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BACKGROUND Osteoporosis is a metabolic bone disease that commonly affects the elderly. Degenerative spinal disease that may require surgical intervention is also prevalent in this susceptible population. If undiagnosed or untreated before spine surgery, osteoporosis may result in an increased risk of postoperative adverse events. Nontreatment of osteoporosis preoperatively may be related to a poor understanding of bone physiology, a lack of standardized treatment algorithms, limited cost-effective interventions, and reluctance by spine surgeons to be the primary provider of osteoporosis management. OBJECTIVE The objective of this evidence-based review is to develop guidelines for the preoperative assessment and treatment of osteoporosis in patients undergoing spine surgery. METHODS A systematic review of the literature was performed using the National Library of Medicine/PubMed database and Embase for studies relevant to preoperative diagnostic studies that predict increased risk of osteoporosis-related postoperative adverse events and whether the preoperative treatment of low bone mineral density (BMD) in patients with osteoporosis improves outcome. RESULTS Out of 281 studies, 17 met the inclusion criteria and were included for systematic review. The task force affirmed a Grade B recommendation that preoperative osteoporosis testing with a dual-energy X-ray absorptiometry scan (T-score < -2.5), a computed tomography scan (Hounsfield units

Introduction Postdischarge patient calls are an effective intervention to decrease unplanned readmissions. Despite its efficacy, calls are time consuming and compete with other clinical obligations. The purpose of this study was to evaluate the viability of intern-led quality improvement (QI) on conducting initial postdischarge calls to filter patients who require clinical or nurse follow-up. Methods QI interns from an academic medical center's QI program completed postdischarge patient calls within 72 hours of patient discharge from a neurosurgery service between June 2018 and July 2019. QI interns filtered patients who required follow-up calls from a clinical service or nurse department. The departments called patients within 48 hours of requests. Unplanned readmission rate was compared between the cohort of patients who requested and received a follow-up call versus a cohort of patients who requested and did not receive a follow-up call (control). Results QI interns completed 83.8% postdischarge patient calls within 72 hours of discharge. Reasons for unsuccessful calls included patient unresponsiveness (74.6%), wrong phone number on file (13.9%), and request to be called at a different time (11.5%). Nurses completed 57.2% follow-up requests within the targeted 48 hours and completed remaining requests within 7 days. QI intern postdischarge follow-up calls, in conjunction with nurse follow-up intervention, showed a significant (risk ratio = −3.31, p = 0.012) preventive effect on unplanned readmission rate. Conclusions QI interns are a viable alternative to nurses to conduct the first contact of postdischarge patient follow-up calls. This system of QI interns filtering calls to the correct clinical service or nurse department increased postdischarge patient follow-up calls success rate and decreased readmission rates.

Objective Transforaminal lumbar interbody fusion (TLIF) is a common approach and results in varying degrees of lordosis correction. The purpose of this study is to determine preoperative radiographic spinopelvic parameters that predict change in postoperative segmental and lumbar lordosis after TLIF. Materials & Methods This study is a single surgeon retrospective review of one-level and two-level TLIFs from L3-S1. All patients underwent bilateral facetectomies, 10 mm TLIF cage (non-lordotic) insertions, and bilateral pedicle screw-rod construct placements. Pre- and post-operative X-rays were assessed for preoperative segmental lordosis (SL), lumbar lordosis (LL), and pelvic incidence (PI). Univariate and multi-predictor linear regression analyses were performed to determine the relationships between preoperative radiographic findings and change in early postoperative segmental and lumbar lordosis. Results Ninety-seven patients contributing 128 intervertebral segments were examined. The mean change in SL after TLIF was 7.3 (range: 0.10-28.9°, SD 6.39°). The mean change in LL after TLIF was 5.5˚ (range: -14.8-39.2°, standard deviation (SD) 7.16°). Greater preoperative LL predicted less postoperative LL correction, while greater preoperative PI predicted more postoperative SL and LL correction. Greater anterior disk height was noted to be associated with a decreased change in SL (∆SL). An annular tear on preoperative magnetic resonance imaging (MRI) predicted a 2.7° decrease in ∆SL. A Schmorl's node on preoperative MRI predicted a 4.0° decrease in change in LL (∆LL). Conclusions A greater preoperative lordosis and a lower spinopelvic mismatch lessen the potential for an increase in the postoperative SL and LL after a TLIF, which is likely due to a ‘ceiling’ effect of an otherwise optimized spinal alignment. A greater anterior disk height and the presence of an annular tear are associated with decreased ∆SL.

Expert opinion-modified Delphi study.We used a modified Delphi approach to obtain consensus among leading spinal deformity surgeons and their neuroanesthesiology teams regarding optimal practices for obtaining reliable motor evoked potential (MEP) signals.Intraoperative neurophysiological monitoring of transcranial MEPs provides the best method for assessing spinal cord integrity during complex spinal surgeries. MEPs are affected by pharmacological and physiological parameters. It is the responsibility of the spine surgeon and neuroanesthesia team to understand how they can best maintain high-quality MEP signals throughout surgery. Nevertheless, varying approaches to neuroanesthesia are seen in clinical practice.We identified 19 international expert spinal deformity treatment teams. A modified Delphi process with two rounds of surveying was performed. Greater than 50% agreement on the final statements was considered "agreement";75% agreement was considered "consensus."Anesthesia regimens and protocols were obtained from the expert centers. There was a large amount of variability among centers. Two rounds of consensus surveying were performed, and all centers participated in both rounds of surveying. Consensus was obtained for 12 of 15 statements, and majority agreement was obtained for two of the remaining statements. Total intravenous anesthesia was identified as the preferred method of maintenance, with few centers allowing for low mean alveolar concentration of inhaled anesthetic. Most centers advocated for150 μg/kg/min of propofol with titration to the lowest dose that maintains appropriate anesthesia depth based on awareness monitoring. Use of adjuvant intravenous anesthetics, including ketamine, low-dose dexmedetomidine, and lidocaine, may help to reduce propofol requirements without negatively effecting MEP signals.Spine surgeons and neuroanesthesia teams should be familiar with methods for optimizing MEPs during deformity and complex spinal cases. Although variability in practices exists, there is consensus among international spinal deformity treatment centers regarding best practices.5.

Cervical kyphotic deformity can be a debilitating condition with symptoms ranging from mechanical neck pain, radiculopathy, and myelopathy to impaired swallowing and horizontal gaze. Surgical correction of cervical kyphosis has the potential to halt progression of neurological and clinical deterioration and even restore function. There are various operative approaches and deformity correction techniques. Choosing the optimal strategy is predicated on a fundamental understanding of spine biomechanics. Preoperative characterization of cervical malalignment, assessment of deformity rigidity, and defining postoperative clinical and radiographic objectives are paramount to formulating a surgical plan that balances clinical benefit with morbidity. This review of cervical deformity treatment provides an overview of the biomechanics of cervical kyphosis, radiographic classification, algorithm-based management, surgical techniques, and current surgical outcome studies.

