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Object: Symptomatic adjacent-segment lumbar disease (ASLD) after lumbar fusion often requires subsequent surgical intervention. The authors report utilizing cortical bone trajectory (CBT) pedicle screw fixation with intraoperative CT (O-arm) image-guided navigation to stabilize spinal levels in patients with symptomatic ASLD. This unique technique results in the placement of 2 screws in the same pedicle (1 traditional pedicle trajectory and 1 CBT) and obviates the need to remove preexisting instrumentation., Methods: The records of 5 consecutive patients who underwent lumbar spinal fusion with CBT and posterior interbody grafting for ASLD were retrospectively reviewed. All patients underwent screw trajectory planning with the O-arm in conjunction with the StealthStation navigation system. Basic demographics, operative details, and radiographic and clinical outcomes were obtained., Results: The average patient age was 69.4 years (range 58-82 years). Four of the 5 surgeries were performed with the Minimal Access Spinal Technologies (MAST) Midline Lumbar Fusion (MIDLF) system. The average operative duration was 218 minutes (range 175-315 minutes). In the entire cohort, 5.5-mm cortical screws were placed in previously instrumented pedicles. The average hospital stay was 2.8 days (range 2-3 days) and there were no surgical complications. All patients had more than 6 months of radiographic and clinical follow-up (range 10-15 months). At last follow-up, all patients reported improved symptoms from their preoperative state. Radiographic follow-up showed Lenke fusion grades of A or B., Conclusions: The authors present a novel fusion technique that uses CBT pedicle screw fixation in a previously instrumented pedicle with intraoperative O-arm guided navigation. This method obviates the need for hardware removal. This cohort of patients experienced good clinical results. Computed tomography navigation was critical for accurate CBT screw placement at levels where previous traditional pedicle screws were already placed for symptomatic ASLD.

Object: The authors conducted a literature-based review of the etiology, diagnosis, and treatment of cervical vertebral osteomyelitis (CVO)., Methods: A Medline (PubMed) search using the key words "cervical vertebral osteomyelitis" yielded 256 articles. These were further screened for relevance, yielding 15 articles. Each publication was reviewed, and several others not identified in the PubMed search were screened and included in the review according to relevance. Each article was identified as involving either the epidemiology/etiology, diagnosis, or treatment of CVO. Separate categories were created for case reports and general reviews., Conclusions: Cervical vertebral osteomyelitis has a spectrum of origins, which include spontaneous, postoperative, traumatic, and hematogenously spread causes. The majority of patients have medical risk factors and comorbidities that include diabetes, trauma, drug abuse, and infectious processes in extraspinal areas. The diagnosis of CVO can be accomplished in most cases by using plain x-ray films and computerized tomography scans. Nevertheless, preferential use of magnetic resonance imaging in cases in which there is a neurological deficit is helpful in identifying epidural compressive processes. Treatment for CVO can be successfully initiated with intravenous antibiotic therapy. Nevertheless, in cases in which there is a neurological deficit, spinal deformity and/or progressive lysis, or intractable pain, the earliest feasible surgical intervention with debridement and fusion is warranted.

Object: The authors conducted a review of the literature to establish reasonable practical guidelines for the management of complications in patients who have undergone recent spinal surgery and who require Level 1 anticoagulation therapy., Methods: A MEDLINE (PubMed) literature search was performed using the key words "postoperative anticoagulation," "spinal surgery," and "postoperative epidural hematoma," for articles published between 1990 and 2004. The search yielded 148 articles, which were then further screened for relevance and classified according to level-of-evidence guidelines established by the American Association of Neurological Surgeons/Congress of Neurological Surgeons joint committee for spinal cord injury. A total of 12 relevant articles were reviewed. There were no relevant articles meeting Class 1 standards of evidence, two met Class 2 evidence standards (one was a nonrandomized cohort study, the other was case-controlled), and the remaining 10 articles contained Class 3 evidence., Conclusions: There are insufficient data to establish evidence-based guidelines for the use of Level 1 heparin or an equivalent anticoagulation protocol in patients who have recently undergone spinal surgery. Nevertheless, a search of the limited peer-reviewed literature on the subject indicates that there is an anecdotally high risk of complications in patients who have undergone spinal surgery and in whom a Level 1 or equivalent heparin protocol is administered. It therefore seems most prudent to arrange for placement of a vena cava filter in patients who have undergone spinal surgery and in whom a pulmonary embolus is found postoperatively. In patients who undergo spinal surgery and who require heparinization therapy for myocardial ischemia or infarction, the use of frequent neurological examinations in conjunction with anticoagulation therapy seems to be the only reasonable option.

