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© 2019 Elsevier Inc. Background: In patients with neurological disorders, a divergence can exist between patients' perceptions regarding the outcomes and the objective neurological findings. Degenerative cervical myelopathy (DCM), a prevalent condition characterized by progressive compression of the cervical spinal cord, can produce debilitating symptoms and profound neurological findings. The purpose of the present study was to determine whether the physician-derived neurological examination findings, as recorded by American Spine Injury Association (ASIA) summary score, correlated with the patient-derived outcome measures for DCM. Methods: A total of 78 patients underwent surgical management of DCM with completion of preoperative and 6-month follow-up assessments. Surgical management consisted of either anterior or posterior cervical decompression. All patients underwent a neurological evaluation, including an ASIA assessment before surgery and 6 months after surgery, and completed the modified Japanese Orthopaedic Association (mJOA), neck disability index (NDI), and Short-Form 36-item (SF-36) scales pre- and postoperatively to measure both disease-specific and general perceived outcomes. Results: The objective physician-derived neurological testing (ASIA) did not correlate with the patient-derived scales (mJOA, NDI, and SF-36) pre- or postoperatively. Patients reported significant improvements (P < 0.001) at 6 months postoperatively in extremity functioning (mJOA), neck pain (NDI), overall physical health (SF-36), and objective strength and sensory functioning (ASIA). All patient-perceived outcome measures correlated with each other pre- and postoperatively (P < 0.01). Conclusions: Objective scoring of postoperative neurological function did not correlate with patient-perceived outcomes before and after surgery for DCM. Traditional testing of motor and sensory function as part of the neurological assessment may not be sensitive enough to assess the scope of neurological changes experienced by patients with DCM.

STUDY DESIGN This was a prospective, randomized control pilot study. OBJECTIVE The aim of this study was to determine whether continuous monitoring and adjustment of the endotracheal tube cuff pressure (ETTCP) to 15 mm Hg during ACSS would alter the incidence of postoperative dysphagia. SUMMARY OF BACKGROUND DATA Postoperative dysphagia is a recognized potential complication of anterior cervical spine surgery (ACSS). Recent findings on preventive measures suggest that certain intraoperative practices may minimize this complication. METHODS Fifty patients undergoing ACSS, arthroplasty, or fusion, completed routine lateral cervical preoperative plain films and questionnaires [Dysphagia Disability Index (DDI), Bazaz-Yoo Dysphagia Score (BYDS), and Short Form (36) Health Survey]. Patients were randomized into 2 groups: treatment group with ETTCP maintained at 15 mm Hg and control group with cuff pressure monitored without manipulation. Radiographs and questionnaires were obtained at 24 hours, 6 weeks, and 3 and 6 months postsurgery to assess soft tissue thickness and rates of dysphagia. RESULTS There were no significant differences between the groups in the soft tissue thickness or questionnaire scores at any timepoint (P>0.05). Within-group analysis revealed treatment and control groups had a significantly higher 24-hour postoperative soft tissue thickness and questionnaire scores compared with follow-up measurements (P

ObjectiveTo analyze MRI characteristics of lumbar facet synovial cysts and distinguish those requiring subsequent surgical management for recurrence, after percutaneous synovial cyst rupture.Methods and materialsRetrospective chart review conducted in patients undergoing percutaneous synovial cyst rupture between February 2012 and April 2015. Pre- and post-percutaneous rupture procedure MRI spine studies were serially reviewed. Synovial cyst sizes, T1 and T2 signal characteristics and changes therein, T2 hypointense (or ‘dark rim’) thickness and change, and changes in the complexity of cyst signals were compared. Operative notes for patients who underwent subsequent surgical removal of recurrent synovial cysts were reviewed.Results24 patients received 41 percutaneous synovial cyst rupture procedures, with a technical success rate of 82.9%. There was a significant difference in the mean increased thickness of the T2 hypointense rim on the first post-rupture MRI scan (p=0.0411) between patients requiring subsequent surgery and those who did not. There was a significant difference in the average sizes of synovial cysts before the procedure (p=0.0483) in those requiring subsequent surgery and those who did not. Five complications were noted (12.2%), mostly involving leg pain or weakness. Of the nine patients who underwent subsequent surgery post-synovial cyst rupture, six of the surgeries had recorded difficulty pertaining to scarring and/or adherence of the cyst to dura.ConclusionsA larger increase in thickness of the T2 hypointense rim on the first post-rupture MRI scan and a larger synovial cyst size were associated with the need for subsequent surgical resection.

Background:Spontaneous intracranial hypotension (SIH) is an increasingly described entity, with over 70 cases reported in the literature. The classic triad includes orthostatic headache, diffuse pachymeningeal enhancement on magnetic resonance imaging (MRI) with gadolinium, and low cerebrospinal fluid pressure (CSF) in the lateral decubitus (2O) and sitting positions.Method:We present four rare clinical presentations of SIH, two of which have not been previously described in the literature, to the best of our knowledge.Results:Patient 1 presented with dyspnea, dysphagia, bilateral ptosis, diplopia and seizures. Patient 2 presented with a paradoxical positional pattern of orthostatic hypotension. In Patient 3, bilateral subdural hematomas (SDH) were encountered; while in Patient 4, a recurrent unilateral SDH requiring multiple surgical interventions was demonstrated.Conclusion:Although uncommon clinical presentations, all four cases of intracranial hypotension were spontaneous, demonstrated diagnostic MRI findings, and responded favorably to blood patches or saline injections.

Objectives:To describe the tumor characteristics and visual function in conservatively managed patients with non-functioning pituitary macroadenoma (NFMA) that contacted/compressed the visual pathway.Design:Retrospective case-series.Setting:Tertiary-care academic institution.Participants:Six patients with diagnosis of NFMA.Main Outcome:Visual function and radiological characteristics of the optic apparatus and pituitary tumor.Results:All patients had radiological evidence of optic apparatus compression but only one had visual field defect at the initial presentation. While two of the six patients developed visual field changes during follow-up (41±34.8 months), the patient with visual field defect at the time of diagnosis improved to normal vision.Conclusions:Select NFMAs that contact the optic apparatus, without visual dysfunction, may be managed with close ophthalmological and radiographic monitoring, depending on tumor and imaging characteristics. This may be of particular relevance in patients considered to have a high peri-operative risk, such as advanced age or significant co-morbidities.