Starting in the 1960s, ossification of the posterior longitudinal ligament (OPLL) became more commonly diagnosed in Japan. The disease is characterized by a gradual increase in calcification of the posterior longitudinal ligament with the eventual sequelae of cervical canal stenosis and myelopathy. Surgical interventions to relieve stenosis and neurologic symptoms are performed to decompress the cervical canal. Studies demonstrate continued ossification of the OPLL in both nonsurgical and surgically treated patients. In this review, the authors evaluate the epidemiology, pathophysiology, and literature regarding disease progression in OPLL after cervical fusion.

BACKGROUND There are no current recommendations for preoperative pulmonary evaluation and management of patients undergoing elective spine surgery. OBJECTIVE The aim of this guideline is to determine preoperative risk factors for perioperative and postoperative pulmonary adverse events and to determine the optimal preoperative evaluation and management of at-risk patients. METHODS A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to postoperative pulmonary adverse events in patients undergoing spine surgery. Clinical studies evaluating preoperative patient risk factors and preoperative diagnostic and treatment interventions were selected for review. RESULTS The literature search yielded 152 abstracts relevant to the PICO (patient/population, intervention, comparison, and outcomes) questions included in this chapter. The task force selected 65 articles for full-text review, and 24 were selected for inclusion in this systematic review. Twenty-three articles addressed preoperative patient risk factors. One article addressed preoperative diagnostic studies of pulmonary function. There were no studies meeting the inclusion criteria for preoperative pulmonary treatment. CONCLUSION There is substantial evidence for multiple preoperative patient factors that predict an increased risk of a postoperative pulmonary adverse event. Individuals with these risk factors (functional dependence, advanced age [≥65 yr], chronic obstructive pulmonary disease, congestive heart failure, weight loss, and obstructive sleep apnea) who are undergoing spine surgery should be counseled regarding the potential increased risk of a perioperative and postoperative pulmonary adverse events. There is insufficient evidence to support any specific preoperative diagnostic test for predicting the risk of postoperative pulmonary adverse events or any treatment intervention that reduces risk. It is suggested, however, to consider appropriate preoperative pulmonary diagnostic testing and treatment to address active pulmonary symptoms of existing or suspected disease.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/5-preoperative-pulmonary-evaluation-optimization.

OBJECTIVE The purpose of this retrospective multicenter study was to compare prognostic factors for neurological recovery in patients undergoing surgery for cervical ossification of the posterior longitudinal ligament (OPLL) based on their presenting mild, moderate, or severe myelopathy. METHODS The study included 372 consecutive patients with OPLL who underwent surgery for cervical myelopathy between 2006 and 2016 in East Asian countries with a high OPLL prevalence. Baseline and postoperative clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) myelopathy score and recovery ratio. Radiographic assessment included occupying ratio, cervical range of motion, and sagittal alignment parameters. Patient myelopathy was classified as mild, moderate, or severe based on the preoperative JOA score. Linear and multivariate regression analyses were performed to identify patient and surgical factors associated with neurological recovery stratified by baseline myelopathy severity. RESULTS The mean follow-up period was 45.4 months (range 25–140 months). The mean preoperative and postoperative JOA scores and recovery ratios for the total cohort were 11.7 ± 3.0, 14.5 ± 2.7, and 55.2% ± 39.3%, respectively. In patients with mild myelopathy, only age and diabetes correlated with recovery. In patients with moderate to severe myelopathy, older age and preoperative increased signal intensity on T2-weighted imaging were significantly correlated with a lower likelihood of recovery, while female sex and anterior decompression with fusion (ADF) were associated with better recovery. CONCLUSIONS Various patient and surgical factors are correlated with likelihood of neurological recovery after surgical treatment for cervical OPLL, depending on the severity of presenting myelopathy. Older age, male sex, intramedullary high signal intensity, and posterior decompression are associated with less myelopathy improvement in patients with worse baseline function. Therefore, myelopathy-specific preoperative counseling regarding prognosis for postoperative long-term neurological improvement should include consideration of these individual and surgical factors.

Background Treatment of thoracolumbar burst fractures has traditionally involved spinal instrumentation with fusion performed with standard open surgical techniques. Novel surgical strategies, including instrumentation without fusion and percutaneous instrumentation alone, have been considered less invasive and more efficient treatments. Objective To review the current literature and determine the role of fusion in instrumented fixation, as well as the role of percutaneous instrumentation, in the treatment of patients with thoracolumbar burst fractures. Methods The task force members identified search terms/parameters and a medical librarian implemented the literature search, consistent with the literature search protocol (see Appendix I), using the National Library of Medicine PubMed database and the Cochrane Library for the period from January 1, 1946 to March 31, 2015. Results A total of 906 articles were identified and 38 were selected for full-text review. Of these articles, 12 articles met criteria for inclusion in this systematic review. Conclusion There is grade A evidence for the omission of fusion in instrumented fixation for thoracolumbar burst fractures. There is grade B evidence that percutaneous instrumentation is as effective as open instrumentation for thoracolumbar burst fractures. Question Does the addition of arthrodesis to instrumented fixation improve outcomes in patients with thoracic and lumbar burst fractures? Recommendation It is recommended that in the surgical treatment of patients with thoracolumbar burst fractures, surgeons should understand that the addition of arthrodesis to instrumented stabilization has not been shown to impact clinical or radiological outcomes, and adds to increased blood loss and operative time. Strength of Recommendation: Grade A. Question How does the use of minimally invasive techniques (including percutaneous instrumentation) affect outcomes in patients undergoing surgery for thoracic and lumbar fractures compared to conventional open techniques? Recommendation Stabilization using both open and percutaneous pedicle screws may be considered in the treatment of thoracolumbar burst fractures as the evidence suggests equivalent clinical outcomes. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_12.

Background Thoracic and lumbar burst fractures in neurologically intact patients are considered to be inherently stable, and responsive to nonsurgical management. There is a lack of consensus regarding the optimal conservative treatment modality. The question remains whether external bracing is necessary vs mobilization without a brace after these injuries. Objective To determine if the use of external bracing improves outcomes compared to no brace for neurologically intact patients with thoracic or lumbar burst fractures. Methods A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically comparing external bracing to no brace for neurologically intact patients with thoracic or lumbar burst fractures were selected for review. Results Three studies out of 1137 met inclusion criteria for review. One randomized controlled trial (level I) and an additional randomized controlled pilot study (level II) provided evidence that both external bracing and no brace equally improve pain and disability in neurologically intact patients with burst fractures. There was no difference in final clinical and radiographic outcomes between patients treated with an external brace vs no brace. One additional level IV retrospective study demonstrated equivalent clinical outcomes for external bracing vs no brace. Conclusion This evidence-based guideline provides a grade B recommendation that management either with or without an external brace is an option given equivalent improvement in outcomes for neurologically intact patients with thoracic and lumbar burst fractures. The decision to use an external brace is at the discretion of the treating physician, as bracing is not associated with increased adverse events compared to no brace. Question Does the use of external bracing improve outcomes in the nonoperative treatment of neurologically intact patients with thoracic and lumbar burst fractures? Recommendation The decision to use an external brace is at the discretion of the treating physician, as the nonoperative management of neurologically intact patients with thoracic and lumbar burst fractures either with or without an external brace produces equivalent improvement in outcomes. Bracing is not associated with increased adverse events compared to not bracing. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_8.

