusions:
Full anticoagulation should be avoided in the early postoperative period. In cases requiring early vigorous anticoagulation, patients should be closely monitored for changes in neurologic status. Combined cervical, thoracic, and lumbar laminectomy, without instrumentation or fusion, is an acceptable treatment option.
PMCID: PMC2031966  PMID: 17684896
Spinal stenosis, lumbar; Spinal decompression; Anticoagulation; Epidural hematoma; Laminectomy

Results 1-7 (7)