Background:Post-operative cerebrospinal fluid (CSF) leaks are a common complication of endoscopic pituitary surgery and account for a significant proportion of hospital costs associated with this procedure. Tisseel® is a tissue glue commonly used as an adjunct in dural repair but is not optimal for this purpose. DuraSeal® has several properties advantageous for dural repair but is not widely accepted in Canada partly due to its increased cost.Objective:A cost analysis of DuraSeal® versus Tisseel® in endoscopic pituitary surgery.Methods:A cost analysis was performed based on typical endoscopic pituitary surgery cases performed at our tertiary care institution. Operating room, hospital admission, and surgical sealant costs were obtained directly while estimates of patient recovery time and post-operative CSF leak rates were based on consensus values reported in the literature. Outcomes were reported for various possible clinical scenarios of sealant use.Results:In a model where surgical sealant is employed only in high-risk cases, use of DuraSeal® allows for a yearly cost savings of at least $4486.72. If surgical sealant is used in all cases, regular use of DuraSeal® versus Tisseel® either marginally reduces yearly costs or increases them by a maximum of $7619.25, depending on the case volume and estimated post-operative CSF leak rate.Conclusion:In most clinical scenarios, use of DuraSeal® in endoscopic pituitary surgery may reduce overall yearly hospital costs compared to Tisseel®.

We present a case of an atypical clival meningeal melanoma treated with a multidisciplinary staged transcrusal and transsphenoidal endoscopic surgical approach. A 45-year-old woman presented with a 15-month history of visual symptoms, neck pain, and unsteadiness. Magnetic resonance imaging of the head revealed a clival mass with both intracranial and extracranial involvement. Endoscopic clival biopsy suggested a melanocytic tumor. Extensive imaging and dermatological workup did not demonstrate a primary source. A multidisciplinary staged surgical resection included a transcrusal approach to resect the intracranial component, followed by transsphenoidal endoscopic resection of the extracranial component. Postoperatively, she received adjuvant radiation. At 1 year following surgery, the patient retains full preservation of hearing, facial nerve function, and extraocular movements. To our knowledge, this is the first case report of a combined surgical approach for a primary clival meningitic melanoma.

Study design Multicenter retrospective analysis. Objectives To review the results of surgical treatment during the last 6 years of C2 fractures in patients over the age of 70. Summary of background data Little information exists about the clinical outcome of surgical treatment of elderly patients with C2 fractures, their ability to return to their previous environment, and their postoperative level of independence. Methods The medical records and radiographs of 29 patients who had undergone surgical treatment for C2 fractures were reviewed. The type of C2 fracture, neurologic examination at presentation, type of surgical treatment, perioperative morbidity and mortality, presence of osseous union, and stability of alignment were recorded. Long-term disposition was determined from office visits or by telephone interview. Results Twenty-four of 29 patients had type II dens fractures alone. The remaining 5 had associated C1 fractures. All patients were neurologically intact at presentation except for 2 patients with signs and symptoms of central cord syndrome. Perioperative complications occurred in 3 patients (10.3%). One patient died on postoperative day 6 from a myocardial infarction. Mean+/-SD radiographic follow-up was 9+/-3.2 months (range, 3 to 24). Of the 16 patients who underwent odontoid screw fixation, 6 (37.5%) had osseous union, and 9 (56.2%) were stable on radiographs. An additional patient who had odontoid screw initially required a posterior approach reoperation. Of the 13 posterior fusions, 4 (30.7%) had osseous unions and 9 (69.2%) were stable on flexion extension radiographs. Mean+/-SD clinical follow-up was 18+/-2.2 months (range, 3 to 72 mo). Twenty-five of 29 patients (86.2%) returned to their previous environment. Two patients died of unrelated etiology. Conclusions C2 fractures in the elderly can be treated surgically with both anterior and posterior approaches with acceptable morbidity and mortality rates. The majority of patients can be mobilized early and return to their previous levels of independence.

Background context Cervical arthroplasty is designed to maintain cervical motion of the functional spinal unit after cervical discectomy. The impact of the ProDisc-C (Synthes Spine, Paoli, PA) on in vivo kinematics and sagittal alignment requires further assessment. Purpose The purpose of this study is to test the hypothesis that the ProDisc-C increases range of motion (ROM) in flexion and extension at the surgical level, and assess its impact on cervical alignment. Study design Clinical study. Patient sample Fifteen patients with a mean age of 49 years were included in this study. Each patient had a single-level arthroplasty. Patients with multilevel arthroplasty, previous cervical spine surgery, and length of follow-up less than 6 months were excluded from this study. Outcome measure Lateral dynamic radiographs of the cervical spine were analyzed using quantitative measurement analysis (QMA) preoperatively and postoperatively. QMA software was also used to determine the ROM and sagittal translation at the surgical level. Methods Flexion/extension lateral radiographs of the cervical spine were prospectively collected and reviewed in 15 patients preoperatively and at early (1–3 months) and late (6–14 months) follow-up after placement of the ProDisc-C. Shell angle (SA) and C2–C7 Cobb angles were measured. Sagittal translation and ROM were calculated at each time point. Preoperative values were compared with early and late follow-up values using paired Student t tests and Pearson's correlation. Results The C2–C7 Cobb angle did not change significantly after surgery. Segmental ROM increased significantly from neutral to flexion (p=.02) and neutral to extension (p=.002) at late follow-up. SA correlated significantly with ROM from neutral to extension (Pearson's r =−0.55; p=.02) and translation from neutral to extension (Pearson's r =−0.58; p=.02). Conclusions The ProDisc-C increased overall segmental ROM. A lordotic SA may be associated with restricted segmental ROM and translation in extension. This study did not detect any change in overall cervical spinal alignment after insertion of the device.