Question 1 Does routine screening for deep venous thrombosis prevent pulmonary embolism (or venous thromboembolism (VTE)-associated morbidity and mortality) in patients with thoracic and lumbar fractures? Recommendation 1 There is insufficient evidence to recommend for or against routine screening for deep venous thrombosis in preventing pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. Question 2 For patients with thoracic and lumbar fractures, is one regimen of VTE prophylaxis superior to others with respect to prevention of pulmonary embolism (or VTE-associated morbidity and mortality)? Recommendation 2 There is insufficient evidence to recommend a specific regimen of VTE prophylaxis to prevent pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. Question 3 Is there a specific treatment regimen for documented VTE that provides fewer complications than other treatments in patients with thoracic and lumbar fractures? Recommendation 3 There is insufficient evidence to recommend for or against a specific treatment regimen for documented VTE that would provide fewer complications than other treatments in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. Recommendation 4 Based on published data from pooled (cervical and thoracolumbar) spinal cord injury populations, the use of thromboprophylaxis is recommended to reduce the risk of VTE events in patients with thoracic and lumbar fractures. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_7.

Cervical disc arthroplasty (CDA) has received widespread attention as an alternative to anterior fusion due to its similar neurological and functional improvement, with the advantage of preservation of segmental motion. As CDA becomes more widely implemented, the potential for unexpected device-related adverse events may be identified.The authors report on a 48-year-old man who presented with progressive neurological deficits 3 years after 2-level CDA was performed. Imaging demonstrated periprosthetic osteolysis of the vertebral endplates at the CDA levels, with a heterogeneously enhancing ventral epidural mass compressing the spinal cord. Diagnostic workup for infectious and neoplastic processes was negative. The presumptive diagnosis was an inflammatory pannus formation secondary to abnormal motion at the CDA levels. Posterior cervical decompression and instrumented fusion was performed without removal of the arthroplasty devices or the ventral epidural mass. Postoperative imaging at 2 months demonstrated complete resolution of the compressive pannus, with associated improvement in clinical symptoms. Follow-up MRI at > 6 months showed no recurrence of the pannus. At 1 year postoperatively, CT scanning revealed improvement in periprosthetic osteolysis.Inflammatory pannus formation may be an unexpected complication of abnormal segmental motion after CDA. This rare etiology of an epidural mass associated with an arthroplasty device should be considered, in addition to workup for other potential infectious or neoplastic mass lesions. In symptomatic individuals, compressive pannus lesions can be effectively treated with fusion across the involved segment without removal of the device.

Devastating functional deficits following spinal cord injury (SCI) are no longer considered irreversible. Laboratory findings indicate that some improvements can be achieved with therapeutic approaches designed to promote tissue repair. It also has become widely recognised that the spinal cord is not a ‘hard-wired’ structure; neural circuits can undergo spontaneous anatomical, neurophysiological, or molecular remodelling (i.e. endogenous neuroplasticity) after injury with accompanying behavioural changes. New rehabilitation regimens and spinal cord electrical stimulation have likewise been found to have great potential for enhancing neuroplasticity and activating synaptic networks below the spinal level of injury. While many challenges remain, promising therapeutic strategies are now emerging for promoting significant improvements in quality of life after SCI by integrating cellular and molecular treatments with neurorehabilitation and complementary neuroengineering approaches. Key Concepts Spinal cord injury is no longer viewed as an untreatable condition. The spinal cord is not a rigidly wired structure; it can exhibit structural and functional remodelling. Intrinsic ‘neuroplasticity’ can contribute to partial improvement in function post spinal cord injury. Novel therapeutic approaches have emerged, which target cellular responses to spinal cord injury. Spinal cord injuries are rarely anatomically complete, even when defined clinically as being functionally or neurologically complete. Uninjured pathways and spinal interneurons can play important roles in subserving spontaneous functional improvements in lieu of original pathways that fail to show long-distance regrowth. Transplantation of neural progenitors that are destined to become spinal neurons may contribute to interneuronal relays capable of transmitting functional information between separated regions of the injured spinal cord. Specialised rehabilitation regimens, exercise and electrical stimulation of muscles can promote and guide plasticity that improves motor function. Electrical stimulation of the injured spinal cord can evoke some voluntary movement in people who otherwise exhibit complete loss of voluntary control of movement below the spinal level of injury. Optimal therapeutic approaches for spinal cord injury are unlikely to result from a single type of treatment, but rather from strategies involving two or more complementary approaches. Keywords: neuroplasticity; locomotor training; rehabilitation; spinal cord injury; spinal cord repair; intermittent hypoxia; operant conditioning; neural stimulation

Symptomatic cervical spine pathology commonly presents with findings of radiculopathy and/or myelopathy. The underlying pathobiologic mechanism for radiculopathy and myelopathy is often multifactorial. Radiculopathy is the motor and/or sensory manifestation of neurologic dysfunction in the distribution of a given cervical nerve root. This can be due to static mechanical or dynamic compression of the nerve or secondary to biochemical factors. There are characteristic clinical symptoms and exam findings in cervical radiculopathy that correspond to specific cervical nerve roots. Myelopathy is the involvement of upper motor neuron and sensory impairment and can include long ascending and descending spinal tracts as well as multiple spinal root levels. Myelopathy can also be secondary to static mechanical or dynamic compression of the nerve. Additionally, vascular ischemia and stretch and shear forces have been implicated in myelopathy. The characteristic clinical presentation is often defined by loss of coordination, sensory dysfunction, hyperreflexia, and in severe cases weakness and bowel or bladder incontinence.

Question 1 Does the surgical treatment of burst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? Recommendation 1 There is conflicting evidence to recommend for or against the use of surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fracture who are neurologically intact. Therefore, it is recommended that the discretion of the treating provider be used to determine if the presenting thoracic or lumbar burst fracture in the neurologically intact patient warrants surgical intervention. Strength of Recommendation: Grade Insufficient. Question 2 Does the surgical treatment of nonburst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? Recommendation 2 There is insufficient evidence to recommend for or against the use of surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgery for such fractures be at the discretion of the treating physician. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.