Object: The goal of this prospective study was to review a series of 27 patients who underwent bilateral posterior lumbar interbody fusion with instrumented pedicle fixation and two HYDROSORB (known generically as 70:30 poly[L-lactide-co-D,L-lactide]) rectangular cages packed with locally harvested autograft at a total of 48 levels, and to assess the safety and efficacy of this novel technique. This analysis, conducted at a mean of 26 months of follow up, is the first report of a long-term evaluation of this technique. Fusion rates and clinical outcomes are presented., Methods: A prospective clinical and radiographic review of findings in 27 consecutive patients was performed. Fusion rates and clinical outcome were assessed at 6-month intervals up to the 32-month follow-up end point. Two patients with four corresponding fusion levels were lost to follow up. Radiographic evidence of satisfactory fusion was achieved in 42 (95.5%) of 44 levels fused. Satisfactory fusion at all levels was achieved in 23 (92%) of 25 patients. Two patients required repeated operations for treatment of symptomatic pseudarthrosis during the study period. The likelihood of all levels attaining fusion in a given patient decreased as the number of levels treated increased, which is consistent with previously published studies. Nonetheless, fusion rates per treated level were similar for patients in whom one to three levels were treated. No significant surgical complication occurred., Conclusions: Posterior lumbar interbody fusion in which the HYDROSORB bioabsorbable implant packed with locally harvested autograft and segmental internal fixation are used appears to be an interbody fusion alternative whose efficacy is comparable with previously reported procedures.

Spinal pseudomeningoceles and cerebrospinal fluid (CSF) fistulas are rare extradural collections of CSF that result following a breach in the dural-arachnoid layer. They may occur due to an incidental durotomy, during intradural surgery, or from trauma or congenital abnormality. The majority are iatrogenic and occur in the posterior lumbar region following surgery. Although they are often asymptomatic, they may cause low-back pain, headaches, and even nerve root entrapment. Leakage of CSF from the wound may cause a fistulous tract, which is a conduit for infection and should be repaired immediately. Diagnosis can be confirmed on clinical examination or imaging studies including magnetic resonance imaging, computerized tomography myelography, and radionuclide myelography. Treatment must be specific to each patient because the timing, size, symptoms, and location of the dural breach all affect the choice of therapy. Nonsurgical methods may be used, but more frequently operative repair is required. In this article, the authors review the diagnosis and treatment of spinal pseudomeningoceles and CSF fistulas.

Object: The authors report the cases of 12 patients with medically refractory mechanical low-back pain and intermittent radicular symptoms in whom radiography demonstrated evidence of multilevel lumbosacral degenerative kyphotic and scoliotic deformity and spondylolisthesis., Methods: These patients underwent multilevel posterior lumbar interbody fusion in which Macropore bioabsorbable spacers were placed. Each patient underwent at least 1 year of clinical and radiographic follow up., Conclusions: This series illustrates the novel use of bioabsorbable interbody spacers and fusion technique for correction of spinal deformity due to advanced degenerative kyphoscoliosis and spondylolisthesis.

Anterior fixation devices for the thoracolumbar spine have gained wide acceptance as viable alternatives to long-segment posterior fixation in cases of thoracolumbar spine trauma. This review was undertaken to evaluate the safety and efficacy of the Synthes anterior thoracolumbar locking plate (ATLP) system. Over a 3-year period, 31 patients with unstable traumatic fractures of the thoracolumbar spine underwent corpectomy, placement of a structural bone graft, and anterior fixation in which the Synthes ATLP system was used. Long-term follow-up data were obtained in 29 patients. Two patients were lost to follow up, one at 4 months and the other at 1 year. In the remaining patients, the average length of follow up was 20 months. In all patients radiographic evidence of solid bone fusion was demonstrated on follow-up plain x-ray films, and there were no signs or symptoms of pseudarthrosis. No patient suffered neurological deterioration as a result of surgery, and there was relatively little morbidity associated with this plating system. To date, none of the patients in this study has developed any delayed complications related to the fixation device. In one patient, who had sustained a severe flexion injury, loosening of the anterior fixation device occurred, and the patient developed progressive kyphosis, which required a posterior stabilization procedure. These results appear slightly better than those obtained in published studies in which other anterior plating systems were used, indicating that this system is safe and effective in the treatment of unstable fractures of the thoracolumbar spine.

Lumbar spinal stenosis is often the result of advanced degeneration of motion segments of the lumbar spine. Loss of disc height, facet displacement and hypertrophy, spondylosis, and spondylolisthesis, as well as buckling of the ligamentum flavum and annulus fibrosus, all contribute to impingement on the spinal canal and intervertebral foramen in lumbar stenosis. There is a subgroup of patients with spinal stenosis in whom the spine is unstable preoperatively or becomes destabilized following decompression who would benefit from an initial fusion procedure. Posterior lumbar interbody fusion (PLIF) addresses several aspects of the multifactorial pathophysiology responsible for spinal stenosis and may arrest the degenerative changes at the fused level. Fusion, in particular PLIF, should be considered in complex cases of lumbar spinal stenosis, most notably in patients with postlaminectomy stenosis or stenosis associated with spondylolisthesis.