The present article reviews the design rationale of currently available cervical disc replacements. Recent prospective randomized control trials comparing cervical disc replacement and anterior fusion have demonstrated safety as well as equal or superior clinical results. Increasingly, more devices are becoming available on the market. Understanding design rationale will provide context for the surgeon to optimize decision making for the most appropriate prosthesis. Cervical arthroplasty is a technique that is undergoing rapid design refinement and development. Further improvements in device design will enable patient-specific device selection. Understanding the design rationale and complication profile of each device will improve clinical and radiographic outcomes.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) for the management of cervical spondylosis may contribute to further degenerative changes at adjacent levels secondary to abnormal spinal motion. Insertion of a Bryan Cervical Disc (AD) (Medtronic Sofamor Danek, Memphis, TN) may prevent this accelerated degeneration. This retrospective study compares the in vivo x-ray cervical spine kinematics in patients with ACDF and AD. METHODS: Ten patients with single-level AD were matched to 10 patients with single-level ACDF based on age and sex. Lateral neutral, flexion and extension cervical x-rays were obtained preoperatively and at regular intervals up to 24 months postoperatively. Kinematic parameters, including range of motion, anteroposterior translation, and disc height, were assessed for all cervical functional spinal units using quantitative motion analysis software. Changes in these parameters were compared between matched patients from both groups using paired Student's t tests. RESULTS: The range of motion at the operated level was greater in the AD group compared with the ACDF group at early (6.9 versus 0.89 degrees, P < 0.01) and late (8.4 versus 0.53 degrees, P < 0.01) follow-up evaluations. Translation was greaterat the operated level in patients with AD at late follow-up (6.8 versus 0.8%, P< 0.03) evaluation. No significant between-group kinematic differences were seen at adjacent levels. CONCLUSION: Patients with AD and those with ACDF demonstrated similar in vivo adjacent level kinematics within the first 24 months after anterior cervical decompression.

Study Design. Prospective, randomized, controlled and double-blinded study on imaging of artificial discs. Objective. The purpose of this study is to compare postoperative imaging characteristics of the 4 currently available cervical arthroplasty devices at the level of implantation and at adjacent levels. of Background Data. Cervical arthroplasty is being performed increasingly frequently for degenerative disc disease and, in most cases, with frank neural compression. Unlike lumbar arthroplasty, performed mainly for axial back pain, decompression of neural elements may need to be confirmed with postoperative imaging after cervical arthroplasty. Methods. Preoperative and postoperative magnetic resonance imaging scans of 20 patients who had undergone cervical arthroplasty were assessed for imaging quality. Five cases each of the Bryan® (Medtronic Sofamor Danek, Memphis, TN), Prodisc-C® (Synthes Spine, Paoli, PA), Prestige LP® (Medtronic Sofamor Danek), and PCM® devices (Cervitech, Rockaway, NJ) were analyzed. Six blinded spinal surgeons scored twice sagittal and axial T2-weighted images using the Jarvik 4-point scale. Statistical analysis was performed comparing quality before surgery and after disc implantation at the operated and adjacent levels and between implant types. Results. Moderate intraobserver and interobserver reliability was noted. Preoperative images of patients in all implant groups had high-quality images at operative and adjacent levels. The Bryan and Prestige LP devices allowed satisfactory visualization of the canal, exit foramina, cord, and adjacent levels after arthroplasty. Visualization was significantly impaired in all PCM® and Prodisc-C® cases at the operated level in both the spinal canal and neural foramina. At the adjacent levels, image quality was statistically poorer in the PCM® and Prodisc-C® than those of Prestige LP® or Bryan®. Conclusions. Postoperative visualization of neural structures and adjacent levels after cervical arthroplasty is variable among current available devices. Devices containing nontitanium metals (cobalt-chrome-molybdenum alloys in the PCM® and Prodisc-C®) prevent accurate postoperative assessment with magnetic resonance imaging at the surgical and adjacent levels. Titanium devices, with or without polyethylene (Bryan® disc or Prestige LP®), allow for satisfactory monitoring of the adjacent and operated levels. This information is crucial for any surgeon who wishes to assess adequacy of neural decompression and where monitoring of adjacent levels is desired.

The early clinical results with the Bryan Cervical Disc prosthesis are encouraging but 2 recent small published series have noted postoperative radiologic kyphosis of the functional spinal unit (FSU) of 4 and 6 degrees. The current study was undertaken to accurately assess the extent of any sagittal deformity after the use of this prosthesis in a substantial, multisurgeon case series. The neutral, erect x-rays of 67 consecutive patients (88 disc levels) operated by one of 3 surgeons, were examined using manual and digital image analysis techniques for FSU sagittal angulation (lordosis), prosthesis shell angulation, segmental olisthesis, and overall cervical alignment. Measurement accuracy was confirmed using interobserver and intraobserver studies. There was a median loss of 2 degrees in FSU lordosis when compared with preoperative imaging (P

STUDY DESIGN In vitro biomechanical flexibility experiment studying 5 sequential conditions. OBJECTIVE To determine the biomechanical differences among 3 fixation techniques after a simulated hangman's fracture. SUMMARY OF BACKGROUND DATA Type II hangman's fractures are often treated surgically with a C2-C3 anterior cervical discectomy, fusion, and plating. Other techniques include direct fixation with C2 pars interarticularis screws or posterior C2-C3 fixation connecting C2 pars screws to C3 lateral mass screws. METHODS Seven cadaveric specimens (Oc-C4) were tested intact, after a simulated hangman's fracture, and after each fixation technique. Flexion, extension, lateral bending, and axial rotation were induced using nonconstraining torques while recording angular motions stereophotogrammetrically. RESULTS Direct screw fixation reduced motion an average of 61% +/- 13% during lateral bending and axial rotation compared to the injured state (P < 0.007). However, instability remained during flexion and extension. Posterior C2-C3 rod fixation provided significantly greater rigidity than anterior plate fixation during lateral bending (P < 0.008) and axial rotation (P < 0.04). CONCLUSIONS Direct fixation of the pars ineffectively limits flexion and extension after a Type II hangman's fracture. If pars screw fixation can be achieved, posterior C2-C3 fixation more effectively stabilizes a hangman's fracture than anterior cervical plating.