QUESTION 1 Which neurological assessment tools have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures (ie, do these instruments provide consistent information between different care providers)? RECOMMENDATION 1 Numerous neurologic assessment scales (Functional Independence Measure, Sunnybrook Cord Injury Scale and Frankel Scale for Spinal Cord Injury) have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures. Unfortunately, other contemporaneous measurement scales (ie, American Spinal Cord Injury Association Impairment Scale) have not been specifically studied in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade C. QUESTION 2 Are there any clinical findings (eg, presenting neurological grade/function) in patients with thoracic and lumbar fractures that can assist in predicting clinical outcomes? RECOMMENDATION 2 Entry American Spinal Injury Association Impairment Scale grade, sacral sensation, ankle spasticity, urethral and rectal sphincter function, and AbH motor function can be used to predict neurological function and outcome in patients with thoracic and lumbar fractures (Table I https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_4_table1). Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_4.

Question Does the administration of a specific pharmacologic agent (eg, methylprednisolone) improve clinical outcomes in patients with thoracic and lumbar fractures and spinal cord injury? Recommendation There is insufficient evidence to make a recommendation; however, the task force concluded, in light of previously published data and guidelines, that the complication profile should be carefully considered when deciding on the administration of methylprednisolone. Strength of recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_5.

Question Does the active maintenance of arterial blood pressure after injury affect clinical outcomes in patients with thoracic and lumbar fractures? Recommendations There is insufficient evidence to recommend for or against the use of active maintenance of arterial blood pressure after thoracolumbar spinal cord injury. Grade of Recommendation: Grade Insufficient However, in light of published data from pooled (cervical and thoracolumbar) spinal cord injury patient populations, clinicians may choose to maintain mean arterial blood pressures >85 mm Hg in an attempt to improve neurological outcomes. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_6.

Objective Traumatic high-grade cervical spinal dislocations are rare injuries, generally associated with severe neurological compromise. In particular, cervical spondyloptosis (>100% subluxation) is rarely reported. The object of our study is to present a case series describing presentation, management, and outcome in traumatic high-grade cervical spinal dislocations. Methods Retrospective analysis was performed involving two level 1 trauma centers. Patients with a high-grade traumatic cervical subluxation were selected from a database, and these patients were admitted between August 2007 and July 2011. Results Fifteen patients were identified; three had spondyloptosis. The admission American Spinal Injury Association Impairment Scale (AIS) grade varied (A = 9; B = 2; C = 1; D = 2; E = 1). Fourteen patients underwent attempted closed reduction with six (43%) failing closed reduction. High-dose methylprednisolone was administered in nine patients (60%). All patients underwent surgical stabilization: three underwent anterior only, three underwent posterior only, and nine underwent a combined anterior-posterior approach. Postoperatively, one patient improved two AIS grades, three improved one AIS grade, nine maintained their preoperative score, and two patients worsened. Conclusions In this series, 26.7% of patients had improvement in their AIS grade postoperatively, and the majority of patients (60%) maintained their preoperative AIS grade. In 57% of patients placed in traction, reduction was possible. Likely due to the severity of these injuries, there was a high incidence of complications. However, review of patient outcomes reveals that these patients can have improvement of neurological function. We recommend aggressive reduction and surgical stabilization. Our preference is either a combined anterior-posterior approach or a posterior-only approach.

Study Design Retrospective clinical study. Objectives Recent biomechanical studies have shown no differences in stiffness or range of motion following minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) between unilateral pedicle and contralateral facet screw (UPFS) and bilateral pedicle screw (BPS) constructs. No studies have compared these two constructs based upon clinical outcomes. Methods Twenty-six consecutive patients who had single-level MIS TLIF were retrospectively reviewed. Outcome measures collected for patients with BPS were compared with those with UPFS. Results No associations were found between construct and length of stay ( p = 0.5), operative time ( p = 0.2), or Odom's criteria ( p = 0.7); 79% of patients in the UPFS group as compared with 71.5% in the BPS group had good or excellent outcomes. Mean follow-up was 17.7 months for the UPFS group and 20.2 months for the BPS group. There was one complication in each group, including a seroma in the BPS group and a revision operation in the UPFS group. Implant costs for the BPS group were 35% greater than the UPFS group. Conclusions The present study is the first to demonstrate that patients undergoing MIS TLIF with BPS as compared with UPFS for single-level degenerative lumbar disease had similar clinical outcomes.

BACKGROUND Spontaneous thoracic ankylosis is a progressive degenerative process that predisposes patients to potentially highly unstable traumatic injuries. Acute hyperextension fractures result in dynamic instability putting the spinal cord at risk. OBJECTIVE To describe preoperative radiographic characteristics of fractures of the ankylotic thoracic spine and relate findings to early postoperative radiographic and clinical outcomes. METHODS A single center, retrospective review was performed of 28 surgically treated patients with fractures of the ankylotic thoracic spine. Radiographic assessment included preoperative fracture angulation (FA) and fracture displacement (FD), and postoperative change in sagittal alignment. Early clinical outcomes included preoperative and postoperative American Spinal Injury Association (ASIA) grade and perioperative complications. RESULTS Seven patients (25%) presented with poor neurological grade (ASIA A-C) compared to 21 (75%) with good grade (ASIA D, E). At presentation, poor grade patients had a mean FA of 16.4° (range 0°-34.5°), and FD of 7.76 mm (range 0.8-9.2). Good grade patients had a mean FA of 18.2° (range 0°-43.3°), and FD of 4.77 mm (range 0-25.1). There was no statistically significant difference in FA or FD between groups (P = .70 and .20 respectively). All underwent posterior pedicle screw fixation for stabilization. Fifty per cent of patients presenting with ASIA C or D spinal cord injury improved 1 or more ASIA grades. There were no perioperative complications. Early postoperative sagittal alignment was maintained with a mean change of -2.6°. CONCLUSION Presenting fracture alignment does not significantly correlate with pre- or postoperative neurological status. Early posterior stabilization preserved neurological function, with neurological recovery occurring in a portion of individuals.

Ossification of the posterior longitudinal ligament (OPLL) is a disease process characterized by progressive growth and calcification resulting in spinal canal compromise and serious neurological sequelae in advanced cases. Historically, OPLL has most commonly been treated with posterior surgical decompression. Although this procedure indirectly decompresses the spinal cord, it does not address the offending pathological entity, and further growth of the lesion may result in delayed neurological deterioration. This fact is particularly relevant because a number of long-term studies have revealed both longitudinal and transverse disease progression in individuals treated both surgically and conservatively. Despite these high rates of radiographically documented progression, however, the rate of neurological decline in patients undergoing posterior surgery with laminoplasty is low. In this article, the authors review the pathophysiology of OPLL, evidence of disease progression, and outcome data addressing conservative and surgical treatments.

BACKGROUND The evidence of or against the presence of a 'July phenomenon' in resident teaching hospitals has been inconsistent. Moreover, there are limited data on the "July phenomenon" in the field of neurosurgery. OBJECTIVE To determine whether a "July phenomenon" exists for neurosurgical mortality or complications. METHODS A search of the National Inpatient Sample database from 1998 to 2008 was performed for all admissions for International Classification of Diseases, 9th Revision codes corresponding to nontraumatic hemorrhage, central nervous system (CNS) trauma, CNS tumor, and hydrocephalus. Generalized linear mixed-model analysis was performed, adjusted for patient demographics and hospital characteristics, for the outcomes of mortality and complications for the month of July compared with all other months in teaching hospitals. RESULTS Generalized linear mixed-model analysis demonstrated that the risk of dying in the month of July vs any other month in a teaching hospital was not statistically different for any of the 4 diagnoses: nontraumatic hemorrhage (P = .071), CNS trauma category (P = .485), CNS tumor category (P = .578), hydrocephalus category (P = .1505). Moreover, the risk of any complication in the month of July vs any other month in a teaching hospital was not statistically different for any of the 4 diagnoses: nontraumatic hemorrhage (P = .529), CNS trauma category (P = .378), CNS tumor category (P = .461), and hydrocephalus category (P = .441). The same findings were true in an analysis of nonteaching hospitals performed as a control. CONCLUSION No "July phenomenon" was found for neurosurgical mortality or complications in patients with nontraumatic hemorrhage, CNS trauma, CNS tumor, or hydrocephalus.

Oncomodulin, an ~12 kDa Ca(2+)-binding protein secreted from activated macrophages, has been shown to promote axonal regeneration from retinal ganglion cells (RGCs) following optic nerve injury. However, to date, the axonal growth-promoting capacity of oncomodulin in other models of 'regenerative failure' has not been evaluated. We assessed the capability of preconditioning treatment with oncomodulin to promote sensory axonal regeneration in an in vitro spot model of regenerative failure, and across the dorsal root zone (DREZ) after root crush injury. Neither the direct exposure of adult rat DRGs to oncomodulin, nor preconditioning of DRGs by intraganglionic injection of oncomodulin, stimulated axonal outgrowth in the in vitro proteoglycan spot gradient assay. However, direct exposure of unconditioned DRGs to both oncomodulin and db-cAMP in vitro, as well as preconditioning of DRGs with the combined treatment in vivo, resulted in significant, albeit modest, neurite extension across the inhibitory proteoglycan barrier. We next quantified axon regeneration through the C8 DREZ in adult rats after oncomodulin and/or db-cAMP preconditioning and chondroitinase (ChABC) injection into the DREZ immediately following a root crush injury. Axonal regeneration across the DREZ was not observed in control animals, or after injection of ChABC-alone. Treatment with oncomodulin- or db-cAMP-alone resulted in extremely sparse regeneration. However, significant, but meager, sensory axon regeneration across the DREZ was observed using the oncomodulin/ db-cAMP combination (p

The prognosis for substantial and lasting neurological recovery after complete traumatic spinal cord injury (SCI) remains dismal. Disruption of motor and sensory pathways involving not only limb activity, but also respiratory, urinary, and autonomic function, contributes to lifelong morbidity. Obstacles impeding the spinal cord’s ability for self-repair are multifactorial. Principal among these, however, is the limited growth potential of the injured spinal cord, as well as the problematic task of functionally reconnecting supraspinal to spinal neurons, and vice versa. Exciting recent developments in preclinical SCI research, however, are bringing to light novel strategies for circumventing these barriers to spinal recovery with potential for near-future translational therapies. Contrary to traditional thought, axons within the injured adult spinal cord have the capacity to grow, if given optimal circumstances. The propensity for spontaneous axonal growth, however, is limited by the extent of the intrinsic growth potential of adult neurons, and the degree of growth inhibition mediated by the injured cord. A significant component of the inhibitory, internal milieu after injury is due to the presence of chondroitin sulfate proteoglycans (CSPGs) (2, 10). CSPGs are molecules found within the perineuronal net, which have been identified as key factors in preventing axonal growth. Under normal conditions, CSPGs likely function to stabilize mature axons and prevent aberrant growth. After injury, CSPGs are up-regulated at the glial scar that forms at the injury site, and around partially denervated neurons distal to the injury. This increase in CSPGs causes sprouting axons to dieback as they approach the injury epicenter, thereby failing to restore connectivity. Chondroitinase ABC (ChABC) is an enzyme that cleaves the inhibition-mediating sugar chains of CSPGs. In animal models, intraspinal delivery of ChABC has been shown to promote a growth-permissive environment, facilitating spontaneous axonal growth across a spinal cord injury (3, 4). Lasting neurological recovery, however, requires not only axonal growth but also the re-establishment of functional connections between relevant supraspinal and spinal neurons. Precise restoration of point-to-point neural circuitry is a therapeutic challenge that is seemingly unrealistic, particularly of complex long distance neuronal pathways. Increasing recent scientific studies reveal, however, that under ideal conditions, spinal interneurons can sprout new axons after injury. More remarkably, growing

Intraoperative manipulation to correct scoliotic deformities relies upon spinal instrumentation for stabilization and fusion. However, novel strategies and innovative implant biotechnologies have emerged, applying natural growth and elongation of the immature spine for the treatment of scoliosis in young patients. In this work, we review the principles of growth modulation and the Hueter-Volkmann law as it applies to experimental models of scoliosis formation and correction. Current implant technologies, including shape memory alloy vertebral staples, growing rods, and vertical expandable titanium prosthetic ribs, are explored, with regards to implant design, surgical techniques, and clinical investigations. An exciting area of spinal implant technology is now becoming available to expand the surgical armamentarium for treating severe scoliotic deformity in young patients.