STUDY DESIGN: Retrospective review. OBJECTIVE: To describe the incidence, clinical features, and treatment of traumatic spinal cord injury (SCI) treated at a Canadian tertiary care center. SUMMARY OF BACKGROUND DATA: Understanding the current epidemiology of acute traumatic SCI is essential for public resource allocation and primary prevention. Recent reports suggest that the mean age of patients with SCI may be increasing. METHODS: We retrospectively reviewed hospital records on all patients with traumatic SCI between January 1997 and June 2001 (n = 151). Variables assessed included age, gender, length of hospitalization, type and mechanism of injury, associated spinal fractures, neurologic deficit, and treatment. RESULTS: Annual age-adjusted incidence rates were 42.4 per million for adults aged 15-64 years, and 51.4 per million for those 65 years and older. Motor vehicle accidents accounted for 35% of SCI. Falls were responsible for 63% of SCI among patients older than 65 years and for 31% of injuries overall. Cervical SCI was most common, particularly in the elderly, and was associated with fracture in only 56% of cases. Thoracic and lumbar SCI were associated with spinal fractures in 100% and 85% of cases, respectively. In-hospital mortality was 8%. Mortality was significantly higher among the elderly. Treatment of thoracic and lumbar fractures associated with SCI was predominantly surgical, whereas cervical fractures were equally likely to be treated with external immobilization alone or with surgery. CONCLUSION: A large proportion of injuries was seen among older adults, predominantly as a result of falls. Prevention programs should expand their focus to include home safety and avoidance of falls in the elderly. Language: en

STUDY DESIGN Prospective cohort study. OBJECTIVE To assess the biomechanical profile of the cervical spine following cervical arthroplasty. SUMMARY OF BACKGROUND DATA Spinal arthroplasty offers the promise of maintaining functional spinal motion, thereby potentially avoiding adjacent segment disease. Disc replacement may become the next gold standard for the treatment of degenerative cervical spine disease, and must be studied rigorously to ensure in vivo efficacy and safety. METHODS A total of 20 patients underwent single or 2-level implantation of the Bryan artificial cervical disc (Medtronic Sofamor Danek, Memphis TN) for treatment of cervical degenerative disc disease producing radiculopathy and/or myelopathy. Lateral neutral, flexion, and extension cervical radiographs were obtained before surgery and at intervals up to 24 months after surgery. Kinematic parameters, including sagittal rotation, horizontal translation, change in disc height, and center of rotation (COR), were assessed for each spinal level using quantitative motion analysis software. RESULTS Motion was preserved in the operated spinal segments (mean range of motion 7.8 degrees) up to 24 months following surgery. The relative contribution of each spinal segment to overall spinal sagittal rotation differed depending on whether the disc was placed at C5-C6 or C6-C7. Overall cervical motion (C2-C7) was moderately but significantly increased during late follow-up. Sagittal rotation, anterior and posterior disc height, translation, and COR coordinates did not change significantly following surgery. The COR was most frequently located posterior and inferior to the center of the disc space. CONCLUSIONS The Bryan artificial cervical disc provided in vivo functional spinal motion at the operated level, reproducing the preoperative kinematics of the spondylotic disc.

STUDY DESIGN Unilateral facet dislocation was created in human cadaveric cervical spines. Specimens were sequentially instrumented with posterior or anterior screws and plates, and studied biomechanically. OBJECTIVE To determine the biomechanical differences between anterior and posterior fixation for stabilization of a reduced unilateral cervical facet dislocation. SUMMARY OF BACKGROUND DATA Although previous studies have compared anterior to posterior instrumentation, no data exist on the biomechanics of either type of stabilization after this particular injury. METHODS In 6 human cadaveric cervical spine segments, a reproducible unilateral facet dislocation was created and then unlocked (reduced). Nondestructive torques were applied to specimens that were intact, injured-reduced, fixated using posterior nonlocking lateral mass plates, and fixated using a bone graft plus an anterior nonlocking plate. Flexion, extension, lateral bending, and axial rotation were measured stereophotogrammetrically. RESULTS Lateral mass plating was more effective than anterior plating in limiting motion after reduction of a unilateral facet dislocation. Averaged, over all loading directions, lateral mass plates reduced the range of motion to 17% of normal; anterior plates reduced range of motion to 89% of normal. In all loading directions, lateral mass plates performed significantly better than anterior plates (P < 0.05, paired Student t-tests). CONCLUSIONS Anterior and posterior plating effectively stabilized a reduced unilateral facet dislocation. Lateral mass fixation provided better immobilization than anterior graft and plate.

Angiolipomas are rarely encountered in the spine. We report the case of a 47-year-old man with a thoracic angiolipoma involving the T9 vertebral body. A preoperative spinal angiogram confirmed a highly vascular neoplasm. The lesion was treated with endovascular embolization prior to a T9 corpectomy and resection of the epidural component of the tumor. At time of surgery, minimal blood loss occurred during resection of the vertebral body and the epidural mass. Pathologic examination demonstrated features consistent with spinal angiolipoma. This report emphasizes the clinical, radiographic, and pathologic features of infiltrating spinal angiolipoma and discusses therapeutic management options.

Object Spinal arthroplasty may become the next gold standard for the treatment of degenerative cervical spine disease. This new modality must be studied rigorously to ensure in vivo efficacy and safety. The authors review the preliminary clinical experience and radiographic outcomes following insertion of the Bryan Cervical Disc Prosthesis (Medtronic Sofamor Danek, Memphis, TN). Methods This prospective cohort study included 26 patients undergoing single- or two-level implantation of the Bryan artificial cervical disc for treatment of cervical degenerative disc disease resulting in radiculopathy and/or myelopathy. Radiographic and clinical assessments were made preoperatively 1.5, 3 months, and at 6, 12, and up to 24 months postoperatively. The Neck Disability Index (NDI) and Short Form–36 (SF-36) questionnaires were used to assess pain and functional outcomes. Segmental sagittal rotation from C2–3 to C6–7 was measured using quantitative motion analysis software. A total of 30 Bryan discs were placed in 26 patients. A single-level procedure was performed in 22 patients and a two-level procedure in the other four. Follow-up duration ranged from 1.5 to 27 months, with a mean duration of 12.3 months. A statistically significant improvement in the mean NDI scores was seen between pre- and late postoperative follow-up evaluations. A trend toward improvement in the SF-36 physical component was also found. Motion was preserved in the treated spinal segments (mean range of motion 7.8°) for up to 24 months postsurgery. The relative contribution of each segment to overall spinal sagittal rotation differed depending on whether the disc was placed at C5–6 or C6–7. Overall cervical motion (C2–7) was moderately increased on late follow-up evaluations. Conclusions The Bryan artificial cervical disc provided in vivo functional spinal motion at the treated level. Overall cervical spinal motion was not significantly altered. Sagittal rotation did not change significantly at any level after surgery.