A retrospective national administrative database study. Patient safety indicators (PSIs) and hospital-acquired conditions (HACs) are metrics for quality of health care and are linked to reimbursement. The prevalence of PSIs/HACs may impact access to health care for certain conditions. We estimated the national occurrence rates of PSIs/HACs among cervical trauma patients and identified patient factors that correlate with their occurrence. United States of America. We queried Nationwide In-patient Sample database (NIS) hospitalizations (2002–2010) for diagnoses of cervical fracture with and without spinal cord injury (SCI). The incidence of each PSI/HAC was determined by ICD-9 (International Classification of Disease, 9th Revision) codes. Multivariate analysis was used to identify the correlation between specific variables and the probability of each indicator. There were 52 377 hospitalizations for cervical fracture in the NIS (without SCI, n=41 708; with SCI, n=10 669). Among those without SCI, there were 5374 (12.9%) reported PSIs and 117 (0.3%) HACs. Leading adverse events were postoperative respiratory failure (8.45%), pulmonary embolism (1.70%) and pressure ulcer (1.12%). Among those with SCI, there were 6600 (61.9%) PSIs and 143 (1.3%) HACs. Leading adverse events were postoperative respiratory failure (39.2%), pressure ulcer (7.78%), sepsis (5.71%), deep venous thrombosis (3.81%) and PE (1.70%). Adverse events were associated with several factors, including age, gender, Comorbidity Score and Injury Severity Score. Those with ⩾1 PSI/HAC had significantly longer lengths of stay (P

¶Background. Safety, feasibility, and efficacy trials in non-human primate stroke models are essential to the evaluation of experimental therapies and their translation to humans. Although Laser Doppler Flowmetry has been successfully employed in rodent stroke to continuously monitor cerebral blood flow, it has not been applied in primate studies. This investigation examined the utility of Laser Doppler Flowmetry in refining an existing baboon model of cerebral ischemia/reperfusion. Method. Continuous Laser Doppler Flowmetry monitoring was used, in non-human primates, to document local cerebral blood flow before, during, and after middle cerebral artery territory occlusion. In each baboon (n = 7) a single Doppler probe was placed into the left frontal cortex through a precoronal burr hole. Correlations between Laser Doppler Flowmetry values and latencies to Motor Evoked Potential dropout were compared using a linear regression model. Findings. Placement of the Laser Doppler probe was easily accomplished in all animals. Laser Doppler Flowmetry tracings accurately documented blood flow changes that occurred with each technical manipulation during the procedure. Laser Doppler confirmed decreased perfusion that coincided both regionally and temporally with vessel occlusion. Depth of ischemia as measured by Laser Doppler Flowmetry was associated with Motor Evoked Potential dropout latencies for individual animals. Conclusions. Continuous, single probe Laser Doppler Flowmetry is a reliable method of documenting perfusion changes following middle cerebral artery territory occlusion in a baboon model of reperfused stroke. This advanced intraoperative monitoring technique may lead to more accurate evaluation of acute stroke therapies in pre-clinical trials.

There is renewed interest in primate models of acute stroke for the evaluation of potential therapeutic agents prior to clinical trials. The development of more precise functional outcome measures would improve the pre-clinical assessment of neuroprotective strategies. We have constructed a grading scale that utilizes an increased number of goal-oriented tasks to assess both behavior and motor function. The new scoring system is designed to enhance precision and accuracy when compared to existing scales. Twenty-seven male baboons were subjected to 1 h of middle cerebral artery territory occlusion followed by reperfusion. Outcome was evaluated using both a standard neurological function scale and a new task-oriented scale. Each scoring system was assessed for reproducibility (inter-observer reliability) and for association with radiographic infarct volume. The task-oriented grading system was significantly less variable than the standard outcome measure (p0.0001). The task-oriented neurological scale demonstrated stronger correlation with radiographic infarct volume (p0.0001) than the standard scale (p0.01) and more accurately reflected infarct size in animals with small strokes. Compared to the accepted system for grading neurological function, the task-oriented scale demonstrates improved inter-observer variability and a better association with radiographic outcome measures. Incorporating this refined neurological evaluation into a baboon model of stroke may serve to increase the functional predictive value of pre-clinical studies.

Object Venous thromboembolism (VTE) represents a significant complication after spine surgery, with reported rates as high as 2%–4%. Published institutional practices for VTE prophylaxis are highly variable. In 2008, the authors implemented a departmental protocol for early VTE prophylaxis consisting of combined compressive devices and subcutaneous heparin initiated either preoperatively or on the same day of surgery. In this study, the authors compared the incidence of VTE in spine surgery patients before and after implementing this protocol. Methods An institutional review board–approved retrospective review of outcomes in patients undergoing spine surgery 2 years before protocol implementation (representing the preprotocol group) and of outcomes in patients treated 2 years thereafter (the postprotocol group) was conducted. Inclusion criteria were that patients were 18 years or older and had been admitted for 1 or more days. Before 2008 (preprotocol), VTE prophylaxis was variable and provider dependent without any uniform protocol. Since 2008 (postprotocol), a new VTE-prophylaxis protocol was administered, starting either preoperatively or on the same day of surgery and continuing throughout hospitalization. The new protocol consisted of 5000 U heparin administered subcutaneously 3 times daily, except in patients older than 75 years or weighing less than 50 kg, who received this dose twice daily. All patients also received sequential compression devices (SCDs). The incidence of VTE in the 2 protocol phases was identified by codes of the International Classification of Diseases, Ninth Revision (ICD-9) codes for deep vein thrombosis (DVT) and pulmonary embolus (PE). Bleeding complications arising from anticoagulation treatments were evaluated by the Current Procedural Terminology (CPT) code for postoperative epidural hematoma (EDH) requiring evacuation. Results In total, 941 patients in the preprotocol group met the inclusion criteria: 25 had DVT (2.7%), 6 had PE (0.6%), and 6 had postoperative EDH (0.6%). In the postprotocol group, 992 patients met the criteria: 10 had DVT (1.0%), 5 had PE (0.5%), and 4 had postoperative EDH (0.4%). This reduction in DVT after the protocol's implementation was statistically significant (p = 0.009). Despite early aggressive prophylaxis, the incidence of postoperative EDH did not increase and compared favorably to the published literature. Conclusions At a high-volume tertiary center, an aggressive protocol for early VTE prophylaxis after spine surgery decreases VTE incidence without increasing morbidity.

Respiratory dysfunction is one of the most devastating consequences of cervical spinal cord injury (SCI) with impaired breathing being a leading cause of morbidity and mortality in this population. However, there is mounting experimental and clinical evidence for moderate spontaneous respiratory recovery, or “plasticity”, after some spinal cord injuries. Pre-clinical models of respiratory dysfunction following SCI have demonstrated plasticity at neural and behavioral levels that result in progressive recovery of function. Temporal changes in respiration after human SCI have revealed some functional improvements suggesting plasticity paralleling that seen in experimental models – a concept that has been previously under-appreciated. While the extent of spontaneous recovery remains limited, it is possible that enhancing or facilitating neuroplastic mechanisms may have significant therapeutic potential. The next generation of treatment strategies for SCI and related respiratory dysfunction should aim to optimize these recovery processes of the injured spinal cord for lasting functional restoration.