Object Cervical arthroplasty offers the promise of maintaining motion of the functional spinal unit (FSU) after anterior cervical discectomy. The impact of cervical arthroplasty on sagittal alignment of the FSU needs to be addressed, together with its effect on overall sagittal balance of the cervical spine. Methods The authors prospectively reviewed radiographic and clinical outcomes in 14 patients who received the Bryan Cervical Disc prosthesis (Medtronic Sofamor Danek, Memphis, TN), for whom early (< 6 months) and late (6–24 months) follow-up data were available. Static and dynamic radiographs were measured by hand and computer to determine the angles formed by the endplates of the natural disc preoperatively, those formed by the shells of the implanted prosthesis, the angle of the FSU, and the C2–7 Cobb angle. The range of motion (ROM) was also determined radiographically, whereas clinical outcomes were assessed using the Neck Disability Index (NDI), and Short Form–36 (SF-36) questionnaires. The ROM was preserved following surgery, with a mean preoperative sagittal rotation angle of 8.96°, which was not significantly different from the late postoperative value of 8.25°. When compared with the preoperative disc space angle, the shell endplate angle in the neutral position became kyphotic in the early and late postoperative periods (mean change −3.8° in the late follow-up period; p = 0.0035). The FSU angles also became significantly more kyphotic post-operatively, with a mean change of −6° (p = 0.0006). The Cobb angles varied widely preoperatively and did not change significantly after surgery. There was no statistical correlation between the NDI and SF-36 outcomes and cervical kyphosis. Conclusions Cervical arthroplasty preserves motion of the FSU. Both the endplate angle of the treated disc space and the angle of the FSU became kyphotic after insertion of the Bryan prosthesis. The overall sagittal balance of the cervical spine, however, was preserved.

OBIECTIVE AND IMPORTANCE: Desmoplastic fibroma is a benign bone tumor that can be locally aggressive. it usually occurs in the long bones and mandible. We report on a patient with a desmoplastic fibroma arising in the temporal bone and review previously published cases of desmoplastic fibroma originating within the cranium. CLINICAL PRESENTATION: A 43-year-oid woman presented with a 12 year history of progressively worsening head asymmetry . Magnetic resonance imaging and computed tomography demonstrated a mass Originating from the bone and involving the adjacent soft tissues. INTERVENTION: A temporal parietal cranietomy was performed with excision of a large tumor involving the bone. An acrylic cranioplasty. was used to replace the bone. Pathological examination of the lesion identified desmoplastic fibroma of the cranium After surgery, the patient's cranial asymmetry was corrected. CONCLUSION: Desmoplastic fibroma of the cranium is rare. Surgical resection is the treatment of choice.

STUDY DESIGN: Human cadaveric cervical spines were subjected to nondestructive repeated-measures flexibility tests before, during, and after unilateral facet dislocation. OBJECTIVES: To assess the relative stability and kinematics of the spine in the normal condition, after unilateral facet lock without bony injury and after reducing (unlocking) the facet dislocation. SUMMARY OF BACKGROUND DATA: Experimental unilateral facet dislocation has been studied only when associated with extensive damage to disc, bone, or both. The relative stability of the normal, locked, and unlocked cervical spine has not been studied. METHODS: Unilateral facet dislocation with minimal associated injury was created by slowly applying axial torque while specimens were bent laterally and flexed. Before and after injury, nondestructive torques were applied about each anatomic axis, while three-dimensional specimen motion was recorded stereophotogrammetrically. RESULTS: Unilateral facet dislocation was created with a mean axial torque of 10.2 +/- 2.7 Nm. After locking, range of motion, lax zone, and stiff zone were significantly reduced relative to normal (P < 0.05). After unlocking, the same parameters were significantly increased relative to normal. The position of the axis of rotation shifted when the facet was locked and the centrode elongated after the facet was unlocked. CONCLUSIONS: Unilateral facet dislocation without fracture can be created with moderate loads when axial torque is applied while the facet is distracted. The spine is stable while the articular masses are locked unilaterally; however, the motion segment becomes overtly unstable after the facet dislocation is reduced.

Selecting the most appropriate surgical approach to the craniovertebral junction (CVJ) is based on minimizing the associated morbidity and maximizing the operative exposure in relation to the size, pathology, and specific location of the lesion. With the evolving repertoire of modern neurosurgical techniques, direct access to the CVJ can be attained along all 360 degrees of the occipital-spinal axis. Anterior-superior approaches to the CVJ, which include the transoral approach, are best suited for extradural, midline lesions of the clivus and upper cervical vertebrae. Anterior lesions that have a paramedian location or extend inferiorly from the CVJ may be exposed by either a retropharyngeal or mandibular swing approach. The lateral approaches to the CVJ include the lateral transcervical, transpetrosal, and infratemporal fossa approaches. These approaches are particularly well suited for ventrally situated intradural lesions. Finally, posterior approaches are preferred for midline posterior or posterolaterally situated intradural lesions. The far lateral approach provides direct access to the lower ventral brainstem and the anterior foramen magnum while minimizing the need for retraction. The following article is a synopsis of the most common surgical approaches.

During central nervous system (CNS) development, intermediate filaments are subjected to a sequential remodelling process. Nestin is a distinct intermediate filament which is transiently expressed in proliferating neuroepithelial stem cells during the neurulation stage of development. Nestin re-expression in the adult rat was studied following transient (2 h) middle cerebral artery occlusion. Seven days after the ischemic insult, nestin reactive astrocytes were found in the border zone surrounding cerebral infarction. Nestin immunoreactivity delineated a zone between infarction and the surrounding intact cerebral parenchyma. In situ hybridization for nestin mRNA showed early changes in small cells in the surround of the ischemic lesion. These results with nestin, along with other stem cell markers expressed by reactive astrocytes, suggest an embryonic reversion of the mature cytoskeleton as a response of astrocytes to cerebral injury.

Background We present a rare complication of bilateral caudate infarcts and necrosed nasoseptal flaps after endoscopic transsphenoidal resection of tuberculum sellae meningioma. This case highlights the importance of early and accurate diagnosis and treatment of a postoperative cerebrospinal fluid (CSF) leak and associated bacterial meningitis, and reviews any existing guidelines regarding its management. Case description A 54-year-old otherwise healthy man presented with progressive bitemporal hemianopsia. Magnetic resonance imaging of the head revealed a large, homogeneously enhancing sellar and suprasellar mass consistent with a meningioma. An endoscopic endonasal transsphenoidal approach was performed to resect the tuberculum sellae meningioma. The patient developed basal bacterial meningitis secondary to a CSF leak, requiring repair on two separate occasions. At the time of both repairs, there was evidence of necrosis of the nasoseptal flaps used for the repairs. Soon after the diagnosis of meningitis, the patient developed bilateral caudate infarcts. Conclusion This report discusses the possible underlying etiologies for the bilateral caudate infarcts and necrosed flaps including bacterial meningitis with associated local vasospasm of nearby vessels resulting in infarction. This case emphasizes the importance of concise management of postendoscopic CSF leak and discusses the guidelines regarding antimicrobial therapy and the management of lumbar drains.

Alterations in motor function in cervical myelopathy secondary to degenerative disease may be due to local effects of spinal compression or distal effects related to cortical reorganization. This prospective study characterizes differences in metabolite levels in the motor cortex, specifically N-acetylaspartate, creatine, choline, myo-inositol and glutamate plus glutamine, due to alterations in cortical function in patients with reversible spinal cord compression compared with healthy controls. We hypothesized that N-acetylaspartate/creatine levels would be decreased in the motor cortex of patients with cervical myelopathy due to reduced neuronal integrity/function and myo-inositol/creatine levels would be increased due to reactive gliosis. Twenty-four patients with cervical myelopathy and 11 healthy controls underwent proton-magnetic resonance spectroscopy on a 3.0 Tesla Siemens Magnetom Tim Trio MRI. Areas of activation from functional magnetic resonance imaging scans of a finger-tapping paradigm were used to localize a voxel on the side of greater motor deficit in the myelopathy group (n = 10 on right side and n = 14 on left side of the brain) and on each side of the motor cortex in controls. Neurological function was measured with the Neck Disability Index, modified Japanese Orthopaedic Association and American Spinal Injury Association questionnaires. Metabolite levels were measured relative to total creatine within the voxel of interest. No metabolite differences were detected between the right side and left side of the motor cortex in controls. The myelopathy group had significantly decreased neurological function compared with the control group (Neck Disability Index: P

Background context Cervical arthroplasty theoretically reduces the risk of adjacent level disc degeneration and segmental instability that may be seen after a cervical fusion. An essential argument in confirming the utility of cervical arthroplasty is long-term confirmation that cervical disc replacements can maintain physiological kinematics at the index and adjacent levels. Purpose The purpose of this in vivo prospective study was to characterize the long-term segmental kinematic outcomes after cervical arthroplasty. Study design/setting Prospective cohort study. Patient sample Twenty patients with a 5-year clinical follow-up who underwent anterior cervical discectomy with insertion of the Bryan cervical disc. Outcome measures Physiological measures (kinematic analysis of lateral neutral, flexion, and extension radiographic imaging). Methods Twenty consecutive patients with degenerative disc disease were followed with regular radiographic imaging after implantation of the Bryan cervical disc prosthesis. Lateral neutral, flexion, and extension radiographs (n=240) were analyzed using Quantitative Motion Analysis software (Medical Metrics, Inc., Houston, TX, USA) to measure the biomechanical profile at the index level and adjacent levels up to 5 years after surgery. Parameters collected included range of motion (ROM), functional spinal unit (FSU) angle, anterior and posterior disc heights, sagittal translation, and center of rotation (COR). Results Biomechanics of the implanted artificial cervical disc was maintained up to 5 years with no significant changes in ROM, FSU angle, disc height, sagittal translation, and COR values when compared with early postoperative performance. Artificial discs were able to adequately restore and maintain preoperative kinematics. Early differences seen in disc height and FSU angle did not change during the duration of follow-up. No significant kyphotic changes or decrease in ROM were seen at the adjacent spinal levels. Conclusions The Bryan cervical disc prosthesis provides for a durable solution for functional spinal motion at the operated level and maintained the preoperative kinematics at adjacent levels at the 5-year follow-up.

Study Design: A prospective study of 22 patients with single-level cervical spondylosis.Objective: To quantify the changes in the biomechanics of thecervical spine after the insertion of a ProDisc-C (Synthes Spine,Paoli, PA) artificial disc.Summary of Background Data: Cervical arthroplasty is designedto maintain cervical motion of the functional spinal unit (FSU)after cervical discectomy. The impact of the ProDisc-C on invivo kinematics and sagittal alignment requires further assess-ment.Methods: Flexion/extension lateral radiographs of the cervicalspine were prospectively collected and reviewed in 22 patientspreoperatively and after the placement of ProDisc-C. Discheight (DH), FSU angle, range of motion (ROM), and center ofrotation (COR) were calculated at each time point usingvalidated, computer-assisted methods. Preoperative values werecompared with the postoperative values using paired studentt tests.Results: Mean follow-up time was 11.0 months (SD, 2.4mo). Atthe surgical level, the ProDisc-C produced increased segmentalROM (P=0.03), an anterior shift of 1.1mm in COR X(P=0.004), and increased DH both anteriorly (P

Background and importance Spinal cord compression may induce cortical reorganization. This study follows a patient with cervical spondylotic myelopathy to investigate changes in cortical activation before and after decompressive surgery. The relationship with functional recovery is also described. Clinical presentation A 37-year-old right-hand-dominant man presented a 1-month history of rapidly worsening right-hand clumsiness, right-sided hemiparesis, and gait difficulties. Physical examination confirmed severe right-sided weakness, impaired dexterity, hyperreflexia, and wide-based gait. The patient underwent blood oxygenation level-dependent functional magnetic resonance imaging at 4 T. Images were obtained before and 6 months after an anterior cervical discectomy with insertion of an artificial disk. Blood oxygenation level-dependent functional magnetic resonance imaging was used to detect changes in cortical activation over time during a finger-tapping (motor) paradigm. Improvement in clinical function was recorded with validated clinical tools, including the Japanese Orthopedic Association scale for cervical spondylotic myelopathy, the Nurick neurological function score, and the Neck Disability Index, along with clinical examination. Conclusion After decompressive cervical spine surgery in a patient with cervical spondylotic myelopathy, functional magnetic resonance imaging detected increased cortical activation in the primary motor cortex during finger tapping. These changes occurred concomitantly with improvement in motor function. Upper- and lower-extremity motor subscores of the Japanese Orthopedic Association scale demonstrated 40% and 43% improvement, respectively. These observations suggest that cortical reorganization or recruitment may accompany the recovery of function after spinal cord injury.