Recent developments in surgical technique and technology have advanced the capabilities for surgical treatment of complex spinal pathology. Various surgical approaches allow for anterior, lateral, posterior, and circumferential exposure of the vertebral column, spinal cord, and nerves from the skull base to the pelvis. Contemporary spinal instrumentation provides optimal three-dimensional spinal fixation with improved biomechanical advantage for correction of spinal malalignment and long-term stabilization. The combination of these advances has resulted in broadened capabilities for treating traumatic, infectious, oncologic, and spinal deformity conditions in patients with complicated underlying primary disease as well as comorbidities. Optimal care includes a collaborative multidisciplinary effort including spine surgeons, neuro-anesthesiologists, and advanced neuro-critical care physicians. In this chapter, surgical approaches, techniques, and instrumentation are outlined with focus on specific anatomic and clinical considerations as well as potential complications.

Traumatic spinal cord injury can result in devastating motor and sensory deficits with resulting significant morbidity. Sequelae of spinal cord injury can include not only loss of upper and lower extremity function but potentially respiratory, urinary, and autonomic dysfunction with both acute and chronic complications. Currently, there is no available effective treatment for reversing neurologic deficits after traumatic spinal cord injury. Minimizing primary injury and preventing secondary injury depend on appropriate multidisciplinary management by first responders, trauma and spinal surgeons, and neurocritical care physicians. In this chapter, key clinical and neurologic assessment modalities, injury classification schemes, and critical care and surgical treatment strategies are outlined.

Spinal cord injury (SCI) is a significant public problem, with recent data suggesting that over 1 million people in the U.S.A. alone are affected by paralysis resulting from SCI. Recent advances in prehospital care have improved survival as well as reduced incidence and severity of SCI following spine trauma. Furthermore, increased understanding of the secondary mechanisms of injury following SCI has provided improvements in critical care and acute management in patients suffering from SCI, thus limiting morbidity following injury. In addition, improved technology and biomechanical understanding of the mechanisms of spine trauma have allowed further advances in available techniques for spinal decompression and stabilization. In this chapter we review the most recent data and salient literature regarding SCI and address current controversies, including the use of pharmacological adjuncts in the setting of acute SCI. We will also attempt to provide a reader with basic understanding of the classifications of SCI and spinal column injury. Finally, we review advances in spinal column stabilization including improvements in instrumented fusion and minimally invasive surgery.

Background Iliac screw fixation is a powerful tool used by spine surgeons to achieve fusion across the lumbosacral junction for a number of indications, including deformity, tumor, and pseudarthrosis. Complications associated with screw placement are related to blind trajectory selection and excessive soft tissue dissection. Objective To describe the technique of iliac screw fixation using computed tomographic (CT)-based image guidance. Methods Intraoperative registration and verification of anatomic landmarks are performed with the use of a preoperatively acquired CT of the lumbosacral spine. With the navigation probe, the ideal starting point for screw placement is selected while visualizing the intended trajectory and target on a computer screen. Once the starting point is selected and marked with a burr, a drill guide is docked within this point and the navigation probe re-inserted, confirming the trajectory. The probe is then removed and the high-speed drill reinserted within the drill guide. Drilling is performed to a depth measured on the computer screen and a screw is placed. Results Confirmation of accurate placement of iliac screws can be performed with standard radiographs. Conclusion CT-guided navigation allows for 3-dimensional visualization of the pelvis and minimizes complications associated with soft-tissue dissection and breach of the ilium during screw placement.

Dehydroascorbic acid (DHA), a blood–brain barrier transportable form of ascorbic acid, confers robust neuroprotection following murine stroke. In an effort to translate this promising neuroprotective strategy into human clinical trial, we evaluated postischemic DHA administration in a large-animal stroke model. Thirty-six adult male baboons were initially randomized to undergo transorbital craniectomy to induce transient cerebral artery occlusion and to receive postischemic dosing of either 500 mg/kg of DHA or vehicle. Primary outcomes included infarct volume, determined by magnetic resonance imaging, as well as neurological function evaluated on the day of sacrifice. The midpoint interim analysis (n = 9 per cohort) revealed that DHA administration did not significantly improve either infarct volume or neurological function. The study was terminated after a determination of statistical futility. We were unable to confirm a neuroprotective effect for postischemic DHA administration in our large-animal model using a dosing scheme that was previously successful in rodents. Further analysis of the efficacy of DHA administration must thus be undertaken prior to clinical translation.

✓Cervical kyphosis in patients with ankylosing spondylitis (AS) can be severely disabling. Surgical treatment of this disorder is technically demanding, however, with a considerable risk of neurological and vascular injuries. The extension osteotomy is a well-described posterior treatment for this condition, but this approach presents the risk of acute subluxation and spinal column translation during the reduction. In this paper, the authors report the novel use of a hinged posterior cervical rod for controlled correction of cervical kyphosis. After sustaining a traumatic spinal fracture, a 57-year-old man with AS developed a delayed cervical flexion deformity. The patient was neurologically intact, but suffered from disabling impairment in horizontal gaze and activities of daily living, and from neck pain. The patient subsequently underwent surgical correction via a posterior cervical extension osteotomy at C7–T1 with manual extension of the neck for osteoclastic reduction of the cervical kyphosis. Controlled correction was performed by using a hinged rod affixed to posterior cervical and thoracic screws, allowing for free sagittal correction while restricting translational forces. Once the desired angle of correction was achieved, the hinge connector was locked, transforming the rod into a rigid device for permanent internal fixation. The use of hinged rods in cervical kyphosis correction provides a controlled method for reduction at the osteotomy site, decreasing the risk of neurological injury.

STUDY DESIGN: Retrospective single-center study OBJECTIVES: To determine the long-term outcome of pediatric spinal cord injuries SUMMARY OF BACKGROUND DATA: Spinal cord injuries are uncommon events in the pediatric population. In the few large series reported in the literature, recovery of neurologic function was demonstrated after mild injuries but was rare after severe injuries. METHODS: A total of 4,876 cases of pediatric trauma treated at the Children's Hospital of Los Angeles over a 9-year period (1993-2001) were reviewed. During the study period, 91 cases of spinal cord or spinal column injury were identified, and 30 cases involving a spinal cord injury were identified. Cauda equina injuries were excluded. Seven craniocervical, 12 cervical, 5 thoracic, and 6 thoracolumbar cases were identified. There were 6 cases of spinal cord injury without radiographic abnormality. Eight of the 30 patients received methylprednisolone at the time of admission. Follow-up ranged from 2 to 54 (mean = 19) months. RESULTS: Twenty patients presented with complete injuries (ASIA grade A). Of these, 7 died, 7 had no neurologic recovery, and 6 experienced neurologic improvement. Five of these six eventually became ambulatory with functional gains occurring over a 4- to 50-week period. None of these 5 patients was found to have spinal cord injury without radiographic abnormality. Of the remaining 10 patients (grades B-D), 8 experienced improvements in neurologic function. Cervical dislocation injuries were associated with a low likelihood of neurologic improvement and atlanto-occipital injuries were associated with early death. CONCLUSIONS: Recovery of neurologic function following severe traumatic spinal cord injury occurs with a significantly greater incidence in children than adults, and these improvements can occur over a prolonged postinjury period. Language: en