Object Cervical total disc replacement has emerged as a surgical option to preserve motion and potentially avoid adjacent-segment disease after anterior cervical discectomy and fusion. Recently, much attention has been directed at the ability of a given device to maintain and/or restore normal segmental alignment. Nonphysiological disc and segmental angulation could result in increased stresses transmitted to the facet joints and posterior elements, conflicting with the essence of arthroplasty and potentially leading to adjacent-segment disease. The goal of this study was to contrast device alignment and segmental kinematics provided by 3 different cervical disc prostheses. Methods Sixty patients were retrospectively analyzed and divided into 3 groups receiving the Bryan, ProDisc-C, or Synergy disc. Only single-level arthroplasty cases were included in the study. Lateral dynamic radiographs of the cervical spine were analyzed using quantitative motion analysis software (Medical Metrics, Inc.) to analyze the kinematics at the index level both preoperatively and postoperatively. Several parameters were noted, including range of motion, disc angles, shell angles, anterior and posterior disc heights, translation, and center of rotation. Preoperative and postoperative data were compared using the Student t-test with a significance level of p < 0.05. Results Postoperatively, all 3 disc groups maintained adequate range of motion at the implanted level. With respect to the shell angles, the Synergy disc demonstrated the least variability, maintaining 6° lordotic configuration between the device endplates. In the Bryan disc group, significant shell kyphosis developed postoperatively (p < 0.0001). Both ProDisc-C and Synergy discs significantly increased anterior and posterior disc heights (p < 0.0001). The Bryan and Synergy discs maintained the natural center of rotation, whereas significant anterior shift occurred with ProDisc-C. Conclusions The goal for motion preservation at the implanted level was achieved using all 3 devices. The Synergy disc was unique in its ability to alter device angulation by 6°. The Bryan disc demonstrated device endplate kyphosis. Both the Synergy disc and ProDisc-C increased disc space height.

OBJECTIVE: We examined the incidence of perioperative fever and its relationship to outcome among patients enrolled in the Intraoperative Hypothermia for Aneurysm Surgery Trial. METHODS: One thousand patients with initial World Federation of Neurological Surgeons grades of I to III undergoing clipping of intracranial aneurysms after subarachnoid hemorrhage were randomized to intraoperative normothermia (36 degrees C-37 degrees C) or hypothermia (32.5 degrees C-33.5 degrees C). Fever (> or =38.5 degrees C) and other complications (including infections) occurring between admission and discharge (or death) were recorded. Functional and neuropsychologic outcomes were assessed 3 months postoperatively. The primary outcome variable for the trial was dichotomized Glasgow Outcome Scale (good outcome versus all others). RESULTS: Fever was reported in 41% of patients. In 97% of these, fever occurred in the postoperative period. The median time from surgery to first fever was 3 days. All measures of outcome were worse in patients who developed fever, even in those without infections or who were World Federation of Neurological Surgeons grade I. Logistic regression analyses were performed to adjust for differences in preoperative factors (e.g., age, Fisher grade, initial neurological status). This demonstrated that fever continued to be significantly associated with most outcome measures, even when infection was added to the model. An alternative stepwise model selection process including all fever-related measures from the preoperative and intraoperative period (e.g., hydrocephalus, duration of surgery, intraoperative blood loss) resulted in the loss of significance for dichotomized Glasgow Outcome Scale, but significant associations between fever and several other outcome measures remained. After adding postoperative delayed ischemic neurological deficits to the model, only worsened National Institutes of Health Stroke Scale score, Barthel Activities of Daily Living index, and discharge destination (home versus other) remained independently associated with fever. CONCLUSION: These findings suggest that fever is associated with worsened outcome in surgical subarachnoid hemorrhage patients, although, because the association between fever and the primary outcome measure for the trial is dependent on the covariates used in the analysis (particularly operative events and delayed ischemic neurological deficits), we cannot rule out the possibility that fever is a marker for other events. Only a formal trial of fever treatment or prevention can address this issue.

Part 1 of the current study found that use of the Bryan Cervical Disc prosthesis resulted in a median loss of 2 degrees in functional spinal unit (FSU) lordosis when compared with preoperative imaging (P0.0001, range: 8-degree loss to 5-degree gain). The observed changes were generally small but varied among both the patients and the surgeons, suggesting that variables may exist which affect postoperative sagittal alignment. The aim of the current study was to identify which, if any, of a range of patient and surgical variables may contribute significantly to postoperative FSU malalignment. The change in FSU angulation between the preoperative and postoperative neutral, erect x-rays of 67 consecutive patients (88 disc levels) were correlated with 35 demographic and radiographic variables. Postoperative change in disc space height, angle of prosthesis insertion, and the amount of bone removed from the anterior aspect of the cephalad vertebra varied significantly among the 3 surgeons and correlated with change in FSU alignment. Intraoperative disc space distraction correlated with subsequent loss of disc space height. Multiple linear regression analysis confirmed that loss of disc space height and angle of prosthesis insertion contributed independently to a model with a coefficient of determination of 0.39 (P0.0001). Attempts to identify factors contributing to change in alignment have not shown any single factor to be wholly responsible. Although the prescribed surgical technique is relatively standardized, it seems likely that a number of surgical variables, particularly those leading to loss of disc space height and affecting annular tension are important.