Precise assessment of stroke outcome is critical for pre-clinical testing of cerebroprotective strategies. Differences in stroke volume measured by various magnetic resonance imaging (MRI) techniques are documented in humans, but not well described in experimental primate stroke. This study characterizes changes in stroke volume using serial MRI scans in a baboon model of reperfused cerebral ischemia. The location/area of hyperintensity on MRI corresponded with the TTC-stained infarct region. T2-weighted fast spin echo (T2W FSE), fluid attenuated inversion recovery (FLAIR), and diffusion weighted imaging (DWI) showed a decrease in infarct volume between 72 h and nine days post-ischemia (p = ns, p = 0.029, and p = 0.006). T2W FSE and FLAIR demonstrated an increase in infarct volume from 24 h to nine days post-ischemia, while DWI displayed a decrease over the same period. While early T2W FSE, FLAIR, and DWI all correlated with late infarct volume (p0.001), 72 h T2W FSE was the best direct measure (2.39% +/- 1.40% unity deviation). Serial MRI in a nonhuman primate model of focal cerebral ischemia recapitulates findings in clinical stroke. MRI at 72 h accurately predicts late infarct volume.

BACKGROUND Although the development of significant interhemispheric intracranial pressure (ICP) gradients in the setting of unilateral stroke remains controversial, no study to date has investigated the existence of these gradients in a controlled, reproducible, clinically relevant model. Therefore, we used a primate model of reperfused hemispheric stroke to better characterize the development of these gradients. METHODS Bilateral intraparenchymal ICP was continuously monitored in 7 adult male baboons subjected to left hemisphere reperfused stroke. Interhemispheric ICP gradients were calculated for each baboon and plotted over time. Infarct volume was determined using T2-weighted magnetic resonance imaging (MRI) at sacrifice. RESULTS A bimodal distribution of interhemispheric ICP gradients was observed in animals with >20% infarct volume (22.1% ± 0.9; range 21–23%) versus ≤ 15% infarct volume (6.6% ± 2.7; range 1–15%). In animals with >20% infarct volume, interhemispheric gradients developed early and persisted throughout the monitoring period. At 12 hours postreperfusion, animals with large infarcts demonstrated a mean pressure gradient of 13.8 ± 4.3 mm Hg, compared to a mean gradient of −2.6 ± 1.1 mm Hg for animals with ≤15% infarct volume. The difference in pressure gradients was statistically significant at all time points from 4 to 12 hours postreperfusion (p < 0.01). CONCLUSIONS These data suggest that, in nonhuman primates, infarcts of a size approaching 20% of the hemisphere may be associated with significant ICP gradients. With these larger infarcts, ipsilateral monitoring is required if regional cerebral perfusion pressure is to be accurately assessed.

Object. Although upregulated adhesion molecule expression has been demonstrated in experimental models of subarachnoid hemorrhage (SAH) and in the cerebrospinal fluid of patients with aneurysmal SAH, the clinical significance of these proinflammatory findings remains unclear. The authors hypothesize that 1) serum levels of soluble intercellular adhesion molecule-1 (ICAM-1) are increased in all patients with aneurysmal SAH shortly after the hemorrhagic event, and 2) elevated soluble ICAM-1 values are associated with poor patient outcome, even when controlling for the severity of the initial hemorrhagic insult. Methods. One hundred one patients were prospectively enrolled and stratified according to their admission Hunt and Hess grade and functional status at discharge (modified Rankin Scale [mRS] score). Soluble ICAM-1 levels were determined every other day for 12 days post-SAH by using the enzyme-linked immunosorbent assay. Early soluble ICAM-1 levels (post-SAH Days 2–4) were increased compared with levels in control patients without SAH (p < 0.05). Patients with aneurysmal SAH who had a poor outcome (mRS Grades 4–6) had significantly higher soluble ICAM-1 levels over the first 2 weeks post-SAH compared with patients who had a good outcome (mRS Grades 0–3, p < 0.01). This association with outcome was predicted by late increases (Day 6, p = 0.07; Days 8–12, p < 0.05) rather than early increases (p = not significant) and was best seen in patients with Hunt and Hess Grades I and II, in whom only those with poor outcomes demonstrated delayed ICAM-1 elevations (p < 0.05). Conclusions. These data demonstrate a correlation between soluble ICAM-1 levels and functional outcome following aneurysmal SAH that appears to be, at least in part, independent of the initial hemorrhage.

Objective Several different methodologies for proximal occlusion and retrograde suction decompression of large paraclinoid aneurysms have been reported previously. In this article, we describe the novel use of an endovascular embolectomy device (F.A.S.T. funnel catheter; Genesis Medical Interventional, Inc., Redwood City, CA) for temporary internal carotid artery occlusion and suction decompression of an intracranial aneurysm to facilitate surgical clip ligation. The combination of atraumatic occlusion technology and large lumen size makes this technique safer and easier. Clinical presentation A 53-year-old woman with progressive headaches underwent computed tomographic angiography, which revealed an unruptured large left paraclinoid aneurysm. Cerebral angiography confirmed the diagnosis. The patient did not tolerate a balloon test occlusion for therapeutic Hunterian internal carotid occlusion. The patient was subsequently taken to the operating room for a craniotomy and clip ligation of the aneurysm. Intervention A standard left pterional craniotomy was performed with opening of the sylvian fissure and exposure of the left paraclinoid aneurysm. Intraoperative angiography with introduction of a new endovascular embolectomy device was performed. The device was deployed to achieve temporary occlusion of the cervical internal carotid artery, and aspiration through the central lumen allowed for retrograde suction decompression of the aneurysm. Collapse of the aneurysm through this technique permitted visualization of the aneurysmal neck with successful clip ligation. Conclusion A new endovascular embolectomy device can be used to safely perform suction decompression of large paraclinoid aneurysms to facilitate clip ligation.

✓ Ankylosing spondylitis can lead to severe cervical kyphosis, causing problems with forward vision, swallowing, hygiene, patient functionality, and social outlook. Evaluation of patients with cervical flexion deformity includes assessment of global sagittal balance and chin–brow angle. The primary treatment in extreme disabling cases is surgical correction involving a posterior cervical extension osteotomy, which is a technically demanding procedure with considerable risk of neurological injury. To address the potential complications with extension osteotomy, the authors of several reports have described modifications to the surgical technique. These developments incorporate recent advances in anesthesia, neuromonitoring, and spinal instrumentation. Complications associated with the procedure include subluxation at the osteotomy level, spinal cord injury, radiculopathy, dysphagia, and pseudarthrosis. Although the risks of spinal correction are considerable, extension osteotomy remains an effective treatment modality for patients with disabling cervical flexion deformity.