Objective The Bryan disc prosthesis (Medtronic Sofamor Danek, Memphis, TN) relies on a precise fit between the device and the vertebral endplates to provide immediate stability after cervical arthroplasty. The safety of the cervical arthroplasty in the setting of trauma is unknown. We compare the segmental strength of the normal cervical spine and the cervical spine after single-level arthroplasty. Methods Fifteen cadaveric cervical spines with arthroplasty placed at the C5-C6 level were compared with 16 intact cadaveric controls. A pure moment was applied to induce flexion, extension, or axial rotation until the segment failed. Results The prosthesis provided 63, 45, and 69% of the strength of a normal spine during flexion, extension, and rotation, respectively. There were no cases of prosthesis expulsion. Conclusion After insertion of the Bryan disc, the remaining ligamentous tissues provide adequate acute stability to the spine.

Objectifs : La meilleur technique d'arthrodese et de prise en charge des patients qui subissent une dyscectomie cervicale anterieure (DCA) n'est pas bien etablie. Nous rapportons les pratiques courantes parmi les chirurgiens canadiens concernant la chirurgie pour spondylarthrose cervicale degenerative unique. Methodes : Nous avons effectue une enquete electronique aupres des neurochirurgiens et des orthopedistes pratiquant des chirurgies spinales au Canada. Le questionnaire comprenait des questions sur le traitement de la discopathie degenerative cervicale unique causant une radiculopathie et ou une myelopathie, sur la frequence de l'arthrodese apres une dyscectomie unique, la technique d'arthrodese de choix, les indications et la frequence d'utilisation d'une plaque d'osteosynthese anterieure et d'une orthese cervicale externe apres la chirurgie. Les facteurs demographiques recueillis comprenaient la formation du chirurgien, son type de pratique et la duree de celle-ci. Resultats : Soixante repondants qui ont indique que la chirurgie spinale constituait au moins 5% de leur pratique ont ete inclus dans l'etude. Parmi eux, 59% etaient des neurochirurgiens et 41% des orthopedistes. L'arthrodese etait utilisee chez 93% des patients apres une DCA; le materiau de choix etait l'os autologue utilise chez 76% des cas. Les neurochirurgiens utilisaient des plaques d'osteosynthese dans 42% des discectomies cervicales anterieures et des cas d'arthrodese alors que les orthopedistes l'utilisaient chez 70% des cas. Chez 92% des patients qui n'avait pas recu de plaque d'osteosynthese, on recommandait une orthese cervicale externe de meme que chez 61% des patients qui en avaient recu une. Les chirurgiens qui etaient en pratique depuis moins de cinq ans etaient ceux qui avaient le plus souvent recours a la chirurgie spinale, utilisaient une plaque d'osteosynthese cervicale anterieure et recommandaient l'utilisation d'une orthese cervicale apres la chirurgie. Conclusion : Bien qu'il existe des variations dans les techniques utilisees par les chirurgiens canadiens, presque tous utilisent l'arthrodese et plusieurs utilisent l'instrumentation pour la DCA unique. La formation du chirurgien, son type de pratique et la duree de celle-ci influencent ses choix.

Objective and importance:Fusion following anterior cervical discectomy has been implicated in the acceleration of degenerative changes in the adjacent spinal segments. Discectomy followed by implantation of an artificial cervical disc maintains the functionality of the spinal unit, while still providing excellent symptomatic relief. We describe our preliminary experience with implantation of the Bryan Cervical Disc System in two cases of single-level cervical disc herniation.Clinical presentation:Two male patients presented with a left C6 radiculopathy, without evidence of myelopathy. Magnetic resonance imaging revealed a disc herniation at C5-6 in both cases. Pre-operative flexion and extension radiographs demonstrated preserved motion at the involved levels.Intervention/technique:Following a standard anterior cervical decompression, precision drilling of the vertebral endplates was carried out using a drill attached to a bed-mounted, gravitationally-referenced retraction frame. An artificial cervical disc, composed of a polyurethane nucleus with titanium endplates, was fitted between the contoured endplates without fixation to the vertebral bodies. No complications were experienced during the insertion of the prosthesis, or in the postoperative course. Both patients experienced immediate postoperative resolution of their radicular pain and were discharged from hospital the following day. At nine months following surgery, both patients continue to have complete relief of radicular symptoms. Postoperative radiographs at six months following surgery confirm accurate placement of the prosthesis and preserved mobility of the functional spinal unit.Conclusion:Insertion of the Bryan artificial cervical disc prosthesis following anterior cervical discectomy is a relatively straightforward procedure, which appears to be safe and provides good clinical results, without requiring additional surgical time. Long-term follow-up is required to assess its safety, efficacy, and ability to prevent adjacent segment degeneration.

OBJECTIVE: Anterior lumbar interbody fusion (ALIF) has gained popularity for the treatment of degenerative disease of the lumbar spine. In this report, we present our experience with the ALIF procedure for treatment of failed back surgery syndrome (FBSS) in a noncontrolled prospective cohort. METHODS: In a 2-year period, we treated patients diagnosed with FBSS with ALIF. Clinical and radiological outcomes were recorded in a prospective, nonrandomized, longitudinal manner. Neurological, pain, and functional outcomes were measured preoperatively and 12 months alter surgery. Operative data, perioperative complications, and radiological and clinical outcomes were recorded. RESULTS: Thirty-three patients with a preoperative diagnosis of FBSS, with degenerative disc disease (n = 17), postsurgical spondylolisthesis (n = 13), or pseudarthrosis (n = 3), underwent ALIF. Back pain, leg pain, and functional status improved significantly, by 76% (P < 0.01), 80% (P < 0.01), and 67% (P < 0.01), respectively. CONCLUSION: On the basis of our results, we found ALIF to be a safe and effective procedure for the treatment of FBSS for selected patients.

Different methods have been described by numerous investigators for experimentally assessing the kinematics of cervical artificial discs. However, in addition to understanding how artificial discs affect range of motion, it is also clinically relevant to understand how artificial discs affect segmental posture. The purpose of this paper is to describe novel considerations and methods for experimentally assessing cervical spine postural control in the laboratory. These methods, which include mechanical testing, cadaveric testing, and computer modeling studies, are applied in comparing postural biomechanics of a novel postural control arthroplasty (PCA) device versus standard ball-and-socket (BS) and ball-in-trough (BT) arthroplasty devices. The overall body of evidence from this group of tests supports the conclusion that the PCA device does control posture to a particular lordotic position, whereas BS and BT devices move freely through their ranges of motion.